Reviewer ’s report  
 
Title: Menstrual hygiene management among women and adolescent girls in the aftermath of the  
earthquake in Nepal  
 
Version: 0 Date: 14 Jun 2017  
 
Reviewer: Bethany Caruso  
 
Reviewer's report:  
 
Overview  
 
The authors conducted a descriptive study of women's  experiences managing menstruation after 
an earthquake in Nepal. There are limited studies that document the needs of women after 
disaster situations, thus this work does fill an important gap in the literature. That being said, the 
study requires extensiv e revision and strengthening. Significantly more details are needed in the 
methods section for readers to be confident in the information reported. The qualitative methods 
were particularly lacking. The results would be stronger if further analyses were pe rformed to 
understand if various socio -demographic characteristics influenced women's access and use of 
MHM related materials. Additional comments are made regarding the results below.  Finally, the 
discussion needs strengthening and editing. The authors m ake claims of what the results indicate, 
yet these results are not reported in the manuscript. The recommendations made should reflect 
the findings reported.  
 
 
 
General Comments  
 
1. In many places, approximate fractions (i.e. nearly 1/5th, about 2/3rds) are used (see 
abstract). Please use percentages instead for readability and greater accuracy.  
 
 
 
2. Watch use of MHM as the subject. MHM is a practice. For example, the authors write: 
"MHM was found to be missing in immediate relief activities by humanitarian agencies." 
Better to say relief efforts lacked MHM activities. MHM is not missing; women perf orm 
menstrual hygiene regardless of agencies. It is a minor detail but an important point. 
MHM is not a thing that is concrete.  
 
 
3. In many places, citations seem randomly placed in the middle of sentences without 
justification. Review citations and have t hem be at the end of sentences or at the end of 
one key point that is vastly different than another later raised. Currently, the placement if 
not at the end seems haphazard.  
 
Abstract  
 
1. The final sentence of the abstract is weak. Don't tell the reader th at the findings are new 
as the conclusion, tell the reader what is new and why that new information is important. 
Being new does not mean it is important. What can now be done wit this new information 
from this study?  
 
 
 
Intro  
 
1. P 3.; Lines 61 -64. Better to  actually put in the definition of menstrual hygiene management 
than to put in your own words. As it is defined here, it is not fully accurate and does not capture 
the completeness of the definition (i.e. water, etc.). Revision needed.  
 
 
2. P3. Lines 64 -66: Regarding: "Menstruation has strong social and cultural dimensions, and 
young women and adolescent girls in societies with strong traditional beliefs often require 
psychosocial support. (3 -5)."  
 
 
This statement does not make sense; it makes it seem that girls require psychosocial support just 
because they come from countries with strong traditions. What does that mean? That is not what 
these studies say. Girls need support to manage menses in terms of education, etc. But this makes 
it seem like girls have  mental health issues in certain places because of their culture. I suggest a 
re-read of the articles and a revision of the statement.  
 
 
 
3. P3. Lines 66 -70: Regarding: "In some low -income countries, menstruation and associated 
activities are surrounded by  silence, shame and social taboos that are further manifested in social 
practices that restrict mobility, freedom and access to normal activities. For instance, drinking 
milk, preparing food, interacting with people or refraining from performing religious rituals are 
restrictions found in many cultures (5 -9)."  
 
Be specific as to where these restrictions are.  
 
 
 
4. P3. Lines 71 -73: Material types are noted. Where do these range? In Nepal, across the world? 
More specifics needed. Too general.  
 
 
 
5. P3 -P4. Lines 75-77: Regarding "improper MHM": This is too general. These studies are very 
specific about what drives or may be associated with these outcomes. Simply saying 'improper 
MHM is insufficient. There is a need to be more specific.  
 
 
 
5. P4. Lines 78 -79: "Usual ly…" Citation needed for this statement.  
 
 
 
6. P4. Lines 79 -81: Citations unnecessarily split.  
 
 
 
Methods  
 
Overall, great details are provided regarding ethical review, but all other sections of the methods 
section are thin and need further detail.  
 
 
1. Line 115: Regarding: "A total of 117 respondents participated in the study resulting in a 
response rate of 92.1%." Did you actually try and interview 127? This percentage is only 
applicable if you actively asked 127 women and 117 said yes. If you only a sked 117, then 
this is not accurate. Further, this number should go in the results section.  
 
 
2. Line 127 -130: Regarding: "A small sample of respondents 128 (n=5) who had their 
menses on the day or within the first week of the earthquake were invited to pa rticipate in 
an experience sharing session. Detailed field notes were taken to record the experiences 
of these 5 adolescent girls and women." It is unclear what an 'experience sharing session' 
is. More details are needed for this data collection activity.  
 
 
3. Was data double entered?  
 
 
4. More details are needed regarding the quantitative and qualitative data collection. Who 
collected data? How were hey trained? What language was data collected in? How was in 
translated, if at all?  
 
