Addressing Menstrual Stigma: A Scoping Review on Menstrual Health Interventions in India

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a very important subject thank you for undertaking the review. All the paragraphs in section 1.1 start with the word Stigma, it would be better to rephrase these first sentences so that they align better with the text- rather than feeling repetitive.

 

What about other emotions than stigma, the readers focus should be on stigma, but you need to clearly show that you have engaged with the literature broadly as well- this could be brought out a little better

 

What were the inclusion and exclusion criteria more clearly please, list them under these headings.

 

Could you say something about the main themes and findings of these papers? Even briefly would be appreciated

 

What are your recommendations for real policy shift and impact from future research? What kind of research is needed for that?

Author Response

Reviewer 1:

Suggestion 1. [This is a very important subject thank you for undertaking the review. All the paragraphs in section 1.1 start with the word Stigma, it would be better to rephrase these first sentences so that they align better with the text- rather than feeling repetitive.]

Answer 1: We thank Reviewer 1 for their kind review of our paper. We have changed the sentence structure in section 1.1 to limit the repetitive use of the word “stigma”. Please see lines 63-98.

Suggestion 2: [What about other emotions than stigma, the readers focus should be on stigma, but you need to clearly show that you have engaged with the literature broadly as well- this could be brought out a little better

Answer 2: We thank Reviewer 1 for this thoughtful reflection. In this paper, we conceptualize stigma not as an emotion, but as a structural factor or condition that produces macro-level processes influencing specific groups’ access to capital and resources affecting the social determinants of health, including housing, education, and employment (see lines 75–83). While stigma may be internalized and thus manifest emotionally at the individual level, the primary focus of this paper is on identifying and highlighting structural ways in which menstrual stigma may be addressed in the Indian context.

At the same time, we recognize that these structural conditions shape individual experiences at the micro level. We have addressed these individual-level impacts in the manuscript, including discussions of how menstruation is surrounded by shame and guilt, affecting girls’ and women’s lived experiences (lines 152–164), as well as how menstrual stigma influences mental health globally and in India, contributing to feelings of fear, loneliness, confusion, and shame (lines 190–199).

Suggestion 3: [What were the inclusion and exclusion criteria more clearly please, list them under these headings]

Answer 3:Thank you for this suggestion. We have separated 2.2 Study Selection into 2.2. Inclusion and Exclusion Criteria, and 2.3 study screening. We have revised the other headings in the methodology chapter accordingly. Please see in-text edits (lines 261-287).

Suggestion 4: [Could you say something about the main themes and findings of these papers? Even briefly would be appreciated ]

Answer 4: The themes and findings of the papers are explained in the old 3.1.1 and mentioned in the scoping table (figure 2). However, to enhance clarity, we have split section 3.1.1 into two sections, called “3.4 Study Characteristics and Assessments Criteria” and “3.5 Study Findings”. Please note that while the edits look major with track and trace, they are in fact minor, as text has only been moved around, not altered (lines 364- 470).

Suggestion 5: [What are your recommendations for real policy shift and impact from future research? What kind of research is needed for that?]

Answer 5: Thank you for this suggestion. We have edited the conclusion to reflect recommendations for future research and local policy. As this is a scoping review, we have focused our attention on recommendations/implications for future research. Please see lines 550-579.

Reviewer 2 Report

Comments and Suggestions for Authors

The strength of the paper is that menstrual stigma is an important social issue at both policy and practice levels in India, and the focus on stigma is an under-explored topic. Despite these strengths, the paper has some limitations that need to be addressed before final acceptance.

1. There is some inconsistency in the time frame of the included interventions, so please verify the actual time span of the intervention dates.
2. Another issue is the assessment of “stigma reduction,” which remains somewhat unclear. For example, please clearly distinguish between knowledge/attitude change and stigma reduction per se.
3. In addition, there are some minor terminological inconsistencies; please organize them for clarity. For example, the use of “menstrual health management” and “menstrual hygiene management.”
4. Figure 1 provides the cycle of menstrual stigma. However, it is also necessary to briefly explain how this conceptual model fits within the study.
5. Overall, the paper is well written, and my assessment is “Minor Revision.”

