Filters used: English language, Human
We imported the identified, eligible studies into EndNote version X5, a specific software program for managing bibliographic data. Two independent researchers reviewed the data to double-check the title and abstracts against the eligibility criteria. Studies that the two reviewers agreed upon were subjected to full-text review. Any dispute was settled by a third reviewer and consensus was sought by discussion. Full-text articles of the potentially relevant studies were then screened for the final inclusion if they met eligibility criteria.
A data extraction spreadsheet was prepared, and two reviewers extracted data manually. The spreadsheet was populated with the variables pertaining to the research question. From each study the following data were extracted; 1) Author name, 2) Year of publication, 3) Location, 4) Study design, 5) Population, 6) Sample size, 7) Duration of intervention, 8) Outcome measurement time, 9) Description of intervention, 10) Mode of intervention, and 11) Outcome of interest.
Two authors assessed the retrieved articles for quality and potential risk of bias using the Joanna Briggs Institute (JBI) critical appraisal assessment tools for Randomized Controlled Trials and Quasi-Experimental Studies/non-randomized experimental studies [ 40 ]. The studies that scored above half of the scored value of the tools were considered for minimum risk of bias and included in the review.
We summarized data using tables, and narrative synthesis to include the type of intervention performed, characteristics of the target population, type of outcome, and a summary of the findings.
Sixteen trial studies that assessed the effect of menstrual hygiene management interventions on schoolgirls’ attendance, school performance, and school dropout, as well as emotional wellbeing and menstrual hygiene knowledge, attitudes, and practices were reviewed. This included 15 peer-reviewed articles and one article in the gray literature ( S1 Fig ). The studies represented a total of 17, 910 schoolgirls, 4,612 mothers, and 4,500 fathers/guardians from Ethiopia, Kenya, Nigeria, Ghana, Uganda, Iran, Nepal, Bangladesh, and Indonesia. The studies analyzed schoolgirls aged 9 to 25 years with a sample size that ranged from 60–8,839. The studies involved menstruating, pre-menarchal, and dysmenorrhea-affected schoolgirls, as well as parents ( Table 2 ).
Author name, year, and location | Study design | Population (P)and Sample size (SS) | Duration of intervention (DOI) and Outcome measurement time (OMT) | Intervention Description (DI) and mode of intervention (MOI) | Outcome of interest |
---|---|---|---|---|---|
Abedian et al. 2011 Mashhad, Iran [ ] | Randomized controlled trial | 19–25-year-old Dysmenorrheic University girls Planed SS: 209 Actual SS: 165 (Peer-led education group n = 54; Health provider-led education group n = 50; Control group n = 61) | At baseline and two consecutive menstrual cycles (approximated to two months) Immediately after intervention | : self-care education Arm 1: received health provider-led self-care education Arm 2: received peer-led self-care education : Small group discussions about self-care education held by health providers and peer educators | • The mean score of menstrual knowledge significantly increased in both groups compared to the control group (the peer-led self-care group increased by 2.1 times and health-provider 2.5 times) • Negative concepts of mean menstrual attitude decreased in the peer-led self-care education group (56.6 vs. 40.2, p = 0.009) more than the health-provider-led self-care education group (56.9 vs. 48.3, p = 0.035). • The severity of dysmenorrhea decreased between the intervention arms and control arm but not significantly between the intervention groups |
Agbede et al. 2021 Ogun State, Nigeria [ ] | Quasi-experimental | 10–19-year-old rural school adolescent girls : 120 (30 in each of 4 study arms) | 4 weeks (number and length of sessions not indicated) Immediately post-intervention (at 4 weeks) and 6 weeks follow-up | Health education related to menstrual hygiene practice • Arm 1: peer-led education intervention • Arm 2: parent-led intervention • Arm 3: a combination of both • Arm 4: Placebo | Menstrual hygiene practices of the three intervention arms have significantly improved both in the 4 (immediate post-intervention) and in the 6 week follow-up. • While the third arm (combination of peer and parent recorded the highest mean score of practice |
Austrian et al. 2019 Kenya [ ] | Cluster-randomized controlled trial (With Four arms) | 10–21-year-old girls : 3,276 schoolgirls | : 25 sessions each lasting for 65–95 minutes for 18 months(Weekly in 2017 and every two weeks in 2018) after 18 months (immediately after completion of the intervention) | Arm 1: No intervention Arm 2: Disposable sanitary pad Arm 3: Reproductive health education Arm 4: sanitary pad and reproductive health education The sanitary pad and education include: one pack of Nia Teen disposable sanitary pads distributed monthly with pairs of underwear provided once per term The reproductive health education includes puberty, gender, gender, power, and rights, being true to yourself : Trained facilitators provided facilitated health education (FHE) and distribution of health magazine developed by ZanaAfrica based on the UNESCO International Technical Guidance on Sexuality Education incorporating gender and power in sexuality and HIV education | • Provision of Pads improved menstrual hygiene management • RH education led to improved SRH knowledge, self-efficacy, gender norms, and attitudes toward menstruation • The combined intervention had stronger impacts on reducing shame/stigma around menstruation • None of the interventions had an impact on education outcomes like school attendance and enrolment for the subsequent grade |
Babapour et al. 2022 Sari, northern Iran [ ] | Quasi-experimental non-randomized controlled trial | 11th-grade single students with regular menstruation (30 in each of the three arms) | Six, one-hour sessions twice a week in WhatsApp messenger. Not indicated | : The education sessions included: menstruation and menstrual disorders including PMS and measures to alleviate, life skills, female reproductive system • Arm 1: received education from peers • Arm 2: received education from a healthcare provider • Arm 3: is the control group • Education is held using WhatsApp messenger • All three groups received routine school counseling. • Education providers individually uploaded a pre-prepared audio files with the related PowerPoint file in each session and allowed participants to ask questions. At the end of each session, the healthcare provider/peer asked questions about the topics and motivated to participate in the discussion. | Premenstrual syndrome (PMS) • PMS score decreased in the intervention groups compared to the control group. • The effect size in the education by a health care provider group (Partial Eta Squared = 0.82, p < 0.0001) was more than the education by peers’ group (Partial Eta Squared = 0.67, p < 0.0001). : General health and premenstrual dysphoric disorder • The mean score of general health (a measure of emotional distress) significantly decreased in the education group by peers (Cohen’s d = 0.25, p<0.0001) and education by health care provider group Cohen’sd = 0.37, p<0.0001) compared with the control group. • The intervention did not significantly reduce the frequency of premenstrual dysphoric disorder among the two intervention groups as compared to the control group (p>0.050). |
Belay et al. 2020 Tigray Ethiopia [ ] | Quasi-experimental | Grade 7–12 students 8,839 Students in 15 intervention schools | : one academic year immediately post-intervention | Menstrual education provided to boys and girls • Girls were provided with menstrual hygiene kits containing four locally produced, reusable menstrual pads and two pairs of underwear. : School-based distribution of a booklet called Growth and Changes, written in English and Tigrinya (the local language). • Students are encouraged to take the booklet home with them to share with their families. • Additional oral instruction was provided on-site by project staff from Mekelle University • Interactive question-and-answer sessions • Distribution of 12 211 pamphlets • Distribution of menstrual kit • Demonstration of how to use sanitary pads for girls | Girls had 24% fewer absences as compared to the control arm during the post-intervention period. |
Blake et al. 2017; Oromia Ethiopia [ ] | Cluster-randomized study triangulated with a qualitative approach | Grade 6 &7 schoolgirls 636 | Puberty book provided to the girls for 4 weeks Four weeks after the distribution of the book (no follow-up in between) | The Ethiopian version of the girl’s puberty book Growth and Changes. The book targeted girls aged 10 to 14 years, covering puberty education, menstruation and menstrual hygiene management; and culturally tailored stories. Book delivered to the study participants to read them. | The intervention had a positive effect on: • The girls’ knowledge about menstruation with effect size of 0.6 (medium effect size • Post-intervention, girls in the intervention group were less likely to indicate that they felt fear regarding menstruation (OR = 0.70, 95% CI = [0.51, 0.95]) or shame (OR = 0.61, 95% CI = [0.38, 0.96]) than girls in the control group. |
Fakhri et al. 2013 Mazandaran province, Iran [ ] | Quasi-experimental (Non-randomized controlled cluster trial | 14 -18-year-old-girls with low socio-economic status from urban and rural public high schools 689 (349 intervention group and 349 control group) | : (20 hrs.) 10 sessions of 2 hr. each (Not indicated for how long) At the end of the education intervention | • Training about: • personal health and hygiene during Menstruation• Significance of adolescence, physical and emotional changes during adolescence,• Pubertal and menstruation health and premenstrual syndrome : Intervention provided by the Youth and School Health Department to the intervention arm | • especially bathing and genital hygiene improved (61.6% in the experimental group compared with 49.3% in the control group engaged in usual bathing during menstruation (p = 0.002)) • was also significantly related to menstrual health. |
Nyadoy et al. 2022 Uganda [ ] | Randomized Controlled Trial | primary school adolescent girls who reached menarche 60 (30 control and 30 intervention group | One-hour session twice a week, after classes for six weeks Outcome assessed immediately after the intervention ended | Menstrual health management storying and gamification : Storying involved Senior Women Teachers and other invited role models sharing stories about the facts and myths of menstruation and menstrual hygiene management. The games involved competitive ball games such as soccer, netball, and rope work | • Girls in the treatment group (t = 8.498, df = 29, p < .05) obtained significantly higher scores (in four courses, English language, Mathematics, Integrated Science, and Social Studies) than those in the control group • The experiment group reported positive attitudes and expressed feelings of liberation from fear of boys during menstruation, |
Oster et al. 2011 Chitwan District, Nepal [ ] | Randomized controlled trial | Grade 7 and 8 schoolgirls (25 girls assigned to treatment group from each school) 198 | : One school-year intervention Outcome assessed immediately after the intervention | Menstrual cup branded as Moon-cup Treatment girls and their mothers were provided with menstrual cups and instructions on how to use them. Girls were provided with a booklet of time diaries that included a menstrual calendar on which they were to note the start and end date of their period in each month. | The menstrual cup does not significantly increase school attendance |
Paul Montgomery 2012 Ghana [ ] | Non-randomized- controlled trial | 12–18-year-old schoolgirls 120 | Five months : At the third and fifth month (at the end of the intervention) | Provision of one pair of underwear and twelve pads per month for the duration of the study with instruction and demonstrations on how to use and dispose of the sanitary pads.Puberty educational about the development of secondary sex characteristics, menstruation, pregnancy, hygiene, and menses managementArm-1: Pads + puberty educationArm-2: Puberty educationArm-3: Control ➢ Trained research assistants provided puberty education ➢ All participants received a daily calendar, pencil, and sharpener to record their menstrual cycles | (pad + education): school attendance improved significantly among participants, (lambda 0.824, F = 3.760, p, .001) education only resulted in a similar school attendance level (M = 91.26, SD = 7.82) all of which were higher than control (M = 84.48, SD = 12.39). The effect size, partial eta-squared, was 0.094. |
Paul Montgomery et al. 2016 Uganda [ ] | Cluster Quasi-Randomized Controlled Trial | Grade 3–5 schoolgirls 356 pre and post-menarcheal girls) from 8 rural schools | Single session of puberty education and two times of pad distribution and soap (one sachet, 45gram (18 months apart) The education session lasted for 1.25hrs : two years later | provision of reusable pad and Puberty education about menstruation, early pregnancy, life skills, prevention of HIV, strategies for avoiding sexual assault, healthy relationships, and friendship formation and goal setting. puberty education provided with reusable pad 3 pairs of underwear, one sachet, and 45 grams of soap with which to wash the pads. puberty education and reusable sanitary pad A control condition | • Control schools had 17.1% (95%CI: 8.7–25.5) greater drop in school attendance than those in any intervention school • No psychosocial change was observed among the study arms |
Phillips-Howard et al. 2016 Gem District Kenya [ ] | Cluster randomized controlled feasibility study open-level RCT | : 14–16 years old girls (with no precluding disability) who experience at least three menses : 3165 (644 analyzed) from 30 rural primary schools | 15 months at the end of the follow-up (intervention) | Girls in all arms received puberty and hygiene training; hand-washing soap; and pencils for calendar completion. received one menstrual cup with written and verbal instructions on how to insert and clean eceived 16 disposable pads and relevant instructions. Control : Nurses provided menstrual product-specific training from study nurses after enrolment | • Cups or pads did not reduce school dropout (control = 8.0%, cups = 11.2%, pads = 10.2%) • This could not be analyzed because self-reported school absences were very rarely reported. • : Lowered prevalence of C. trachomatis and T. vaginalis but not N. gonorrhea. The greatest impact was among girls who had been exposed to intervention for at least 9 months or 12 months. • Prevalence of all STIs at the end-line survey was 7.7% in the control arm versus 4.3% in the pooled cups +pads arms • : Bacterial vaginosis was lower in the cup arm (not significant), but not in the pad arm. • : No case reported |
Rezaei, et al. 2022 Iran [ ] | Quasi-experimental study | 13–16- year-old high school students and their mothers : 111 (56 students and 55 mothers) : 112 (58 students and 57 mothers) | Not indicated : Immediately after intervention and three months later | Educational intervention based on the PRECEDE model provided. Adolescence, puberty, menstrual cycle, abnormal signs, and common problems associated with menstruation, menstrual health, exercise, nutrition, mobility, and pain control in menstruation The education was provided in 3 sessions of two hours each using lecture, face-to-face discussion, and question/answer methods for students and mothers in the intervention arm | • The mean score of menstrual health behavior was significantly higher in the intervention group than in the control group, immediately (P < 0.001), and three months after intervention (P = 0.02) • Mothers’ knowledge, attitude, and practice regarding menstrual health behaviors were significant reinforcing factors among the intervention group compared to the control group |
Setyowati et al.2019 Indonesia [ ] | quasi-experimental pre and post-test with a control group design | 9-12-year-old schoolgirls who had not yet experienced menarche 174 girls | : Not indicated Not indicated | Booklet containing information about preparation for menarche, reproductive organs, physical changes during adolescence, problems during menstruation and how to deal with it, and menstrual hygiene : Distribution of booklet to the intervention group | • Increased menstrual knowledge (OR = 45.1; 95% CI: 13.8–148.1) • Positive emotional response (OR = 12.7; 95% CI: 5.6–28.5) • Positive attitude towards menstruation (OR = 12.4; 95% CI: 5.8–26.6) |
Sol et al. 2017 Bangladesh [ ] | Cluster randomized impact evaluation | Junior secondary school girls planned SS: 3862 girls Actual SS: 2127 (595 treatment-1, 570, treatment-2 and 962 control group) 4,500 mothers/guardians and 4,500 fathers/guardians attended the Household education sessions | At least twice a month from 2017–2019 Two years later (after the intervention) | Construction and maintenance of menstrual health-friendly toilet facilities at school. Incorporating puberty- and menstrual health modules in the school curriculum,A 2-day session to increase menstrual health knowledge and understanding of the benefits of safe menstrual hygiene was produced for parents /guardians schools receiving a school program schools receiving a school program combined with a targeted household program (‘combined program’) control schools An extensive campaign to familiarize teachers, students, and parents, next to festivities, Group discussions, essay writing competitions, and screening of a TV-shows and extracurricular activities | educational outcomes, psychosocial outcomes, and empowerment of adolescent girls. • Absence rates in treatment schools are significantly lower than in the control schools (no significant difference between the school program and combined program schools) • School dropout was reduced in both treatment groups as compared to controls : • Increase in the knowledge of girls about menstruation and menstrual health (on both treatment arms • Lowered restrictive beliefs surrounding the mobility of girls on their menses. (On both treatment arms) • More likely to get permission to go to the toilet when they ask their teacher • No treatment effects on teasing during menstruation |
Wilson et al. 2014 Rural Kenya [ ] | Cluster randomized control | Schoolgirls 302 (143 intervention and 159 control) | One session : One month after intervention | Training on how to make a reusable sanitary pad and provision of equipment to make three reusable pads. • rovide printed hand-out, as a reminder on how to make the pad and instructions about washing and drying, risk of infection or irritation of damp or poorly washed pad; with suggested ways to dry the pad outside and avoid embarrassment. • Did not include general menstrual health education to evaluate the mere effect of pad use : training and provision of handout | • The mean number of days of school missed decreased or stayed constant among the treatment group while schools in the control group either stayed constant or increased |
The menstrual education components of the studies included puberty education, training on making reusable pads, distribution of books, magazines, posters, pamphlets, and menstrual calendars, as well as the incorporation of menstrual health topics into the school curriculum. Information was also shared through WhatsApp, face-to-face discussions, TV shows, festivals, essay competitions, storytelling, gamification, and question-and-answer sessions. These interventions were provided by trained individuals, including trained peer educators, teachers, research assistants, healthcare providers, and parents [ 31 , 32 , 34 , 35 , 41 , 42 , 44 – 46 , 49 – 52 ]. The menstrual supply interventions included the provision of disposable and reusable pads, underwear, menstrual cups, soap, or detergent to wash menstrual pads, and the installation or improvement of water, sanitation, and hygiene (WASH) facilities ( Table 2 ).
The reported trials evaluated several outcomes of interest, including school attendance, school dropout, and academic performance, as well as menstrual hygiene knowledge, attitudes, and practices, physical health, and emotional health including menstruation-related fear, shame, and stigma, as well as social attitudes regarding expected gender-related behavior (gender norms). Montgomery et al. suggested using school attendance and dropout rates as a proxy indicator of academic performance [ 32 ]. Some trials relied on self-reported/recorded attendance, which may have introduced recall bias, while others cross-checked attendance records [ 32 , 35 , 48 , 51 ] (Tables (Tables3 3 and and4). 4 ). The trial by Sol et al. cross-checked attendance of the school record with survey data using spot checks [ 50 ]. Official school attendance records were supplemented by individual diaries filled out by the schoolgirls in one of the trials [ 34 ]. Moreover, despite the presence of a standardized menstrual attitude questionnaire that can be validated contextually [ 53 ], some trials used non-standardized evaluation tools developed by specific researchers [ 31 , 42 , 45 , 52 ]. Causation is difficult to determine in some studies because the sample size was quite small [as few as 60 participants [ 46 ]].
