Title: MENSTRUAL HEALTH AND HYGIENE AMONGST ADOLESCENT GIRLS AND
WOMEN OF REPRODUCTIVE AGE: A STUDY OF PRACTICES AND PREDICTORS,
ODISHA, INDIA
Version: 1 Date: 10 Aug 2023
Reviewer's report:
This is a study in Odisha, India, showing that knowledge of menstruation is severely lacking.
Other studies in India and other countries have shown similar results, but this study's contribution
is that it does not focus on a limited age-group. Rather, its strength is that it can speak about
women of all reproductive ages.
While this paper makes a nice contribution in highlighting important issues that women and
girls face in this particular state, it would be good for the authors to try to make more clear how
this study makes a unique additional contribution in relation to other similar studies in other
places before the paper is ready for publication. In particular, since the authors state explicitly
that they are filling a gap in the literature that MMH in Odisha is largely focused on adolescents
in schools, but this study talks about women at all reproductive ages, I think it would be useful
to expand on this and stratify more of the results by age. This is done in some instances, such
as saying that that younger girls more frequently use pads rather than cloths, but I wonder if
there is more to explore here. Since the authors collected qualitative data, are the authors able
to see any noticeable differences by age of the girls/women in terms of attitudes or expectations
around menstruation? Is anything noticeably changing over time for younger women?
Additionally, more explanation and analyses would be good using the quantitative data. First,
details on what knowledge and practice aspects were asked about is critical to understand what
the knowledge and practice scores mean. Right now, the paper just says that a PCA analysis was
used, but does not describe which facts/practices were asked about. Second, it would be good to
include confidence intervals on the odds ratios presented in the text so that readers know how
much uncertainty exists in these estimates. Third, while it is interesting to see how different
age groups or caste groups or wealth groups differ in their knowledge and practices, how do
these variables work together? For example, caste is such a salient determinant of health access
and health outcomes in India. The authors say that caste matters for knowledge and practice.
In Table 6, we see that those of general caste have better menstrual hygiene practices than the
base group (I believe this is Scheduled Tribe), but Scheduled Caste and OBC groups also do. Do
these differences remain after controlling for wealth and education? The authors could consider
implementing multivariate regressions to see which factors seem to be driving differences.
A few more minor comments are below:
Line 40 - It seems like the authors are saying that menstruation happens over just five years of
a woman's life. But I think they mean to say that in total, all the days of menstruation amount to
five years of time. That is substantial, and an important fact, it just needs to be made clear.
Line 91 - It is unclear why the authors point out the fraction of 15-24 year olds using "hygenic
menstrual protection" when the focus of the study is not only this age group? Is the point that the
government has put some sanitary napkins in schools for school-age girls and so this is likely to
be the age group with the highest access? This should be made clearer.
Line 96 - How were these three sample districts chosen?
Line 135 - Four IDIs? Am I understanding correctly that this means four women in total? How
were these four women chosen? This seems like a very small number compared to 30 Key
informant interviews. Is there a reason for this difference?
Line 137 - Can the authors state how many girls and boys were in the FGDs?
Line 193 - Consider changing "illiterates" to "those who had no education."
Line 242 - It is interesting that women said that knowing ahead of time was important but then
did not do this for their daughters - is it because of a lack of knowledge? Do they feel that they
will get in trouble for telling their daughters? Are they feeling shy or uncomfortable?
Line 253 - It is unique that menstruation in India is celebrated. What about Korapur district is
different that led to girls being aware of menarche and prepared for it, while in most other cases
the authors say girls report being scared?
Line 267 - It is also nteresting that the boys in Koraput had no idea about menstruation, even
though there are celebrations for this. More explanation would be helpful.
Line 283 - It would be helpful for general readers for the authors to spell out why cloth is not
as good as pads. What is the experience like? Are there health issues of using one versus the
other? Or other consequences?
In general, it would be good to be a bit more specific with recommendations. What are things
that communities can do, versus the government, versus schools, versus families? Also, to make
the analysis easier to digest, the authors should consider putting the tables into graphs.