Title: Culture, Self-Esteem and Menstrual Hygiene Management Among Adolescent Girls in
Uganda: The Impact of Economic and Family Strengthening.
Version: 3 Date: 30 Aug 2024
Reviewer's report:
Thank you for the opportunity to review this paper. It presents interesting and important
information on a topic that is gaining wider recognition over the past few years. It utilizes a three-
arm cRCT design to assess  how economic empowerment and family strengthening interventions
impact girls' self-esteem when mediated by menstrual hygiene knowledge and period-related
absence. Please see below my feedback:
1. In Abstract methods - Please more clearly designate which mixed effect models were used to
analyse the outcomes and better specify the outcomes.
2. In Abstract methods - please detail the period under follow-up. Please explain how absence
during menstruation was tracked.
3. In Abstract methods - "menstruation periods" should say "menstrual periods".
4. In Abstract results - you state " showed significantly higher self-esteem in the YDA+MFG
group compared to the control at time point 3 (24-months follow-up) (#=1.282 (0.084, 2.480),
p=0.36)." -- your p-value has a typo - I believe it should say p=0.036. Please also report at all
time points, not only the ones that seemed promising, otherwise it seems as though you have
cherry picked your results.
4. The Abstract conclusion - The conclusion seems overstated. It appears that the most significant
result is that girls self esteem improves naturally as they get older? Please couch your conclusion
with a more complete interpretation for the reader. Also please include the study limitations.
5. Introduction - you write about menstruation related absence being a large challenge in LMIC
and cite Miiro - however, a large number of studies have not found this same link. Please include
information stating that the evidence base on menstruation's role in girls' absence is mixed.
6. Introduction - You state that "Unfortunately, these unhygienic makeshift solutions carry risks,
including wet fabric that increases the likelihood of infections, such as urinary tract infections"
-- recent studies have been conducted in Kenya showing the link between menstrual products
and UTIs which should be incorporated here to strengthen this argument.
7. Introduction - Your paragraph on economic empowerment incentives and adolescent girls'
ability to purchase menstrual products lacks detail on studies that have been conducted on this
topic. Please be more thorough in your introduction to include evidence emerging from the
region on how structural interventions targeting girls economic power have succeeded or failed.
8. Methods, randomization - you state girls were first recruited then randomized. If the
randomisation was at the school level is this accurate? One would assume schools would be
randomised and then girls would be selected from those pre-selected schools. How did girls
consent without knowing which intervention they would be receiving?
9. Methods - please clearly detail how the intervention schedule overlapped with the follow-
up surveys.
10. Methods - please explain why menstrual-related absence was only incorporated if it was
due to cultural and religious reasons, and did not include for pain, discomfort, lack of WASH
at school, etc.
11. Methods - please more clearly designate what type of mixed-effects model was used. You
indicate the model was three-level but only specify school and participant - which was the third
level? You also specify that you adjusted for clustering at school and also included school as a
random effect - I presume only one of these is accurate?
12. Methods - did you validate the menstrual health scales and check for agreement, collinearity,
etc? You provide no detail on if model assumptions were met.
13. Implications - you state the the interventions show promise in enhancing the well-being
of adolescents but include no comparative studies that have looked at economic incentives in
this population in the region. Your discussion would be notably improved if you incorporated
evidence [both pro/con] on what other studies have found about these types of interventions
among adolescent girls in similar settings.
14. Given that 1/3 of the eligible population did not turn up to be in the study, please indicate
what bias this may have introduced to the study.
15. Given that not all girls were menstruating at baseline, please include in your study limitations
how this may have impacted your results.