JBI Critical Appraisal Checklist for Quasi-Experimental Studies | Agbede CO 2021 | Babapour et al. 2022 | Belay et al. 2020 | Chiou et al 2007 | Darabi 2022 | Fakhri 2012 | Paul Montgomery 2012 | Paul Montgomery et al 2016 | Rezaei 2022 | Scott 2009 | Setyowati et al. 2019 | Yilmaz 2019 |
---|---|---|---|---|---|---|---|---|---|---|---|---|
1. Is it clear in the study what is the “cause” and what is the “effect” (i.e., there is no confusion about which variable comes first)? | Yes | Yes | Yes | No | Yes | Yes | No | Yes | Yes | No | Yes | Yes |
2. Were the participants included in any comparisons similar? | Yes | Un | Yes | Yes | Un | Yes | Yes | Yes | Yes | Un | Yes | No |
3. Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? | Un | Yes | Un | No | Un | Yes | Yes | Yes | Yes | Yes | Yes | Un |
4. Was there a control group? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
5. Were there multiple measurements of the outcome both pre and post-intervention/exposure? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | No |
6. Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed? | Yes | Yes | Un | Un | Un | Un | No | Yes | Un | Un | Un | Un |
7. Were the outcomes of participants included in any comparisons measured in the same way? | Yes | Yes | Yes | Yes | Un | Yes | Yes | Yes | Yes | Yes | Yes | Un |
8. Were outcomes measured in a reliable way? | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Un | Yes | Yes |
9. Was appropriate statistical analysis used? | Un | Yes | Yes | Un | Un | Yes | Un | Yes | Yes | Un | Yes | Yes |
7 | 8 | 7 | 4 | 4 | 8 | 6 | 9 | 8 | 4 | 8 | 4 |
JBI Critical Appraisal Checklist for RCT | Abedian et al. 2011 | Alexander et al. 2018 | Austrian et al. 2019 | Blake et al. 2017 | Djalalinia 2012 | Kokiwar 2020 | Mbizvo 1997 | Mohammadzadeh et al 2002 | Nyadoy et al. 2022 | Oster 2011 | Phillips-Howard 2016 | Sol et al. 2017 | Wilson, et al. 2014 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1. Was true randomization used for the assignment of participants to treatment groups? | Yes | Yes | Yes | Yes | Yes | Yes | No | Yes | Yes | Yes | Yes | Yes | Yes |
2. Was allocation to treatment groups concealed? | Un | Un | Un | Un | Un | Un | Un | Un | Un | Un | No | Un | No |
3. Were treatment groups similar at the baseline? | Yes | No | Yes | Un | Yes | Un | No | Yes | Yes | Yes | Yes | Yes | Yes |
4. Were participants blind to treatment assignment? | Un | Un | Un | No | Un | Un | Un | Un | Un | Un | No | Un | No |
5. Were those delivering treatment blind to treatment assignment? | Un | No | No | No | Un | No | Un | Un | Un | No | No | Un | Un |
6. Were outcomes assessors blind to treatment assignment? | Un | Un | No | Un | Un | Un | Un | No | Un | No | Yes | Un | No |
7. Were treatment groups treated identically other than the intervention of interest? | Yes | Yes | Yes | Yes | Un | Un | Yes | Un | Yes | Yes | Yes | Yes | Yes |
8. Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed? | Un | Un | Un | Yes | Un | No | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
9. Were participants analyzed in the groups to which they were randomized? | Yes | Yes | Yes | Yes | Un | No | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
10. Were outcomes measured in the same way for treatment groups? | Yes | Un | Yes | Yes | Un | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
11. Were outcomes measured in a reliable way? | Yes | Yes | Yes | Un | Un | No | No | Yes | Yes | Yes | Yes | Yes | Yes |
12. Was appropriate statistical analysis used? | Yes | Yes | Yes | Yes | Un | Yes | No | Un | Yes | Un | Yes | Yes | Yes |
13. Was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial? | Yes | Yes | Yes | Yes | Un | Yes | Yes | Un | Yes | Yes | Yes | Yes | Yes |
8 | 6 | 8 | 7 | 2 | 4 | 5 | 6 | 9 | 8 | 10 | 9 | 9 |
Montgomery et al. carried out a study on peri-urban schools that were comparable, but they also incorporated a remote rural site lacking experience in using sanitary pads, with no access to electricity and unpaved roads. This may have affected baseline similarity and intervention fidelity, making it harder to determine the intervention’s actual effects [ 32 ]. In some studies, only a single-session educational intervention was provided, and only half of the girls attended the educational session in the study by Montgomery et al. [ 47 , 51 ]. Some studies did not provide information on the follow-up or dropout rates among the study groups [ 31 , 35 , 41 , 43 , 49 ], while others achieved a statistically significant improvement in school attendance and school performance using small sample sizes [ 32 , 46 ]. Blinding with respect to outcomes is crucial in reducing bias in experimental studies, but it is sometimes impractical to blind study participants, intervention providers, and assessors. This may lead to exaggerated intervention-effect estimates and performance bias [ 54 ]. Despite this, there are ongoing controversies concerning the advantage of blinding in clinical trials [ 55 – 57 ]. Outcome assessors, laboratory staff, and statisticians were blinded in only two trials [ 48 , 50 ].
Schoolgirls’ school attendance, performance, and dropout.
Of the trials that evaluated the effect of menstrual hygiene management interventions on school attendance, performance, and dropout, six studies reported that the intervention had a positive effect [ 32 , 35 , 46 , 47 , 50 , 51 ] while the remaining three studies found no significant effect [ 34 , 43 , 48 ].
Implementing pad and education interventions together increased school attendance by almost 6 days per term, equivalent to 9% of a girls’ school year. The study also showed that puberty education alone improved school attendance levels five months after intervention [ 32 ].
Belay et al. carried out an intervention at 15 schools (5 rural and 10 urban) involving 8,839 students, both male and female. All students received an educational intervention concerning menstruation and the female students also received four reusable pads and two pairs of regular underwear. School attendance was analyzed before and after the intervention and compared with attendance data from the prior school year. After the intervention, girls had 24% fewer school absences than boys and student sex was not a predictor of school absence during a similar time period during the previous academic year [ 35 ]. In another study, providing reusable pads, soap, and puberty education; training on making reusable sanitary pads and providing the equipment necessary to make pads resulted in decreased school absenteeism compared to controls [ 47 ].
School and household-based menstrual hygiene management interventions implemented in 148 schools involving 2,127 schoolgirls showed reduced school absences and dropout rates. The interventions included the integration of menstrual health education into the school curriculum and building/maintaining water, sanitation, and hygiene (WASH) infrastructure at schools. The provision of household interventions to improve parents’ knowledge didn’t show significant differences between the household-based and school-based intervention arms [ 50 ] ( Table 2 ).
On the other hand, three trials showed that school-based interventions did not affect school attendance or dropout. According to Phillips-Howard et al. providing either menstrual pads or cups did not reduce school dropout (control = 8.0%, cups = 11.2%, pads = 10.2%), though the finding should be taken with caution because of a nearly 40% loss-to-follow-up. Likewise, in this study school absenteeism was not analyzed because it was rarely reported [ 48 ]. The trial by Oster et al. found that providing menstrual cups to girls did not significantly increase school attendance [ 34 ]. This is congruent with the study by Austrian et al. that found no significant effect on school attendance after the provision of disposable sanitary pads and reproductive health education [ 43 ] ( Table 2 ).
Studies have shown that both menstrual education and menstrual hygiene supply interventions have a positive effect on menstrual hygiene-related knowledge, attitudes, and practices among schoolgirls ( Table 5 ). These interventions help reduce menstrual-related shame, stigma, fear and also increase self-efficacy and promote open discussion about menstruation [ 31 , 41 – 43 , 45 , 46 , 49 , 50 , 52 ]. In Ethiopia, a trial by Blake et al. found that distributing puberty books to schoolgirls improved their menstrual knowledge and attitudes towards menstruation and reduced menstrual shame and fear [ 45 ]. The interventions had a significant effect on menstrual hygiene management practices such as increasing bathing during menstruation [ 31 , 43 ] ( Table 2 ). The impact of menstrual hygiene interventions on lower genital tract infections was assessed in one trial. Though non-significant, there was a lower prevalence of lower genital tract infections among the pooled menstrual cup plus sanitary pad arms, as compared to non-intervention arms [ 48 ] ( Table 2 ).
