PONE-D-24-55215Effects of school menstrual hygiene, water and sanitation interventions on girls’ empowerment, health and educational outcomes: Lasta District, Amhara Regional State, EthiopiaPLOS ONE

Dear Dr. Andargie,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

 All three reviewers have provided extensive comments to the writing of the manuscript which need to be addressed. Please submit your revised manuscript by Feb 21 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Alison Parker

Academic Editor

PLOS ONE

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When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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2. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

3. Please ensure that you refer to Figure 8 in your text as, if accepted, production will need this reference to link the reader to the figure.

4. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The author needs to have all the grammatical errors corrected before submitting the paper for review. Some paragraphs are too wordy, this needs to be addressed without interfering with the meaning. There is poor flow of sentences as well, Some parafraphs do not trelate to the previous ones

Reviewer #2: I appreciate the work addressing this timely public health issue. I would like to raise few concerns regarding the study:

1. Method section

You mentioned that you utilized both methods. Could you clarify the purpose of the cross-sectional study? Additionally, what type of experimental design did you implement (e.g., true randomization, quasi-experiment, longitudinal, etc.)?

2. Details of the Intervention

The description of the intervention lacks specificity in terms of quantity, frequency, and duration. Additionally, the content of the intervention is described too superficially, making it difficult to derive meaningful insights or formulate policy recommendations based on the findings.

3. Contamination

The manuscript does not clearly outline the strategies implemented to prevent contamination or to buffer against potential biases.

4. Ethical Considerations

It is important to understand how the researchers addressed ethical dilemmas faced by non-intervention schools. Clarification on this matter is necessary.

Students under the age of 18 are included in your study. In this case, you must obtain both assent from the students and consent from their parents. Why was not assent considered?

5. Quality Control Mechanisms

What quality control mechanisms were in place to ensure the fidelity of the intervention, particularly regarding educational components? Blinding, randomization, and other quality control mechanisms need to be clearly articulated.

6. Mixed Methods Approach

The implementation of mixed methods is noted. Please clarify the sequence of the qualitative and quantitative studies: which method was conducted first, and what was the rationale behind this choice?

7. Controlling for Confounding Factor

Given that school performance can be influenced by multiple factors, it is essential to explain how the study controlled for the effects of other confounding variables on both school attendance and educational performance.

I recommend that all these concerns be addressed in the body of the manuscript to enhance its clarity and robustness.

Reviewer #3: Thank you for asking me to review this paper on “Effects of school menstrual hygiene, water, and sanitation interventions on girls’ empowerment, health, and educational outcomes: Lasta District, Amhara Regional State, Ethiopia." It is exciting research. However, the following issues must be improved before it is accepted for publication.

Title: The title of this study, which is stated as "Effects of School Menstrual Hygiene, Water, and Sanitation Interventions on Girls’ Empowerment, Health, and Educational Outcomes,” needs modifications. The intervention section, as indicated in lines 184–188, includes MHM education and MHM rooms, which are not included in this title. Therefore the title of this study should be modified to “Effects of School Menstrual Hygiene Management and Water, Sanitation and Hygiene (WASH) Service Interventions on Girls’ Empowerment, health and Educational Outcomes.”

Abstract sections: lines 31–33 should be consistent with the modified title. Please modify it as “This study investigated the effects of school menstrual hygiene management and water, sanitation, and hygiene (WASH) service interventions on girls’ empowerment, health, and educational outcomes. And also use effect or impacts consistently throughout the documents.

The introduction sections: The author’s well explained the context of the study. However, lines 157-160 need rearrangements. Line 157, “…..The significance of this study...” should come after line 160.

Design and setting: in line 173, the authors stated, “Six primary second-cycle schools were selected within the district” without describing first how many primary second-cycle schools are there in the district. The authors should also describe how six primary second-cycle schools were selected. Is randomization conducted? Or is there a baseline difference between exp’tal and controlled schools? Otherwise, it is difficult to conclude whether the effects after six years were due to interventions or results of their baseline difference.

Line 180: “10 primary second cycle schools or 6? This contradicts what was stated in line 173.

The informed consent section from line 234-262 needs modification. The informed voluntary consent for a minor (age < 18 years)/vulnerable individual should be signed by his/her legal competent representative (e.g., a parent/guardian). But in this study, even though around 85% of study participants were less than 16 years old (as indicated in table 1), informed voluntary consent taken from parent/guardian was not explained

Results section: Please rewrite from lines 284 to 288. For example, “Parental education levels were generally low...” Do not interpret the findings in the result section; keep it for the discussion section.

Please remove the gender variable from table 1.

The conclusion section is not well written. The authors should stick to the findings of the study during the conclusion. For instance, line 764-765, ”The interventions significantly boosted their confidence in discussing menstruation and lowered anxieties,” should be removed as not a tool that measures anxiety was indicated in the result.

Please rewrite the structured recommendation for this study and remove lines 770–778.

Finally, there are numerous editorial and grammatical errors that should be corrected before this manuscript is accepted. For instance, the author should use MHM consistently throughout the documents once he/she defined menstrual hygiene management as (MHM), unless it comes after full stop or at the beginning of the paragraph.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: Yes:  Balem Demtsu Betsu

Reviewer #3: Yes:  Abera Cheru

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PONE-D-24-55215.docx

Attachment

Submitted filename: R Comment.docx

PONE-D-24-55215R1Effects of school menstrual hygiene management, water, sanitation and hygiene interventions on girls’ empowerment, health and educational outcomes: Lasta District, Amhara Regional State, EthiopiaPLOS ONE

Dear Dr. Andargie,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Reviewers 1 and 3 have some remaining minor comments that need to be addressed. Please submit your revised manuscript by Apr 13 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Alison Parker

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have done a great job. They need to work on the new comments and the grammer to be able to submit a qualityy paper

Reviewer #2: (No Response)

Reviewer #3: The author's well-responded for almost all comments, but still, the authors should make the measurement measures of confounding variables precise "from lines 337-366". The author should also remove the female variable entirely from table 1 with its frequency and percent; it is clear on the title as the study was conducted on girls

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: Yes:  Balem Demtsu Betsu

Reviewer #3: Yes:  Abera Cheru

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PONE-D-24-55215_R1 (1).docx

Effects of school menstrual hygiene management, water, sanitation and hygiene interventions on girls’ empowerment, health and educational outcomes: Lasta District, Amhara Regional State, Ethiopia

PONE-D-24-55215R2

Dear Dr. Andargie,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Alison Parker

Academic Editor

PLOS ONE

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