Reviewer’s report
Title: 
‘Menstruation means impurity’: multilevel interventions are needed to
break the menstrual taboo in Nepal
Version: 
1 
Date: 
30 Dec 2020
Reviewer's report:
The authors explore why menstruation management interventions in Nepal have
not been effective in addressing retrogressive menstrual health practices. I have
the following comments for the authors to consider to improve the paper further.
1) Background:
a) First paragraph: 
* Second statement (page 3, lines 5-10): Delete "Particularly" at the beginning of
the statement, and "is" after "tradition".
* Third statement (page 3, lines 10-17): Delete "etc." from the statement as it is
tantamount to leaving it to the reader to guess what it entails when the authors
are the experts who should tell the reader what it comprises.
b) Second paragraph:
* First statement (page 3, lines 29-32): Rephrase to read: "A number of
interventions to address menstrual taboo and improve overall menstrual health
…"
* Second statement (page 3, lines 32-39): Rephrase to read: "Such initiatives are
generally referred to as menstruation management interventions …" to avoid
unnecessary repetition of the word "interventions" in the statement.
c) Third paragraph:
* First statement (page 3, lines 54-59): Delete "Especially" from the statement
and provide a citation for the elimination campaign being alluded to here.
* Second statement (page 3, line 59 & page 4, lines 1-3): Change "criminal code
bill" to "law" because a "bill" refers to legislation that has not been enacted.
Also, change "has been enacted since 9 August 2017" to "was enacted on 9
August 2017", and provide a citation at the end of the statement that references
that law.
* Last statement (page 4, lines 5-7): Rephrase the last part to read: "…as well as
segregating them as untouchables (citation)."
d) Fourth paragraph:
* First statement (page 4, lines 10-15): If this statement is based on what people
believe and not on empirical evidence of the effectiveness of the interventions,
then consider rephrasing it to something like, "The interventions are believed to
change the perceptions of women and community members, and the number of
women practising chhaupadi is believed to have been declining over the years
…"
* Third statement (page 4, lines 22-29): Rephrase to read: "A quantitative study
conducted in 2019 … menstrual health, and that women in rural areas, in
particular, have poor …"
* Last statement (page 4, lines 29-37): Change "to establish" to "on", and delete
"to outline" from the statement. 
e) Last paragraph:
* First statement (page 4, lines 39-44): Rephrase the last part to read: "…might
not work, and the opinions and experiences regarding the implementation of
such interventions."
* Last statement (page 4, lines 47-49): Change "include" to "consider", and
"increased" to "enhanced".
* The authors should also tell us what informed this discussion. Is the discussion
informed by their review of existing evidence, experiences implementing
menstrual management interventions, or expert opinions on the topic? Whatever
informed the discussion, the authors should provide a description of the process.
If it is evidence review, how did they go about gathering and analyzing the
evidence, and what were they looking for? If it is experiences implementing
interventions, which interventions were these, when were they implemented,
who was involved, and what were the intended and final outcomes? If it is expert
opinions, whose opinions were considered and how were the experts identified? 
2) Discussion:
a) Section heading (page 4, line 54): The section heading, "Discussion", is not
appropriate, as it is not a key aspect that the authors considered in the paper.
Perhaps it could better read "Results".
b) Section heading (page 4, line 56): Rephrase the section heading into a
statement instead of a question, i.e. "Why current interventions might not work".
c) Why interventions might not work, first paragraph:
* First statement (page 5, lines 1-7): Rephrase to read: "Despite several
interventions to address the menstrual taboo …"
* Second statement (page 5, lines 7-12): Insert "of time" after "duration".
* Third statement (page 5, lines 12-20): Change "have been" to "were", and
delete "in many communities" from the statement to avoid unnecessary
repetition.
* Fourth statement (page 5, lines 20-27): Delete "causing" from the statement,
and insert "in the community" after "consequences". Also, change "have been
circulating" to "circulate".
* Fifth statement (page 5, lines 27-32): Change "these women" to "such
women", and "not practising" to "abandoning".
* Sixth statement (page 5, lines 32-37): Change "their life" to "their lives".
* Eighth statement (page 5, lines 42-47): Change "influence" to "limit".
* Last statement (page 5, lines 47-59): Rephrase to read: "For instance, even if
people gradually change their attitudes and are ready to accept … kitchen), a
majority of the households … their periods due to widespread poverty; thus, …"
d) Why interventions might not work, second paragraph:
* Third statement (page 6, lines 7-20): Delete "clear" and "found to be" as well
as "the" before "male community" from the statement. Also, change
"discrimination" to "discriminatory".
* Fifth statement (page 6, lines 24-32): Rephrase to read: "There is, therefore" a
need to incorporate innovative strategies … leaders who exert some level of
control …" 
e) Why interventions might not work, last paragraph:
* First statement (page 6, lines 39-44): Delete "has" from the statement.