Author | Type of intervention | Measured outcomes | |||||||
---|---|---|---|---|---|---|---|---|---|
School attendance | School performance | School dropout | Menstrual knowledge | Menstrual attitude | Menstrual Practice | Emotional wellbeing | Physical health | ||
Abedian et al. 2011 Mashhad, Iran [ ] | Self-care education | ||||||||
Agbede et al 2021 Ogun State, Nigeria [ ] | Health education related to menstrual hygiene practice | ||||||||
Austrian et al. 2019, Kenya [ ] | Disposable sanitary pad; reproductive health education; sanitary pad plus reproductive health education | ||||||||
Babapour et al. 2022 Sari, Northern Iran [ ] | Education delivered by peers and by healthcare provider | ||||||||
Belay et al. 2020 Tigray, Ethiopia [ ] | Provision of menstrual education | ||||||||
Blake et al. 2017 Oromia, Ethiopia [ ] | Delivery of puberty book (Growth and Changes) | ||||||||
Fakhri et al. 2013 Mazandaran province, Iran [ ] | Providing puberty and menstrual education | ||||||||
Nyadoy et al. 2022 Uganda [ ] | Menstrual health management story letting and games | ||||||||
Oster et al. 2011 Chitwan District, Nepal [ ] | Delivering menstrual cup | ||||||||
Paul Montgomery 2012 Ghana [ ] | Delivering disposable pads and puberty education | ||||||||
Paul Montgomery et al. 2016 Uganda [ ] | Provision of reusable pads and puberty education | ||||||||
Phillips-Howard et al. 2016 Gem District, Kenya [ ] | Delivering puberty and hygiene training; hand-washing soap; and pencils for calendar completion | ||||||||
Rezaei, et al. 2022 Iran [ ] | Provision of adolescence, puberty, and menstrual education | ||||||||
Setyowati et al.2019 Indonesia [ ] | Provision of a booklet about preparation for menarche, reproductive organs, and physical changes during adolescence | ||||||||
Sol et al. 2017 Bangladesh [ ] | Construction and maintenance of menstrual health-friendly toilet facilities at school. Incorporating puberty- and menstrual hygiene modules into the school curriculum | ||||||||
Wilson et al. 2014 Rural Kenya [ ] | Training on how to make a reusable sanitary pad and provision of equipment to make three reusable pads |
Key : 0 = No Impact, + = Positive Impact
This review included trial studies that implemented different types of menstrual hygiene management interventions using diverse delivery strategies, different types of intervention providers, and different durations of intervention. School attendance, school performance, school dropout, menstrual hygiene knowledge, attitudes, and practices, and aspects of emotional health related to menstruation such as menstrual stigma and shame were outcomes of interest.
Six trial studies indicated a positive effect of interventions on school attendance, school dropout rates, and schoolgirls’ academic performance [ 32 , 35 , 46 , 47 , 50 , 51 ]. However, most of the studies had low to moderate levels of bias (Tables (Tables3 3 and and4). 4 ). School attendance is usually documented by schoolteachers or by using self-reported diaries, but this method may not provide data accurate enough to reach firm conclusions. In addition, school attendance alone may not be predictive of the academic performance of schoolgirls. Betsu et al. found that a girl’s physical presence in a classroom did not necessarily correlate with her mental presence or paying attention [ 58 ]. Moreover, mood swings and severe premenstrual symptoms resulting from hormonal changes during menstruation impact paying attention [ 59 ]. Additional indicators such as formal educational achievement, school participation, and enrollment in the succeeding grades of school might provide a more robust picture of schoolgirls’ academic achievement and continuing access to education. The trial by Nyadoy et al. showed improved academic scores after telling stories and playing games about menstrual hygiene management in the intervention arm; however, the outcome was measured only 6 weeks after the baseline assessment, and the small sample size makes it difficult to draw firm conclusions [ 46 ].
On the other hand, some studies have found interventions to have no effect, including the studies that evaluate menstrual cups [ 34 , 43 , 48 ]. Despite being a potentially viable intervention, many people falsely believe that menstrual cups can cause loss of virginity and reduced fertility [ 60 ]. Furthermore, menstrual cups may be difficult to clean effectively whenever water supplies are inadequate. This may influence the results of interventions using this device. Studies reporting positive effects, or no intervention effect may suffer from different forms of bias, posing challenges for policymakers and stakeholders looking for evidence-based menstrual hygiene interventions.
The systematic review by Chandra-Mouli et al. highlighted the importance of providing accurate biological information to menstruating girls. In most cases, girls receive most of their information from their mothers, but schoolgirls also seek menstrual information and support from older siblings, and their peers. All of these sources, and particularly their mothers, may be significant sources of menstrual misinformation [ 17 , 58 ]. There is a great need to improve community knowledge of the biology of menstruation, but despite this fact, mothers as a group are generally not targeted for improved education. In most of the studies we reviewed, premenarchal schoolgirls, in particular, receive insufficient education concerning menstruation, leaving them unprepared for the biological changes associated with menarche and contributing to their frustration, bewilderment, and anxiety when menstruation begins [ 61 ].
For schoolgirls to manage menstruation safely and comfortably, they need supportive social norms in the community as well as a welcoming environment both at home and at school. Interventions that improve parental involvement in menstrual hygiene management and that also target community sources of menstrual misinformation are generally lacking in the literature. The study by Sol et al. that engaged parents found a positive effect on menstrual hygiene management and school attendance [ 50 ]. Another study by Agbede et al. looking at the combined effect of peer and parent educational interventions had the highest mean score of menstrual hygiene management practice among its study arms [ 42 ].
Discussing menstruation with male family members (including, and perhaps especially, fathers) is another challenge faced by schoolgirls [ 62 ]. Approximately 13% of Tanzanian girls have encountered period teasing, while over 80% expressed fear of being teased, particularly by male classmates. This results in reduced school attendance, participation, and concentration in class [ 63 ]. Another article exploring the beliefs and attitudes boys and men hold about menstruation revealed that men generally have more negative attitudes towards menstruation and view it as debilitating and requiring secrecy. However, these attitudes may soften as men age and gain more knowledge and experience with menstruation [ 64 ]. Certain religious texts can be interpreted to associate menstruation with impurity and uncleanliness, which leads to menstrual restrictions, shame, and taboos in some cultures [ 65 ]. Many of these challenges are unaddressed by most of the menstrual intervention studies. A qualitative investigation by Betsu et al. indicated that many school teachers support attitudes promoting menstrual secrecy by their comments in class concerning menstrual hygiene, saying things like “drying reusable pads in a hidden place is helpful to prevent Michi , ” a folk-ailment believed by many locals in Ethiopia to be caused by the exposure of used or washed menstrual pads to sunlight [ 58 ]. Those who provide menstrual hygiene education and interventions should be aware of common cultural misperceptions regarding menstruation that exist in their communities. Better training of the teachers who provide classroom instruction concerning menstruation is also needed.
The review has certain limitations. Many of the studies that were included in this review relied on self-reported menstrual knowledge, attitude, and practices, as well as potentially inaccurate school attendance records, which could lead to over- or under-estimation of the findings due to poor recording of school attendance, social desirability bias and recall bias. Most of the studies reviewed did not address the impact of water, sanitation, and hygiene interventions or other community-based interventions on menstrual hygiene management. The review consisted of trials that used different interventions and methods of measuring outcomes and included a wide range of ages (9–25 years). These variations make it challenging to compare the studies with one another and to capture accurately the impact of menstrual hygiene interventions on the outcomes of interest. All relevant studies may not have been captured for this review due to limitations in the search strategies and limiting the studies reviewed to those in English. Most of the literature about menstrual hygiene management, especially in low- and middle-income countries, doesn’t adequately address the needs of people who identify as gender-nonconforming. Since gender-diverse persons make up such a small percentage of the population, it can be assumed that most of the academic literature on MHM is written from the perspective of cis women. This exclusion may affect menstrual hygiene needs and experiences of transgender, non-binary, and other gender-varied individuals [ 66 ]. There was a paucity of randomized controlled trials and quasi-randomized controlled trials, and this may have biased the resulting literature. As a result, conclusions concerning the effectiveness of menstrual hygiene interventions should be interpreted with caution.
The review also has several strengths, providing an extensive summary of English-language evidence. It offers valuable insights by presenting a comprehensive review of English-language trial studies that evaluate the effect of menstrual hygiene management interventions on various aspects of schoolgirls’ lives. With a large sample size from multiple countries, the study covers a broad range of interventions, including puberty education, distribution of menstrual supplies, and integration of menstrual health topics into school curriculums. The findings not only underscore the positive effects of these interventions, such as increased school attendance and enhanced menstrual hygiene knowledge and attitudes but also shed light on the challenges and limitations observed in certain studies. This review will also have a great contribution to identifying research gaps for further studies.
The results of this review have several implications for practice in the field of menstrual hygiene management. It highlights the need for comprehensive and accurate education about menstruation, not only for girls but also for their parents, teachers, and communities. This education should address misconceptions, and cultural taboos, and provide information on appropriate menstrual hygiene practices. This can be implemented by incorporating menstrual hygiene management into school curriculum and training; providing access to affordable and hygienic menstrual products; ensuring adequate water and sanitation facilities and creating supportive environments that reduce stigma and shame associated with menstruation.
The findings of this review have important policy implications. Governments and policymakers should prioritize menstrual hygiene as a public health issue and develop policies and guidelines to meet the needs of menstruating girls including affordable menstrual products, proper hygiene facilities, education about menstruation, and access to healthcare services for managing menstrual health. It is also crucial to address cultural beliefs and misconceptions surrounding menstruation through awareness campaigns and community engagement. Adequate funding should be allocated to ensure the effective implementation and monitoring of these policies to ensure that all girls have access to menstrual hygiene facilities and education.
While this review provides valuable insights into the effectiveness of menstrual hygiene management interventions, there are several areas that require further research. Future studies should aim to overcome the limitations identified in this review, such as biases and small sample sizes. Longitudinal studies with larger sample sizes are needed to assess the long-term impact of menstrual hygiene management interventions on school attendance, academic performance, and emotional well-being. Additionally, more research is needed to explore the effectiveness of different delivery strategies and intervention providers. It would also be beneficial to investigate the cultural and social factors that influence menstrual hygiene practices and develop interventions that address these specific contexts. Overall, future research should focus on generating robust evidence to inform the development of evidence-based interventions and policies in the field of menstrual hygiene management.
Menstrual hygiene management interventions can have a positive impact on schoolgirls’ attendance, reducing dropout rates, and improving their school performance and emotional health. Moreover, such interventions can improve knowledge, attitudes, and practices pertaining to menstruation and its management. A holistic approach that includes accurate menstrual education, better access to hygiene products, improved water, sanitation, and hygiene facilities; and greater engagement of parents, religious and community leaders is likely to make the greatest impact in this area. Of crucial importance is treating all who menstruate with the respect they deserve and reducing the stigmatization and shame that often surrounds this biological process.
It is also important to standardize the interventions used as well as the tools used to measure outcomes if such programs are to be evaluated properly. This will help to identify best practices and improve the overall effectiveness of the menstrual hygiene interventions used. Organizing large randomized clinical trials to address these issues in a well-structured manner would be extremely useful in moving our knowledge forward on how to improve menstrual hygiene among schoolgirls in low- and middle-income countries.
S1 checklist, s1 protocol, funding statement.
The author(s) received no specific funding for this work.
PONE-D-23-35026Menstrual hygiene management interventions and their effects on schoolgirls’ menstrual hygiene experiences in low and middle countries: A systematic reviewPLOS ONE
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Reviewer #1: I would encourage the authors to tighten the piece prior to publication in two ways. First, the nature of the search seems to have translated into several important studies escaping capture as part of the dataset. This is not fatal; it is the nature of the searches the authors chose to run. But I think the authors will want to cabin their conclusions as being only as good as the data the searches yielded, acknowledging that other work that did not fit the authors' relatively narrow criteria were therefore excluded. Second, I think the authors would be well-served to address the linguistic challenges in talking about "women and girls" and "menstrual hygiene," when those terms have been made much more complicated by excellent work in this field. The authors gesture at this by the use of the term "menstruand" (which I found jarring and out of synch with most other scholarship in the field," but they never address the issue head-on.
Reviewer #2: General
Much is written in passive voice – active voice would be preferable. Occasionally you use ‘we’ – you should pick one narrative style and stick to it.
I don’t think it’s necessary to have the acronyms listed since there are only two (unless this is a requirement of the journal then please ignore me). You haven’t included PICOT.
There are times when you spell out MHM and others when you use the acronym – be consistent and use the acronym throughout
The paper should recognise that it isn’t just cisgender women who menstruate but potentially also transgender men, non-binary and other gender diverse persons. The term ‘menstruator’ could be used instead of women and girls to be inclusive.
I think it would be helpful if you stated the countries where studies present different evidence else you might fall into making sweeping generalising comments. For example lines 88-89.
You’ve used WASH as an acronym and spelled out but haven’t introduced it as an acronym – please revise
You could consider adding a positionality statement at the beginning of the paper.
Why were no studies in any Ethiopian languages selected?
‘intervention’ seems like a rather broad keyword
MHM definition – could point out that depending on the materials used somewhere to wash and dry reusable materials is also necessary. Could also mention the access to and ability to wash and dry underwear is also a necessity.
Lines 84-87 its clearer written as: More than half (52 %) of adolescent girls in Ethiopia
have never received any information about menstrual hygiene due to socio-cultural
87 misinformation, religious taboos, and inadequate menstrual supplies and facilities, which leads to fear, confusion, and lack of confidence when menarche occurs (11-15).
Line 93 – what is meant by gender empowerment exactly? Vague phrase it might be interesting to unpack it.
111-112 you use the word review a lot
Good justification for the work.
I wonder if it would produce, more results if you googled gender neutral terms like ‘menstruator’ – it could be written as a limitation if you didn’t do this.
The systematic review following PRISMA is clearly and transparently described. Having three reviewers to judge papers against the outlined eligibility criteria reduces bias.
Line 175 - I don’t think mode of intervention needs an explanation.
The search strategy is well documented and comprehensive
Data bases and other sources of information are specified
The process of study selection is clearly outlined.
The process of data extraction is well documented
The key characteristics of included studies is clearly presented.
The studies were rigorously assessed for risk of bias using the Joanna Briggs Institute critical appraisal assessment tools
Line 192-193 - I think you mean Saudi Arabia, not Saudi Riyadh
From like 251 – have you listed all of the education components because saying they ‘included things such as…’ makes it seem that the list is not exhaustive but it seems to be that way. And perhaps it should be if not too long to include each component.
Line 279 - Good and transparent analysis of intervention fidelity
Interesting discussion on blinding.
Line 305 – et al is repeated
Table 2 and 3 – could we have colour code for severity of bias?
Table 4 – reduce space between lines so table is less spread out – its currently across 13 pages
Table 4 – expand acronyms
Table 5 – I assume the 0 means no impact and + means positive impact but you need to dd this key somewhere. It would be clearer if you also did a colour i.e. green for positive effect , yellow for neutral. It would also look better if the symbols were in the centre of the square. Table 5 – could you add the type of intervention into the summary table and group similar types of intervention together?
370 – was the not paying attention due to hormonal fluctuations or worry and concern about not being able to manage their period?
An important narrative I feel is missing more on which there is a growing body of literature on is the role of men/boys/non-menstruators is upholding stigma/teasing etc. you touch upon this in lines 405-406 but feel some more literature on how non-menstruators act as a barrier could be added in.
407 – careful not to generalise all religious beliefs be specific.
Implications
447-449 – be more specific – state the unmet needs
Seems like the conclusion is the first instance apart from the title where you mention low and middle income countries… why would this not be an issue in high income countries? The United Kingdom is currently going through a cost of living crises where people are in hygiene poverty – unable to buy basic hygiene items like menstrual pads. Ref - https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255001&utm_source=miragenews&utm_medium=miragenews&utm_campaign=news
Furthermore – Saudi Arabia is one of the countries studied, which is a high income country.
Is categorising countries by their economic status quite western and neoliberal?
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Reviewer #2: Yes: Georgia Hales
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17 Jan 2024
To Reviewer 1
• Dear reviewer, the conclusion provided in the manuscript is yielded from the findings (literatures reviewed). The findings evidenced that the interventions can enhance schoolgirls' educational outcomes, and can improve their menstrual knowledge, attitudes, and practices by helping them manage their periods more effectively.
• We used the term “Menstruant” not “menstruand” may be it is editorial error. The use of women and girl is more dominant in WASH sectors. While menstruants is emerging form gender inclusive perspective, hence, in the write up we tried to balance the use of the terms. However our search clearly identified literatures that assessed the effect of menstrual interventions on “school girls”.
To Reviewer 2
Authors’ response
• We have converted passive voice to active voice in most of the relevant sections.
• Acronyms have been spelled out and made consistent in the current version.
• Although "Menstruants" is a gender inclusive term, the primary objective is to assess its effect on “school girls” and we had to be specific to these group of study participants. Moreover, the studies we have reviewed mostly used the term "Schoolgirls," "Girls," and "Women". For this reason, we maintained the terms. However, in the write up section we have also considered “menstruants”
• The findings are form different low and middle income countries, and citation is in place ( line 89)
• The academic and research language for Ethiopia is English. So, there is no study conducted using Ethiopian language and which is not included.
• We have included positionality statement under the method section on the current version (line 128)
“Intervention" is preceded by "menstrual hygiene management" and expressed as “menstrual hygiene management interventions” to be more specific, (lines 27 and 34)
Authors’ Response: Agreed, we utilized the standard definitions, and employing operational definitions may provide further assistance.
Lines 84-87 its clearer written as: More than half (52%) of adolescent girls in Ethiopia have never received any information about menstrual hygiene due to socio-cultural
The issue is fixed accordingly: (line 86-89)
• “More than half (52 %) of adolescent girls in Ethiopia have never received any information about menstrual hygiene (10), due to religious taboos, socio-cultural misinformation, and inadequate menstrual supplies and facilities, which leads to fear, confusion, and lack of confidence when menarche occurs (11-15).”
• “gender empowerment” modified to “gender equality” ( line 93)
• In fact, we purposefully limited our search terms to be gender-specific to highlight the impact the interventions on schoolgirls, but it is still valued concern because it may have limited searching relevant literature. We have included it on the limitation section of the manuscript
Authors’ Response
Written as “Mode of intervention” only (Line 200, in the modified version)
• Saudi Arabiya is excluded from the analysis as it is one of the high income countries. And modification is made on the manuscript accordingly ( Line 215)
From line 251 – have you listed all of the education components because saying they ‘included things such as…’ makes it seem that the list is not exhaustive, but it seems to be that way. And perhaps it should be if not too long to include each component.
Modified as “The menstrual education components of the studies included; puberty education, training on…” (line 239)
Authors’ response: Amendment made (the repeated et al is deleted/ line 295)
Table 2 and 3 – could we have color code for severity of bias?
Authors’ response: Color code is given accordingly
Authors’ response: Resolved (line space of the table is reduced)
Table 5 – I assume the 0 means no impact and + means positive impact but you need to add this key somewhere. It would be clearer if you also did a colour i.e. green for positive effect, yellow for neutral. It would also look better if the symbols were in the centre of the square. Table 5 – could you add the type of intervention into the summary table and group similar types of intervention together?
• Acronyms are expand on the heading section
• Key is provided for Table-4 on line 337
Authors’ response: lack of attention in education could be attributed by both the hormonal fluctuations and worry about not being able to manage their period. We have added additional literatures to illustrate it. (Line 353)
Authors’ Response: Noted and we have added more details as follows
“One article exploring the beliefs and attitudes boys and men hold about menstruation revealed that men generally have more negative attitudes towards menstruation and view it as debilitating and requiring secrecy. However, these attitudes may soften as men age and gain more knowledge and experience with menstruation” (line 390)
407 – careful not to generalize all religious beliefs be specific.
Authors’ response: Addressed in line 394 as “most religious beliefs”, to avoid generalization.
Authors’ Response: specified on the current version on line 435-439
“Governments and policymakers should prioritize menstrual hygiene as a public health issue and develop policies and guidelines to meet the needs of menstruating girls including affordable menstrual products, proper hygiene facilities, education about menstruation, and access to healthcare services for managing menstrual health.”
Seems like the conclusion is the first instance apart from the title where you mention low- and middle-income countries… why would this not be an issue in high income countries? The United Kingdom is currently going through a cost-of-living crises where people are in hygiene poverty – unable to buy basic hygiene items like menstrual pads. Ref - https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255001&utm_source=miragenews&utm_medium=miragenews&utm_campaign=news
Is categorizing countries by their economic status quite western and neoliberal?
� Menstrual hygiene management is indeed an issue that affects individuals in both high-income and low-income countries. In high-income countries, access to menstrual products and facilities for proper hygiene may be more readily available (as compared to low income countries), but issues such as stigma and access to education about menstrual hygiene persist. In low-income countries, the challenges may include limited access to sanitary products, clean water, and sanitation facilities, as well as social stigma and inadequate education about menstrual health. Therefore, addressing menstrual hygiene management is an important aspect of promoting gender equality and ensuring the well-being of individuals across different socioeconomic contexts.
� We have used the World Bank classification of countries based on economic status and we have excluded the finding from Saudi Arabia.
� Categorization is made by income level ( world bank)
Submitted filename: Response to Reviewers .docx
29 Jan 2024
PONE-D-23-35026R1Menstrual hygiene management interventions and their effects on schoolgirls’ menstrual hygiene experiences in low and middle countries: A systematic reviewPLOS ONE
Thanks for doing a good job with the first round of comments. I'm afraid both reviewers have some further things for you to address but I think these should be pretty straightforward now. Please submit your revised manuscript by Mar 14 2024 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 gro.solp@enosolp . 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.
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.
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: (No Response)
Reviewer #2: (No Response)
2. Is the manuscript technically sound, and do the data support the conclusions?
3. Has the statistical analysis been performed appropriately and rigorously?
4. Have the authors made all data underlying the findings in their manuscript fully available?
5. Is the manuscript presented in an intelligible fashion and written in standard English?
6. Review Comments to the Author
Reviewer #1: Line 24: uses passive voice
Line 32: “Accordingly” doesn’t flow from previous sentence
Line 35: “However” is clunky here.
Line 82: You use the word “menstruants” without explaining this word choice. This absolutely needs to be addressed. It is not widely accepted (by two different “camps” for different reasons). It is jarring and merits context. If you believe that this is the term that is emerging, you should at least cite to some authority for that, because I don’t think there is consensus/agreement that many readers will have heard it before (“menstruator” is much more common in significant literature).
Lines 84-89: You definitely need to explain your focus on women and girls. Your response to the reviewers makes clear that it is because that is what the studies you survey are studying…but this does not come through in your paper. The reader is still left wondering why you are focusing on *girls* (but then again, are you focused just on girls? In fact, later in the paper, such as at Lines 296-98, you do cite studies involving boys). This needs to be clarified.
Lines 95-96: I don’t think the average reader will understand what you mean by “weak enabling environments”’
Line 111: comma missing
Line 114: reviews “were conducted” (passive voice) by WHOM?
Lines 143-145: Here you talk about limiting your search to studies in which the participants were schoolgirls only. Is this accurate? See comment above re Lined 296-98. Perhaps I am misunderstanding.
Line 148: Punctuation missing?
Lines 149, 152, 160: Colon not necessary?
Line 165: Unnecessary comma
Line 210: Do you mean “findings” (plural)?
Line 212: Are “menstrual interventions” the same as “menstrual hygiene management interventions” discussed on Line 146?
Line 254: Passive voice
Line 258: Odd initial cap for “School”
Lines 272-73: Awkward and difficult to follow sentence.
Line 298: Were these period underwear or regular underwear?
Lines 300-302: Run-on sentence.
Line 464: Instead of talking about “menstruating girls and women,” might this be an appropriate place to talk about “all who menstruate,” notwithstanding your focus?
Line 466: Queer theory would ask us to look rigorously at the word “normal.” I think you mean “involuntary” or “inevitable” (or perhaps drop the adjective entirely).
Reviewer #2: Dear authors,
Thanks for the effort you’ve put in to addressing my comments. I feel like the paper has now avoided a couple of easy pitfalls. The information in the tables is also now much easier for the reader to digest – thanks for this. There are just a few things I’m not sure were fully addressed; perhaps I did not explain myself very well so here I elucidate:
I understand the want to just focus on one particular group (schoolgirls). However, I raised this point as it is often gender diverse persons who are left out and not represented in this type of data collection, which is something that needs to change if the research is to remain relevant going forwards. I appreciate the mention of menstruators – it’s important as a limitation if anything to explain the data set is solely focused on cisgender girls and women.
Largely you give the country where the reference is from but not all the time. It’s important to do this consistently in order to avoid making generalisation about all low-income countries.
I’m happy to see the inclusion of the positionality statement – it adds transparency. Something I was looking for was mention of the country/countries the authors are from. There adds incongruence if the authors were from a high-income country say but are commenting on low income countries. How does where the authors are from impact the direction of the study or interpretation of results?
That’s a shame that you’ve now had to exclude Saudi Arabia. I hope my point that menstrual health is a global issue that impacts high-income countries was taken not to diminish the lack of access in lower income countries but to highlight it’s not just an issue in low-income countries and that there are inequalities within countries as well as between them.
Great that you’ve added in some literature regarding men/boys/non-menstruators however the point that I wanted to get at was that it can be these groups that also act as a barrier to schoolgirls’ attendance through teasing or shaming.
I don’t think changing the line to ‘most religious beliefs’ avoids generalisation either… this is a sensitive point and I understand what you’re getting at… but I think what you’re saying could be misinterpreted. Religion is interpreted and enacted differently across the world. For example in the UK, I don’t think many Christians would feel stigma towards menstruation because of what is written in the Bible. But I understand that other cultures might. What you can say instead which is factually true is that in certain religious texts menstruation is presented as making the menstruator impure or unclean. I would be particular about using the exact wording – so much of religious text is down to interpretation.
I feel that for this work to be relevant, contemporary, and self-aware, the authors should take a little more time to contemplate these last points. It would also be good to have a statement from the authors on why this paper is important and what new contribution to the discussions on MHM it brings.
Many thanks,
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.
Reviewer #1:
Line 24: uses passive voice
Authors ‘Response
Dear reviewers I agree with comments in line #24
The statement in line# 24 is replaced with active voice, “To address these issues, researchers have conducted intervention studies, but the impact on school attendance has varied”
I agree with comment of the reviewer, the statement in line 32 is paraphrased as
“Review of sixteen trial studies showed that menstrual hygiene interventions have a positive effect on schoolgirls' school attendance, performance, and dropout rates, as well as on their menstrual knowledge, attitudes, practices, and emotional well-being.”
The comment is well taken and “However” in line # 34 is omitted and the sentences is rephrased as “There was a low to medium risk of bias in the most of the studies.”
I agree with point raised and it is valued concern. Hence the word “menstruants” in line 82 is replaced with “menstruators” as per the recommendation
The comment is well accepted. The reason for focusing on schoolgirls is now explained in line 419-426 as follows, to make it clear to the reader.
“Most of the literature about menstrual hygiene management, especially in low- and middle-income counties, don’t adequately address the needs of people who identify as gender-nonconforming. Menstrual discourses, are frequently written from the perspective of a cis woman, highlighting only the menstrual experiences of adolescent girls and cis women. This exclusion may affect menstrual hygiene needs and experiences of transgender, non-binary, and other gender varied individuals”
This review investigated how involving males (boys, fathers, or parents) in interventions might improve schoolgirls' experiences. We included intervention studies targeting these male groups alongside traditional MHM interventions. This broadens the range of interventions studied, but the outcome/impact must be measured specifically on schoolgirls.
The comment is well accepted. In the old version we explained the word “weak enabling environments”’ using the list of challenges that came after it . i.e. “Insufficient knowledge about menstruation, inadequate access to water, sanitation and hygiene services, lack of adequate hygiene materials, and social norms unsupportive of those who menstruate”
But if it creates confusion for readers, the already listed challenges are more descriptive and we have omitted the phrase “weak enabling environment” to avoid ambiguity to the reader
Authors ‘Response .
This is well taken and Comma is used in line #110 “2015-2016 school year, demonstrated”
Dear reviewer, we have included the list of 4 citations which helps to address the potential question about “who conducted the review?”. The 4 citations in line 116 can address this concern than listing the name of the authors who did the review.
Dear reviewer, your understanding is correct. The statement is rephrased to “
The search was limited to studies that measured outcomes on schoolgirls because the objective of the review was to evaluate how menstrual hygiene management intervention programs impact schoolgirls' attendance, academic performance, or dropout rates. ” The study aimed to evaluate the effects of intervention programs on school attendance, performance, and dropout rates of schoolgirls, as clearly stated in lines 144-145. Therefore, while the intervention may involve parents, the community, and males, the outcomes must be assessed specifically for schoolgirls. We have included studies that involved parents or males in the intervention, with the actual outcomes measured for the schoolgirls. Additionally, we used terms such as fathers, mothers, community, and parents as search terms to encompass various types of interventions.
This is well noted punctuation is in place now, “supplies.”
Well noted and accepted, the colon in line 149 and 152 is removed and we kept the colon in line 159 and we deleted the word “includes” to make appropriate use of colon
Well accepted, comma in line 165 is removed the statement is written as “we excluded studies not available in the English language and conference abstracts.”
This is noted, line 208 in this version, is changed into plural “a summary of the findings”
Yes, it is the same and line 210 is corrected as “Sixteen trial studies that assessed the effect of menstrual hygiene management interventions…”
Dear reviewer the comment is accepted, the statement in line 252 is changed into active voice as follows
“Montgomery et al. suggested that using school attendance and dropout rates as a proxy indicator of academic performance”
This is accepted. Line 256 Changed from Official School attendance� Official school attendance
The comment is well accepted. The statement in line 270-272 which was “Montgomery et al. conducted study on comparable peri-urban schools but included one remote rural site without experience in using sanitary pads that had no electricity, and no paved roads.”is rephrased as follows:
“Montgomery et al. carried out study on peri-urban schools that were comparable, but they also incorporated a remote rural site lacking experience in using sanitary pads, with no access to electricity and unpaved roads.”
Dear reviewer, fortunately I physically knew the underwear’s provided in this specific intervention and they are normal/regular underwear’s and the term “ regular” is added ( line 297-298)
Well noted and accepted. The statement in line 297-299 “School attendance (data collected prospectively on-site by team researchers) was analyzed before and after the intervention and also compared with attendance data from the prior school year”
Is amended as
“School attendance was analyzed before and after the intervention and also compared with attendance data from the prior school year”
Line 464: Instead of talking about “menstruating girls and women,” might this be an appropriate place to talk about “all who menstruate,” notwithstanding your focus
Dear reviewer this comment is accepted. “Menstruating girls and women “is replaced with “all who menstruate” on the current version ( line # 470)
Line 466: Queer theory would ask us to look rigorously at the word “normal.” I think you mean “involuntary” or “inevitable” (or perhaps drop the adjective entirely) (line # 474).
Well Noted, the word “Normal” is dropped from line # 471
Reviewer #2: Dear authors,
The following paragraph would explain the limitation, which is placed in line # 416-421
“Most of the literature about menstrual hygiene management, especially in low- and middle-income counties, don’t adequately address the needs of people who identify as gender-nonconforming. Menstrual hygiene issues, are frequently written from the perspective of a cis woman, highlighting only the menstrual experiences of adolescent girls and cis women. This exclusion may affect menstrual hygiene needs and experiences of transgender, non-binary, and other gender varied individuals.”
Largely you give the country where the reference is from but not all the time. It’s important to do this consistently in order to avoid making generalization about all low-income countries.
The input is considered and included the countries where the citation exists, but country was not included mainly on table 5
Dear reviewer this is well accepted. The following statement is added the statement “I am from Ethiopia one of the low-income countries” in line 130 to indicate the principal investigator is from low income country.
Dear reviewer, issues of menstrual poverty and inequity are global challenges. It is widely recognized that individuals who menstruate in high-income countries encounter various challenges, although the severity and nature of these challenges may vary from LMIC. Our initial focus for the review was on addressing issues in low and middle-income countries. And we wrongly classified Saudi Arabia as LMIC and include it in the review process. However, this does not imply that menstrual hygiene management is not an issue in high income countries. Your feedback in the previous review highlighted the inclusion of one high-income country, Saudi Arabia, in the review. This was an important observation. It would not be appropriate to include a high-income country when the review is intended to focus on LMICs. This was the sole reason for its exclusion.
Dear reviewer the comment is well received. The following statement is included in line #389-392 on the current version which may address the concern about the effect of teasing by boys on school attendance and participation.
“Approximately 13% of Tanzanian girls have encountered period teasing, while over 80% expressed fear of being teased, particularly by male classmates. This results in reduced school attendance, participation, and concertation in class.”
I don’t think changing the line to ‘most religious beliefs’ avoids generalization either… this is a sensitive point or I understand what you’re getting at… but I think what you’re saying could be misinterpreted. Religion is interpreted and enacted differently across the world. For example in the UK, I don’t think many Christians would feel stigma towards menstruation because of what is written in the Bible. But I understand that other cultures might. What you can say instead which is factually true is that in certain religious texts menstruation is presented as making the menstruator impure or unclean. I would be particular about using the exact wording – so much of religious text is down to interpretation.
This is well accepted and the statement “Menstrual restrictions and cultural taboos are often rooted in most religious beliefs and untrue cultural assumptions” Is replaced with following statement on the current version (line #395-397)
“In certain religious texts, menstruation is often framed as making the menstruator impure or unclean, leading to menstrual restrictions, shame, and taboos”
The contribution of the study to the discussion on MHM is highlighted as follows in the strength section (line #425-434)
The review also has several strengths, providing an extensive summary of English-language evidence. It offers valuable insights by presenting a comprehensive review of English-language trial studies that evaluate the effect of menstrual hygiene management interventions on various aspects of schoolgirls' lives. With a large sample size from multiple countries, the study covers a broad range of interventions, including puberty education, distribution of menstrual supplies, and integration of menstrual health topics into school curriculums. The findings not only underscore the positive effects of these interventions, such as increased school attendance and enhanced menstrual hygiene knowledge and attitudes, but also shed light on the challenges and limitations observed in certain studies. This review will also have great contribution in identifying research gaps for further studies.
Submitted filename: Response to reviweres.docx
18 Mar 2024
PONE-D-23-35026R2Menstrual hygiene management interventions and their effects on schoolgirls’ menstrual hygiene experiences in low and middle countries: A systematic reviewPLOS ONE
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. There are just a few more minor points to address, as well as the need to check the grammar further.
Please submit your revised manuscript by May 02 2024 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 gro.solp@enosolp . 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.
Reviewer #1: All comments have been addressed
Reviewer #1: N/A
Reviewer #1: I implore the authors to run their manuscript through a grammar-checking program (Grammarly, Paperpal, anything) or Chat GPT to improve the grammar and punctuation, especially in the first three pages. The authors have nicely addressed the substantive comments and have responded to specific grammatical errors pointed out by the reviewers. The manuscript still needs to be gone through line by line because parts of it are not well-edited. I do not consider it a good use of my professional time to provide a third round of input pointing out grammatical errors that could be addressed readily by the authors.
Reviewer #2: Thanks for addressing the comments. There are just a couple more tiny things to address and then I’m happy for the work to be published.
1. ‘frequently written from the perspective of a cis woman’ – although I completely agree with this perhaps it requires a reference? Maybe you could explain why you know this to be true as I’m not sure you’d actually be able to find a reference. You could say ‘Since gender-diverse persons make up such a small percentage of the population, it can be assumed that the vast majority of academic literature on MHM is written from the perspective of cis women’. Maybe I’m being unnecessarily pedantic here.
2. I think you would do well to read around the purpose of positionality statements and this would help to inform how to write one. I wasn’t looking for you just to state that you are Ethiopian but how that background and identity shapes and influences the research. For example something like: I am a woman (?) who comes from Ethiopia, which is one of the countries studied in this paper. This gives me first-hand experience of what it’s like to be a menstruating schoolgirl in an LMIC. However, I am an outsider to the other countries studied in this paper, which may leave room for bias or misunderstandings in the interpretation of results’. Something like this.
3. Perhaps I’m being too cautious but I still believe this could be interpreted as offensive to some readers ‘In certain religious texts, menstruation is often framed as making the menstruator impure or unclean, leading to menstrual restrictions, shame, and taboos’. To reiterate, so much religious text is down to interpretation and this is what can cause the issues of negative views towards menstruation, not necessarily the words in the text itself. I don’t know if you’re religious or not but this would be an instance where your positionality affects how you interpret data. For example, I’m not religious and therefore don’t understand or have association to any religious texts. I gave a lecture on MHM making the exact same point as you that religious texts e.g. The Quran says that menstruation is impure. This was of course from a translation from Arabic into English where meaning can get lost anyway. A Muslim student put their hand up to explain that this was a very negative interpretation of the text and that it doesn’t mean impure in a dirty way as was interpreted. I think it would be inoffensive but still make the same point to say ‘certain religious texts can be interpreted to associate menstruation with impurity and uncleanliness, which leads to menstrual restrictions, shame, and taboos in some cultures’ you need a reference for this as well.
