Reviewer ’s report  
 
Title: Menstrual health and school ab senteeism among adolescent girls in Uganda 
(MENISCUS): A feasibility study  
 
Version: 0 Date : 30 Oct 2017  
 
Reviewer: Julie Hennegan  
 
Reviewer's report:  
 
This is a well written paper on an important topic. The study employs a mix of methods to assess 
the menstrual health & hygiene of girls in peri -urban Uganda and to explore associations with 
school attendance.  
Overall this is a strong study and methods are appropriate. I have a number of comments related 
to the specific paper sections below.  
 
The paper includes report on the findings of a cross -sectional study, authors should include the 
appropriate STROBE checklist as a supplement to the paper.  
The paper is labelled as a feasibility study, authors should specify if there were a -priori 
hypothes es for quantitative comparisons, or state that analyses were exploratory.  
 
METHODS  
As per the STROBE statement please specify how the sample size was arrived at. Were any 
power analyses undertaken? The group sizes for many analyses are quite small, this s hould be 
noted in study limitations.  
Methods state this is part of a larger study, if this is a trial please provide trial registration 
number in the methods for more effective links between this paper and the trial.  
Many readers may not be familiar with the term 'Forms' (e.g., Pg6 in the Methods). I suggest 
including a note to explain this term.  
The methods do not provide much information on the specific question formats used to ask about 
important characteristics including menstrual hygiene practices, an d school attendance which is 
the primary outcome. The paper highlights the limitations of self -reported absenteeism, so it 
would be particularly useful to be clear about the way in which participants were asked about 
this. Example questions either in text or in supplementary materials would improve replicability 
of the findings.  
RESULTS  
At the start of the results the paper states that eligibility meant being in Form 2 or 3 and present 
on the day of the survey, surely there were some girls 12 -17 who were n ot yet menstruating? 
Were they excluded from the sample? Please clarify.  
It is not stated why the authors have used 4 or more times per day as a cut off for the adequacy of 
change frequency, this should be noted in the methods. Further, Table 3 suggests g irls changing 
more frequently were more likely to be absent from school during menstruation and it would be 
useful to comment on this finding in more detail as this is contrary to current menstrual hygiene 
recommendations.  
It is hard to tell from what is w ritten how much missing data was present in the diaries (how 
representative are they of all days?). As this paper notes the diaries as a potential new strategy 
for assessing school absenteeism this would be useful to report.  
 
Since the diary study was unde rtaken on a sub -sample of the quantitative survey, is it not 
possible to link these data sets? It is unclear why the paper does not provide a comparison 
between girls self -reported 'missing school in the last period' and self -reported absenteeism isn't 
compared to the diary reports for this sub -group. Sparse attention in the paper is given to the 
comparability of reported absenteeism between the diaries and other report methods. E.g., 
comparing the diary % of girls who missed a day during the last menstrual  period, vs the self 
reported %  
Did girls report partial absences in the diaries? How was this included in estimates of absence?  
 
In the qualitative interviews girls noted that school policies (e.g., not using the latrines outside 
breaks) and teacher insen sitivity contributed to absenteeism. Was this reflected in the interviews 
with the 11 teachers in the key informant interviews? Very little is included in results or 
discussion regarding the key informant interviews?  
 
DISCUSSION  
Results state that there we re significant differences between the WASH facilities in the schools. 
Specifically, that the higher SES schools had pour -flush latrines that were more likely to have 
locks. This is briefly picked up in the discussion regarding girls suggestions but it wou ld be 
useful to comment on how differences may be relevant to the other findings presented.  
The paragraph starting 511 seems a bit odd. This seems to focus on a lack of association between 
menstruation and school attendance, despite that this study found 20% of girls reported missing a 
day during their last period in the quantitative survey and that the diaries found girls missed 
school on almost 30% of period days. Further this study found that missing school was 
associated with both menstrual symptoms an d use of certain absorbents.  
Line 520, it seems a bit overstated to say that MHM interventions have not been effective at 
reducing school absenteeism. the Systematic review at ref 10 found an absence of evidence, not 
evidence of absence.  
Line 530 - The st udy at ref 13 indicates that the diary data was not used as absence was rarely 
reported and that no further analyses were conducted. This seems to indicate an issue with the 
data collection method rather than that there was little association between menst ruation and 
absenteeism.  
  
This section then goes on to state that more work is needed around the diary method, why was 
this not undertaken in this paper? (e.g., comparability between self -report data & diary findings)?  
Line 558 - one previous qualitative study may be of use to the authors, as this study found girls 
frequently discussed soiling on the first day of their period: Hennegan, J., Dolan, C., Steinfield, 
L., & Montgomery, P. (2017). A qualitative understanding of the effects of reusable sanitary 
pads and puberty education: implications for future research and practice. Reproductive health, 
14(1), 78.  
 
As per STROBE guidance this paper should include a section on limitations of the study/work.  
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
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 adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
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 ind icate the quality of language in the manuscript:  
 
Acceptable  
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, fu nding, or salary from an organization that 
holds  or has applied for patents relating to the content 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.  
 
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as  confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal