Title: Culture, Self-Esteem and Menstrual Hygiene Management Among Adolescent Girls in
Uganda: The Impact of Economic and Family Strengthening.
Version: 6 Date: 16 Oct 2024
Reviewer's report:
Thank you for addressing my comments and responding to my questions. I believe this article is
now suitable for publication. I leave a few minor suggestions below, none of which are critical
to the success of this manuscript  --
1. Introduction: The sentence - Inadequate MHM has serious implications for health and other
societal outcomes - needs to be supported [add a reference].
2. Introduction: To note REF 16 is missing prior to REF 17 - please re-embed this for numeric
continuity.
3. Introduction: Please adjust your sentence reading: "A recent study in Kenya found that
inadequate menstrual products increased the risk of infections, but participants using menstrual
cups had lower rates of sexually transmitted infections, such as bacterial vaginosis, compared
to those using unsanitary alternatives. Another study showed that the proper use of pads was
associated with a reduced risk of infections [22]." to "Recent studies in Kenya found that
inadequate menstrual products increased the risk of infections, such as bacterial vaginosis and
sexually transmitted diseases [REF 21, 22 and add Mehta 2023 - "Analysis of bacterial vaginosis,
the vaginal microbiome, and sexually transmitted infections ..."].
4. Introduction - please omit the clause reading: "enabling them to focus on education and
work without worrying about menstruation" and start the following sentence with a clearer
transition like "Interventions supporting menstrual health and hygiene have..." To note this
sentence concludes again with a link to menstrual absenteeism, which in the prior paragraph
you have (rightly) noted is mixed. I would consider removing it in this second paragraph and
to instead say something about how MHH interventions support  girls' equity and development.
If useful, you could use your REF 89 Sommer 2021 and say how MHH initiatives support the
SDGs.
5. Introduction: please change "result in" to "engage in" in the sentence reading "For example,
people with low self-esteem...."
6. Introduction - the sentences: "Menstruation is considered a private matter, especially from
men. In other regions, girls are prohibited from bathing or coming into contact with water." -
should be better supported by references if possible.
7. Introduction - please adjust Karnataka to say "India" so its parallel with "Ethiopia".
8. Introduction -- when quoting existing studies please use the past tense - e.g. "Urban girls in
both regions use sanitary pads more frequently and score higher in menstrual hygiene practices
[59, 60]." should be "Urban girls in both regions used sanitary pads more frequently and scored
higher in menstrual hygiene practices [59, 60]."
9. Introduction -- To note the introduction says very little about economic empowerment
incentives among adolescents - would be nice to have a bit more background on this topic.
10. Introduction you introduce the acronym menstrual hygiene management (MHM) twice -
once in all capitals and once in lower case. I would suggest to only introduce it once and keep
it in lower case. Similarly, when discussing the asset theories at times you capitalize Theory
and at times don't.
11. Results - Table 2, some of your p-values <0.05 are not highlighted. Please include a table
legend indicating what bold text refers to. Additionally, in Table 2 - the authors sometimes spell
out "number" and other times use "no." Some reference groups are specified with "ref" but some
are not (e.g. Usual care). It is unclear why some of the parameters listed in the table have no
information at all - should they be removed from the table?
12. Figure 2 cannot be deciphered given the reader is not told which condition is "treatment 1"
and which condition is "treatment 2" - please change this noting that tables and figures should
always be able to stand alone for interpretation.
13. Discussion: "Moreover, the improvement in self-esteem..." should read "However".
14. Discussion: the sentence "Such outcomes align with the anticipated impacts considering
the families' economic circumstances in the study region [80]" is non-specific - what family
economic circumstances, and why would the lack of effect at 12M be anticipated? -- I would
suggest removing this sentence all together.
15. While the authors state "The findings from these studies also suggest that combined
interventions may be more effective among adolescent girls than single-pronged strategies"
however they add no evidence from the literature to support that economic empowerment
incentives on their own do not work and are aligned with their own findings. Do no other studies
exist showing this phenomenon?