31 Mar 2024
Response to Reviewers
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: (No Response)
________________________________________
Reviewer #1: Yes
Reviewer #2: Yes
Reviewer #1: N/A
Reviewer #1: I implore the authors to run their manuscript through a grammar-checking program (Grammarly, Paperpal, anything) or Chat GPT to improve the grammar and punctuation, especially in the first three pages. The authors have nicely addressed the substantive comments and have responded to specific grammatical errors pointed out by the reviewers. The manuscript still needs to be gone through line by line because parts of it are not well-edited. I do not consider it a good use of my professional time to provide a third round of input pointing out grammatical errors that could be addressed readily by the authors.
Authors’ Response:
Dear reviewer, this is valued concern. The necessary grammar and spelling errors are fixed throughout the document on the current version manuscript.
Reviewer #2: Thanks for addressing the comments. There are just a couple tinier things to address and then I’m happy for the work to be published.
Dear reviewer this comment is valued and is addressed as follows in line # 415 and the statement is replaced with the recommended way of rephrasing.
‘Since gender-diverse persons make up such a small percentage of the population, it can be assumed that most of the academic literature on MHM is written from the perspective of cis women’.
2. I think you would do well to read around the purpose of positionality statements and this would help to inform how to write one. I wasn’t looking for you just to state that you are Ethiopian but how that background and identity shapes and influences the research. For example, something like: I am a woman (?) who comes from Ethiopia, which is one of the countries studied in this paper. This gives me first-hand experience of what it’s like to be a menstruating schoolgirl in an LMIC. However, I am an outsider to the other countries studied in this paper, which may leave room for bias or misunderstandings in the interpretation of results. Something like this.
Dear reviewer the comment is well noted and the positionality statement in line #128-136, is rephrased as;
“I (the first author) am a woman, a feminist, and an advocate for girls' education. I am currently pursuing a PhD in public health. I am from Ethiopia, which is one of the countries studied in this paper. This gives me first-hand experience of what it’s like to be a menstruating schoolgirl in an LMIC. However, I am an outsider to the other countries studied in this paper, which may leave room for bias or misunderstandings in the interpretation of results. In this systematic review, the researcher's standpoint influences the research approach and findings. This study advocates for accessible menstrual hygiene resources and aims to address the stigma surrounding menstruation. The conclusions are based on this perspective, and readers are encouraged to take this into account when interpreting the findings.”
3. Perhaps I’m being too cautious, but I still believe this could be interpreted as offensive to some readers ‘In certain religious texts, menstruation is often framed as making the menstruator impure or unclean, leading to menstrual restrictions, shame, and taboos’. To reiterate, so much religious text is down to interpretation, and this is what can cause the issues of negative views towards menstruation, not necessarily the words in the text itself. I don’t know if you’re religious or not, but this would be an instance where your positionality affects how you interpret data. For example, I’m not religious and therefore don’t understand or have association to any religious texts. I gave a lecture on MHM making the exact same point as you that religious texts e.g. The Quran says that menstruation is impure. This was of course from a translation from Arabic into English where meaning can get lost anyway. A Muslim student put their hand up to explain that this was a very negative interpretation of the text and that it doesn’t mean impure in a dirty way as was interpreted. I think it would be inoffensive but still make the same point to say ‘Certain religious texts can be interpreted to associate menstruation with impurity and uncleanliness, which leads to menstrual restrictions, shame, and taboos in some cultures’ you need a reference for this as well.
Dear reviewers I agree with comments. The statement in line Line #392-94: “In certain religious texts, menstruation is often framed as making the menstruator impure or unclean, leading to menstrual restrictions, shame, and taboos”
Is replaced with
‘Certain religious texts can be interpreted to associate menstruation with impurity and uncleanliness, which leads to menstrual restrictions, shame, and taboos in some cultures. And reference is cited.
Submitted filename: Response to Reviewers.docx
PONE-D-23-35026R3
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14 Jun 2024
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COMMENTS
Which of the following can be used as a research question?, Compare the two statements and distinguish which best describes a research statement. Qualitative research statements imply cause and effect. Qualitative research statements seek to understand the behavior and underlying contexts of the observed subject. and more.
Abstract. This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions ...
Correlation does not imply causation; but often, observational data are the only option, even though the research question at hand involves causality. ... They refer to "associations," "relationships," or tentative "links" between variables instead of clear cause-effect relationships, and they usually add a general disclaimer ("Of ...
Qualitative research involves the studied use and collection of a variety of empirical materials - case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts - that describe routine and problematic moments and meanings in individuals' lives.
Qualitative research is defined as "the study of the nature of phenomena", including "their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived", but excluding "their range, frequency and place in an objectively determined chain of cause and effect" [].This formal definition can be complemented with a more ...
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Qualitative research was historically employed in fields such as sociology, history, and anthropology. 2 Miles and Huberman 2 said that qualitative data "are a source of well-grounded, rich descriptions and explanations of processes in identifiable local contexts. With qualitative data one can preserve chronological flow, see precisely which ...
Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research. Qualitative research is the opposite of quantitative research, which involves collecting and ...
Qualitative research has its roots in anthropology, sociology, psychology, linguistics, and semiotics, and has been available since the early 19th century, long before quantitative statistical techniques were employed. Distinctions from Quantitative Research. In qualitative research, the role of the researcher receives critical attention.
Causal relationships are traditionally examined in quantitative research. However, this article informs the discussion surrounding the potential use of qualitative data to explore causal relationships qualitatively through an empirical illustration of a school leadership development team. As school leadership development is supposed to offer continuing development to practicing school leaders ...
Let us distinguish two different ways to ask and address causal questions. One can begin with an outcome, i.e., Y, and then work backward to the causes, i.e., X s. The second option works in the other direction; one starts with a potential cause and then asks about its impact on Y.The former procedure is often called the "causes-of-effects" approach, whereas the latter is known as the ...
The view that qualitative research methods can be used to identify causal relationships and develop causal explanations is now accepted by a significant number of both qualitative and quantitative ...
Qualitative researchers use methods such as observation, interviews, open-ended surveys, focus groups, content analysis, or oral history to investigate the meanings that people attribute to their behavior and interactions. This approach provides an in-depth understanding of attitudes, behaviors, interactions, events, and social processes.
Compare the two statements and distinguish which best describes a research statement. 1. Qualitative research statements imply cause and effect. 2. Qualitative research statements seek to understand the behavior and underlying contexts of the observed subject. A. What is the relationship between the age and income of Filipino professionals?
Revised on June 22, 2023. Correlation means there is a statistical association between variables. Causation means that a change in one variable causes a change in another variable. In research, you might have come across the phrase "correlation doesn't imply causation.". Correlation and causation are two related ideas, but understanding ...
In Study 1, participants interpreted statements of the form "X is associated with Y" to imply that Y causes X. In Studies 2 and 3, participants interpreted statements of the form "X is associated with an increased risk of Y" to imply that X causes Y. Thus, even the most orthodox correlational language can give rise to causal inferences.
Causal research is sometimes called an explanatory or analytical study. It delves into the fundamental cause-and-effect connections between two or more variables. Researchers typically observe how changes in one variable affect another related variable. Examining these relationships gives researchers valuable insights into the mechanisms that ...
Help companies improve internally. By conducting causal research, management can make informed decisions about improving their employee experience and internal operations. For example, understanding which variables led to an increase in staff turnover. Repeat experiments to enhance reliability and accuracy of results.
What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being "qualitative," the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term "qualitative." Then, drawing on ideas we find scattered ...
In scientific research, understanding causality is key to unraveling the intricacies of various phenomena. A causal hypothesis is a statement that predicts a cause-and-effect relationship between variables in a study. It serves as a guide to study design, data collection, and interpretation of results.
This study explored treatment continuity and medical access among local breast cancer patients affected by the 2011 triple disaster through qualitative research methods.
Case study research typically draws on other logics for understanding causation and making causal inferences. We illustrate some of the contributions made by case studies, drawing on a narrative review of research relating to one particularly enduring and complex problem: inequalities in health.
Regression-discontinuity methods have been little used in medical research to date, but they can be helpful in the study of cause-and-effect relationships from observational data . Regression-discontinuity design is a quasi-experimental approach ( box 3 ) that was developed in educational psychology in the 1960s ( 18 ).
The impact of corporate governance mechanisms has been examined directly and independently, considering that such characteristics compete to explain environmental, social, and governance (ESG) performance. However, the nexus may be more complex than that suggested by most scholars, and more research is needed. This study applied a fuzzy-set qualitative comparative analysis to a sample of ...
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However, these reviews had different population intervention control outcome and time (PICOT) criteria, and some included studies that used cross-sectional research methods [9, 21, 22, 36]. This review specifically focuses on schoolgirls and includes up-to-date intervention studies, which distinguishes it from earlier reviews in terms of time ...