 
5. More details are nee ded regarding the qualitative data. It is unclear how this data was 
collected, what was asked. Were these sessions recorded and then transcribed? The 
analysis description is thin. More info needed.  
 
 
Results  
 
As noted above, percentages need to be reported , not fractions. This gets challenging to read.  
 
 
Further, it does not seem necessary to have multiple tables as these are all descriptive. It may be 
better to have all the tables be condensed as one easy reference.  
 
 
Table formatting could be improved (see o ther published papers and match formatting).  
 
 
1. Provide percentages and raw number only. Do not provide percentage and fraction (i.e. 
77/117).  
 
 
 
2. Table 1 and associated text: The table does not make it clear if the absorbent type or the 
changing behav ior reported is pre earthquake or current. Needs to be more specific.  
 
 
 
3. Menstruation timing in relation to earthquake: Why is this reported? It is unclear as to why 
this is important. What purpose does this data serve?  
 
 
 
4, Paragraph starting at line 180 -181: Unclear what the following means: "About 12% of 
respondents remembered adsorbents for menstrual hygiene management on the day of the 
earthquake". Does this mean they remembered to use them that day (before or after earthquake)?  
 
 
For "Almost three qua rters (89/117) of respondents resorted to using reusable cloths for 
managing menstrual bleeding, made mostly from old clothes (78.7%, 70/89)." Does this mean 
they do not normally use cloth under normal circumstances? The term 'resorted to' infers that this  
is a last resort. However, women may be using these normally. Do you know what typical 
practices were and how they changed?  
 
 
For "About85% (24/28) of respondents who could use disposable sanitary pads disposed of them 
at a nearby location after use."  
 
 
 
 
 
-Insert space for "About85%"  
 
-This is lacking too much information to be useful. What does nearby mean? Where specifically? 
In a toilet? Did they throw outside? Were there proper disposal places?  
 
 
 
5. Overall, I think further analysis should be done to lear n more about the women and their 
needs. These analysis could provide better insight about whether or not certain women have 
greater needs than others and should be prioritized, or if women in this situation are the same and 
and all need materials equally. Specifically, the authors report socio -demographic data like age, 
marital status and education. It would be useful to understand if there were differences in 
practices, access, etc. based on these characteristics. For example, were more educated women 
more  likely to get pads if they wanted them? Were married women more likely to receive soap? 
Etc.  
 
 
 
6. The qualitative data is very interesting, though I remain unclear how the data was analyzed. 
The quotes are powerful, but I also remain unclear if these are direct quotes from recordings. The 
authors mention note taking, In that case, are these really to be trusted as word for word or were 
there actual recordings? Further information and su pport on methods needed here. Otherwise, I 
remain unclear about the int egrity of the quotes.  
 
 
 
Discussion  
 
1. It seems that the discussion does not match the findings well. There are claims made in the 
discussion that do not seem to be fully supported in the results. It is important for the discussion 
to draw specifically from  the results and only make claims and recommendations that are 
supported by the results. I encourage the authors to review the discussion and results to confirm 
the claims made.  
 
For example, the authors write: "We found gaps in information, education and communication 
efforts on menstrual hygiene management during and in the aftermath of the earthquake in 
Nepal." At no point in the results do the authors report on information, education and 
communication. The results focus on absorbent types largely.  
 
 
 
2. Line 252: For "While this seems to be the only option during emergencies, other improvised 
adsorbents might not be hygienic and could potentially also be a source of infection." This needs 
to be cited as this is a big claim.  
 
3. Line 254: For "The soap re ceived by half of the respondents was not primarily used for 
maintaining menstrual hygiene." Does it need to be? Why can soap not be used for other 
purposes?  
 
 
 
 
Minor comments:  
 
Abstract:  
 
1. The following should have a comma, not a semi -colon: "Despite bei ng an important issue 
in humanitarian situations such as earthquakes; menstrual hygiene management is often 
overlooked in post -disaster responses."  
 
 
 
2. The word 'need' redundant in the following sentence. Consider re -wording. Also, use 
percentages instead of '1/5th': "Menstrual hygiene needs were perceived as an immediate 
need by nearly 1/5th of the respondents and it was rated as the sixth highest overall 
need."  
 
 
 
3. In the following sentence, it should say 'women' completely depended on as the subject of 
the sentence. Fix. "In the immediate aftermath of the earthquake, menstrual hygiene 
management completely depended on the use of locally available resources by women 
and young girls."  
 
 
 
Intro  
 
1. P4. Lines 79 -81: Citations unnecessarily split.  
 
 
 
Methods  
 
1. Line 101: Space needed: "amongst117"  
 
 
 
 
 
 
Results  
 
1. Remove commas from the following:  
 
- "One respondent reported to have started her menstrual period, immediately in…"  
 
- "As an issue, not openly discussed in society and pertaining just to…"  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequat ely supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript : 
 
Needs some language corrections before being published  
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the c ontent of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
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