* Third statement (page 6, lines 49-56): Provide a citation for the statement.
* Last statement (page 6, line 56 & page 7, lines 1-3): Delete "for" after
"negotiate".
f) How to enhance effectiveness of interventions, section heading (page 7, line
5): Again, rephrase the section heading into a statement instead of a question, i.e.
"How effectiveness of interventions might be enhanced".
g) How to enhance effectiveness of interventions, first paragraph:
* First statement (page 7, lines 7-12): This statement was more appropriate in
the last paragraph of the background section and not here as it does not improve
our understanding of how the interventions could be improved.
* Fifth statement (page 7, lines 42-44): Change "are able to" to "can".
h) How to enhance effectiveness of interventions, second paragraph:
* Second statement (page 8, lines 7-15): Change "non-acceptance towards" to
"non-acceptance of", and rephrase the last part to read: "… driven by external
Western ideals that undermine and ignore …"
* Third statement (page 8, lines 15-20): Rephrase to read: "Interventions … need
to consider the integral parts of the socio-cultural context such as …"
i) How to enhance effectiveness of interventions, last paragraph:
* First statement (page 8, lines 24-32): Change "mobilizing" to "mobilization",
and "group" to "groups". Also, delete "therefore" from the statement.
* Last statement (page 8, lines 39-49): Delete "turn out to" and "also" from the
statement. Also, change "methods" to "approaches".
3) Summary:
a) Section heading (page 8, line 54): Consider changing the section heading to
"Conclusion" given that a summary creates the impression of the content of the
article in a concise form when the reader expects key message(s) to take away
from the article, i.e., conclusion(s).
b) First statement (page 8, lines 56-59): Rephrase the last part to read: "…
including activities to eliminate chhaupadi, are only effective for a short duration
of time."
c) Second statement (page 8, line 59 & page 9, lines 1-10): Delete "the" before
"poor" and before "influence". Also, delete "the effects of" from the statement.
d) Third statement (page 9, lines 10-15): This statement is not a key take-home
message and should be deleted. Instead, the authors should summarize "why"
such interventions are needed based on what they found.
e) Last statement (page 9, lines 15-20): Delete "It is also suggested that" from the
statement, and change "mobilizing" to "mobilization".
4) Abstract:
a) Background:
* Last statement (page 2, lines 12-20): Rephrase to read: "There is lack of clarity
regarding the effectiveness of interventions that have been implemented to
address menstrual taboo and improve menstrual hygiene and practices in Nepal
(e.g., … legislation)."
* Statement of purpose: This section of the abstract needs to end with a
statement of purpose, i.e. the objective of the paper.
b) Methods: Before moving to "Discussion", the authors ought to summarize the
approach/method used in the paper after describing the same in detail in the
main text (refer to earlier comment regarding the same).
c) Discussion:
* Section heading (page 2, line 22): The section heading should actually be
"Results" of what the authors set out to investigate.
* First statement (page 2, lines 22-24): Rephrase the last part to read: "…studies
suggest that interventions to address menstrual taboos have only been effective
for short durations of time due to several reasons."
* Second statement (page 2, lines 24-29): Change "abolish" to "abandon" and
insert "retrogressive" before "menstrual".
* Third statement (page 2, lines 29-32): Change "discriminations" to
"discrimination".
* Fourth statement (page 2, lines 32-37): Rephrase the last part to read:
"illiteracy, limit the effectiveness of such interventions."
* Fifth statement (page 2, lines 37-39): Change "community-sensitizing" to
"community sensitization".
* Last statement (page 2, lines 39-41): Rephrase the last part to read: "…faced
implementation problems, including poor filing of complaints."
d) Summary (page 2, lines 44-54): The section heading should actually be
"Conclusion" to connote take-home message(s) from the article rather than a
summary of the article's content. The messages here also need to be linked to the
findings in the previous section. The first statement could, for instance, begin:
"The findings suggest that multilevel …" Also, change "mobilizing" in the last
statement to "mobilization", and "more responsive" to "effective". 
e) Keywords: "Chhaupadi" is not a good keyword here as the term is only
applicable in a localized context. Also, the keywords should be re-arranged so
that "Nepal" comes last.
5) Declarations, authors' contributions (page 9, lines 41-46): It is here that the
authors mention that they conducted literature search. This ought to have first
been described in a methods section so that when the reader encounters it here, it
does not appear like a surprise. In particular the authors ought to have described
which databases were searched, the search terms used, the number of articles
identified, the number of articles included in the final review, the criteria used to
sieve out articles, and the process for analyzing the articles that were eventually
selected for review. It also needs to be clear in such a section whether it was a
systematic or scoping review.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
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