Associations of menstrual health with school absenteeism and educational performance among Ugandan secondary school students: A longitudinal study

PLOS ONE

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PLOS ONE

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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?

Reviewer #1: Partly

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Partly

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: N/A

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #1: The paper lacks clarity from the statistical perspective. The statistical strategy is poorly presented in this study. Section 10 of the supplemental protocol is well written with sample size justification and various analysis options per endpoints discussed.

When one starts reading the paper, the design and parallel arms not even introduced in the Abstract. One has to wait until section 2.2 and the investigators finally state that the trial was a parallel-arm, cluster-randomized controlled trial in 60 schools with schools randomized 1:1 to either immediate or delayed intervention delivery.

1. What is the control arm mentioned in the abstract?

2. Also, the actual longitudinal input is not clear to the reader. Please relate immediate, delayed, and endline in a longitudinal context with respect to Figure 1.

3. In the Conclusion the authors note that among Ugandan students, multiple dimensions of menstrual health are associated with school absenteeism and educational performance. Where is the analysis of immediate or delayed intervention or is that not part of this report?

4 It looks like Tables 2 to 4 are baseline and Table 5 are endline results from the longitudinal approach? Is that correct?

5. Some sentences are vague. For example ,please explain line 292, ’ After adjusting for factors at the same or more distal levels, there was strong evidence that menstrual-related absenteeism and poorer examination performance were both associated…etc’. What does 'distal level' mean? Please be exact when you mention adjustment throughout the presentation.

6. The entire presentation has to be edited for organization and clarity.

Reviewer #2: 1. Abstract

• Clearly explain how factors such as inadequate menstrual materials, negative attitudes toward menstruation, unmet menstrual practice needs, and experiences of menstrual teasing influence educational performance, not just absenteeism. Also clarify what is meant by “multiple dimensions of menstrual health” and how these are associated with both absenteeism and educational performance(may be in the body).

• Article type: Why is this described as a clinical trial? Since the study used secondary data and so sign of any medical test. Please justify the article type or indicate this clearly in the methods section.

2. Introduction

• Citations: Use square brackets for in-text citations instead of parentheses, to maintain consistency with journal style.

• Objective: Ensure the objective gives equal emphasis to both class absenteeism and educational performance. This balance appears lacking in the last part of the introduction.

• MENISCUS: Define this acronym (e.g., “MENISCUS stands for...”) before using it, to help readers unfamiliar with the term.

3. Methods

• Government vs private schools: What was the purpose of sampling both government and private schools if the outcomes are not contrasted by school type? Please clarify.

• Interventions: Specify the interventions received by the treatment schools versus what the control schools received. One of the selection criteria mentioned was the presence of WASH services, suggesting there might not have been an intervention. Please clarify this point. If there were interventions, how they were managed and how frequent they were?

• Quality control: What methods were employed to minimize recall bias in reporting class absenteeism?

• If the main results of MENISCUS have already been published, what new insights does this data analysis provide? Clearly, highlight the novel contributions/how different is this finding?

• Why did you use both cross-sectional and longitudinal designs? Are there sufficient indicators that support the longitudinal approach? It seems data were collected only at baseline, end line, and through student self-reports, with no evidence of continuous data collection.

4. Results

• Findings on the effects of menstrual health on educational performance are limited and not strongly demonstrated. Consider discussing this limitation.

General comments

• Clearly distinguish between this study and the original MENISCUS study to avoid confusion.

• Explicitly state the specific menstrual-related factors analyzed, instead of repeatedly using the vague term “multiple dimensions.” This will make your findings clearer and more impactful.

• Follow PLOS ONE reference format

Reviewer #3: The authours have presented an intelligble fashion and the grammar is standard. The author should look at the punctuation and the tenses. The methodolgy is okay and the it is technically sound. The authour should avoid being too wordy. Some paragraphs are too long. He should make them brief and to the point.

Reviewer #4: Abstract

Overall the abstract needs a bit of work, context and clarification. Please provide a very brief (understanding the tight word count) description of the intervention in the methods (or background) to help orient the reader.

39: Do you mean “we analysed baseline and endline data”?

The results section needs tailoring.

47: At baseline 3312 participants reported menstruating in the last 6 months.

3312 of how many? Or are you trying to say that your sample was the 3312 participants who reported menstruating in the last 6 months. Please clarify or consider revising: “Of the 3312 participants who reported menstruating in the past 6-months at baseline, 323 (9.8%) reported missing at least one day of school per month due to menstruation.”

49: 1286 (38.8%) missed at least one day a month for any reason.

Is this relevant? Is this key to be reported in the abstract? Without context it lacks definition of why it is relevant.

50: Of the 1192 participants in the control arm seen at endline, 135 (11.3%) missed at 51 least one day due to menstruation

Why is the control endline reported, and not the intervention arm endline? I don’t understand the relevance of reporting the control endline school absenteeism without the intervention data. What are you trying to say here? Can you add some clarifying text or otherwise provide some other data to clarify why this has been reported.

53: associated with multiple dimensions of menstrual health

Multiple dimensions of poor menstrual health. The bracketed examples are the inverse of the dimensions on the conceptual model (described later). Potentially refer to the model here, saying “as per a conceptual model described in the paper” - or something to orient a reader who is not familiar with the model. Another way might be to use the phrasing as per the introduction “aspects of menstrual experience”. Perhaps instead of brackets, change to such as...

55: Menstrual teasing

Please use term menstrual-related teasing. “Menstrual teasing” is not correct (and not used consistently throughout paper). Note: Line 306: “menstrual teasing” and Line 324 should be edited for consistency.

Introduction

71: A widely-cited statistic that “one in 10 school-age girls in Africa misses school or drops out for reasons related to her period” is not evidence-based (3, 4).

I get what you are trying to say here, but it reads strangely to me. Consider rephrasing. “One in ten school-age girls in Africa missed school or drops out for reasons related to her period” is a widely –cited statistic that lacks scientific backing.

74: Consider: drop female – redundant. An average of 31%?

75: Edit: Far too long sentence. Use full-stop after longer duration, then begin sentence with Additionally, the review found menstruation also affected...

89: Consider changing knowledge to evidence or data.

96: LMICs

99: Change to: ...with academic performance a reported consequence of menstruation, mainly due to menstrual pain or heavy menstrual bleeding.

102: Broader educational issues are written here as self-esteem, school participation, and educational performance.

How is educational performance difference from academic performance? Above has been discussing academic performance, please clarify how or if educational performance is different and thus belongs to “broader educational issues.”

102/103: Should this sentence: “In the review among university students...”come above the sentence “There is relatively little and inconclusive evidence..” Im confused as to why this sentence separates the following comment on the review. Please edit or justify.

109: You introduce us to: “Our recent cluster-randomised trial” is this the same cluster-randomised trail described in the methods? Aka the MENISCUS? If so, introduce it here not below. Please clarify or change the use of “our.” This is confusing.

111: Add: showed strong evidence of an intervention effect on multiple dimensions of menstrual health, such as....

Please detail what dimensions were effected, considering below you say little on school absence and nothing on examination performance, or school absence overall.

Additionally, is examination performace to be understood as different to academic performance, or educational performance. Please standardize or define.

117- 121: I suggest moving this last introductory paragraph to the top of the introduction to orient the reader and introduce MENISCUS.

After the first sentence introducing the MENISCUS trial, please provide a brief line to describe what the trial is.

The last sentence in this paragraph has a typo. Do you mean “add to the knowledge-base" or “add to the existing evidence on the impact of..”

I would also advise revising the sentence to read: “based on the impact of multiple dimensions of menstrual health..” or “based on the impact of menstruation..”

Methods

124: Add “The MENSISCUS trial/study”

132: Be consistent with abstract ie: baseline and endline.

132: This should not be the first time you are spelling out the acronym for MENISCUS. Please introduce in the introduction as suggested and spell out on first use.

142-143: Decapitalise Education Institutions

143-148: This sentence is too long. Full-stop at 146 and then start sentence with “School enrolment was to be estimated as....”

148: When you say “we” here, I am confused if you are talking about MENISCUS or your analysis of the trial? There needs to be clearer description of how what you are doing is related to MENISCUS and if you referring to it as “yours” etc.

151: Provide explanation of Secondary 2 in parenthesis as above for School 1.

166-167: Decapitalise subject names (Mathematics, Biology, English Language) (English remains capitalised- but not language)

187: Different reference style

188: Here you use the term “Menstrual-related factors”. I am wondering if you mean the same when you talk about “dimensions of menstrual health or “aspects of menstrual experience.”

If so, could you please choose one, define it and standardize throughout the paper.

190: Delete full-stop after confounders.

198: See 188

Results:

242: Describe/contextualise MPSN score. Is 2.11positive/negative?

Discussion:

355: “These results add..”

365: Support – remove s

378: Sentence need clarification - “but reported that other girls were absent from school due to menstruation” or “but reported that other girls reported absenteeism”?

381-382: Perhaps belongs in strengths and limitations

386: Suggest without adequate (not with inadequate).

392: Menstrual preparedness. Where is this definition of menstrual preparedness from? I don't see obtaining, using, cleaning and disposing of menstrual products and seeking assistance when needed as menstrual preparedness.

Menstrual preparedness is yes about tracking cycle and body literacy. Or pre-menarche about prior knowledge, education and support.

Reviewer #5: This is an automated report for PONE-D-25-29440. This report was solicited by the PLOS One editorial team and provided by ScreenIT.

ScreenIT is an independent group of scientists developing automated tools that analyze academic papers. A set of automated tools screened your submitted manuscript and provided the report below. Each tool was created by your academic colleagues with the goal of helping authors. The tools look for factors that are important for transparency, rigor and reproducibility, and we hope that the report might help you to improve reporting in your manuscript. Within the report you will find links to more information about the items that the tools check. These links include helpful papers, websites, or videos that explain why the item is important. While our screening tools aim to improve and maintain quality standards they may, on occasion, miss nuances specific to your study type or flag something incorrectly. Each tool has limitations that are described on the ScreenIT website. The tools screen the main file for the paper; they are not able to screen supplements stored in separate files. Please note that the Academic Editor had access to these comments while making a decision on your manuscript. The Academic Editor may ask that issues flagged in this report be addressed. If you would like to provide feedback on the ScreenIT tool, please email the team at ScreenIt@bih-charite.de. If you have questions or concerns about the review process, please contact the PLOS One office at plosone@plos.org.

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Reviewer #1: No

Reviewer #2: Yes: Andargie Fisseha

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

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Attachments

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Submitted filename: Reviewer comments.docx

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Submitted filename: PONE-D-25-29440.EAO 14JUL2025docx.docx

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Submitted filename: report_10.1101+2025.06.03.25328933.pdf

Dear Dr. Baleke,

• There are a few more minor comments from reviewer 3 to address.

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 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

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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??>

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: N/A

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

The PLOS Data policy

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Changing the format to prospective and not longitudinal helped. New Figure 2 added to the clarity. Explanations and revisions were noted by the track changes.

Reviewer #2:  I have gone through the comments I provided to the authors' during the first review and therefore, I have found that the author's have addressed the comments adequately.

Reviewer #3:  The grammatical errors that I sited have been addressed. The author can make the paragraphs brief and cite appropriately

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Reviewer #1: No

Reviewer #2: Yes: Fisseha Atale

Reviewer #3: No

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Submitted filename: Reviewers comments.docx

Associations of menstrual health with school absenteeism and examination performance among Ugandan secondary school students: A prospective study

PONE-D-25-29440R2

Dear Dr. Baleke,

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.

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Academic Editor

PLOS ONE

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