Title: Culture, Self-Esteem and Menstrual Hygiene Management Among Adolescent Girls in
Uganda: The Impact of Economic and Family Strengthening.
Version: 5 Date: 23 Sep 2024
Reviewer's report:
Thank you for your detailed response to my prior comments. I believe this manuscript has
improved and have a few remaining pieces of feedback below --
1. The Abstract: results/conclusion - the fact that the YDA intervention alone did not have an
effect on self-esteem is absent. Similarly, the conclusion still reads as very conclusive while the
evidence feels less strong given that the YDA alone and the YDA+ at 12M showed no effect.
You may want to note that YDA alone did not appear effective in improving your measured
outcomes.
2. Introduction: I would recommend the authors re-word your opening sentence to be more
straightforward: e.g. "In Sub-Saharan Africa (SSA) roughly 230 million women are of
reproductive age (15-49 yrs) [refs 1-3]." Or "Among Sub-Saharan Africa's (SSA) 1.4 billion
people (1), approximately 230 million are menstruating [refs 1-3]. Menstruation....
3. Introduction: You may want to specify "menstrual cups" where the authors mention "cups"
for those unfamiliar with this tool.
4. Introduction: Your new sentence reading "A recent study in Kenya has demonstrated the link
between inadequate menstrual products and the risk of Infections (21). " - is vague and could
be better specified. Additionally, there is growing evidence showing not only that menstrual
products can decrease infection risk by creating more hygienic conditions, but also through
mediation with the vaginal microbiome, decreasing the acquisition of BV and STIs like HSV-2.
5. Introduction: The sentences reading: Moreover, low self-esteem adversely affects girls’
participation in physical activities during their cycle, as it compels them to remain self-conscious
or leads to outright isolation at all times (36). On the other hand, people with high self-esteem are
more likely to make informed career decisions (37).  --> reads like a non-parallel comparison.
How does the menstrual cycle affect girls with high self-esteem? While you note for those with
low self-esteem it may lead to isolation, for those with high self-esteem they're likely to pursue
their careers. These ladies are not isolated?
6. Introduction: I would suggest that you change the wording of "before formal education" to
something more like "prior to receiving information in school."
7. Methods: Please include details on how schools were assigned to one of the three study
conditions.
8. Methods: You note in your response that girls were consented twice - once pre assignment
and once post. Please include the refusal rate between the first and second round of consent and
add these details to the consort diagram.
9. Methods: It would be nice if the authors included descriptive details of the selected factors
and scales [study measures] in a supplementary table.
10. Results: Please explain how you designate "average" self-esteem - is there a cut off score
for this?
11. Discussion: You state “Results revealed that our study has compelling evidence suggesting
that interventions, specifically YDAs and MFGs are associated with a progressive improvement
in the self-esteem of adolescent girls (59).” However, it does not appear that YDAs alone are
associated with improvement from your results thus I suggest you temper this statement.
12. Discussion: Your discussion is missing key analysis around why YDA alone [which you
describe as “tangible assets”] did not seem to have an effect on improving self-esteem. The
authors focus on the positive results in the combined intervention arm while ignoring the lack of
effect in the single intervention arm. Please include this in your discussion and bring in evidence
from other recent studies looking at structural interventions among adolescents in the region:
e.g. Adolescent Girls Initiative [Austrian et al]; Cups or Cash for Girls Trial [Zulaika et al] with
the author’s theory on why no effect was seen.
13. Implications – From your results I am not led to believe that “economic empowerment
strategies show considerable promise in enhancing the well-being of adolescents.” Please refrain
from making such statements when they are not supported by the findings of your study [also
in your conclusion].
14. Your implications focus around menstrual poverty and lack of products but nowhere in your
analysis do you show that girls in this study lacked period products or were unable to engage in
school due to menstruation for reasons other than cultural beliefs. Thus, the implications section
of the manuscript seems unaligned with the implications of the study.