Author Response

Reviewer 2:

[The strength of the paper is that menstrual stigma is an important social issue at both policy and practice levels in India, and the focus on stigma is an under-explored topic. Despite these strengths, the paper has some limitations that need to be addressed before final acceptance.

Suggestion 1: There is some inconsistency in the time frame of the included interventions, so please verify the actual time span of the intervention dates.]

Answer 1: Thank you for this important clarification request. We’ve looked through the included reports, the scoping table, and the article itself to ensure there are no inconsistencies. There is a difference between the ‘intervention timeframe’ (i.e., how long the intervention itself takes to carry out) and ‘study timeframe’ (i.e, the full study, being the intervention and data collection components). As an example, Dharmalingam et al., (2022)’s study took place over 3 months from November 2019 to January 2020, but their intervention (i.e., the educational element) only took one day per session. To avoid confusion for the reader, we have specified this in-text, please see lines 344-362.

Suggestion 2: [Another issue is the assessment of “stigma reduction,” which remains somewhat unclear. For example, please clearly distinguish between knowledge/attitude change and stigma reduction per se.]

Answer 2: We thank the reviewer for this important point. We agree that changes in knowledge, understanding, attitudes, and practices related to menstrual stigma are conceptually distinct from stigma reduction per se, which involves measurable changes in stigmatizing beliefs, social norms, or discriminatory behaviors. Given this distinction. We have revised the manuscript to focus explicitly on strategies and interventions aimed at improving knowledge, understanding, and practices related to menstrual stigma, rather than claiming evidence of stigma reduction. Accordingly, we have removed references to “stigma reduction” throughout the manuscript (including lines 393, 418, 525, and 568) and clarified our framing to avoid overstating outcomes.

 

Suggestion 3: [In addition, there are some minor terminological inconsistencies; please organize them for clarity. For example, the use of “menstrual health management” and “menstrual hygiene management.”]

Answer 3: Thank you for this observation. We used the term “menstrual hygiene” twice in the article. The first is to describe “Menstrual Hygiene Management Products (MHMPs) (line 47), which is an established term to describe products used to absorb and/or collect menstrual blood. We’ve added a description to make this clearer, see lines 55-57.

The second use of the term ‘menstrual hygiene’ can be found on line 342. For consistency, we have changed the wording to menstrual health, as suggested (line 348).

Suggestion 4: [Figure 1 provides the cycle of menstrual stigma. However, it is also necessary to briefly explain how this conceptual model fits within the study.]

Answer 4: Thank you for this suggestion. We have incorporated the figure into section 1.2. to better explain how this conceptual model fits within the study. Please see lines 112-175.

Suggestion 5 [Overall, the paper is well written, and my assessment is “Minor Revision.”]

Answer 5: We thank you for this assessment.  

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the article titled: “Addressing Menstrual Stigma: A Scoping Review on Menstrual Health Interventions in India.” This study offers important insights into interventions that reduce menstrual stigma experienced by girls and women in India. The review underscores persistent gaps that must be considered to effectively address the pervasive menstrual stigma in India, highlighting a critical area for ongoing research and intervention. Please find my review below with suggestions aimed at strengthening the overall clarity and presentation of the study.

Abstract: Effectively summarizes the study.

Introduction: Overall, the introduction provides a comprehensive discussion of key concepts, such as MHM, period poverty, menstrual stigma, and the scope and impact of stigma in India, drawing appropriately on relevant literature. There are, however, several areas where further refinement could strengthen this section. The opening paragraph presents the global prevalence of menstruation and introduces it as a stigmatized topic. Expanding and further unpacking this discussion would offer a more robust foundation and better situate the issue of stigma globally for readers. Figure 1 is not explicitly referenced in the text. While it is implicitly connected to the content being discussed, it should be formally introduced to guide readers more clearly, or alternatively, removed. The lengthy discussion of school absenteeism related to menstruation could be condensed to improve clarity and more directly emphasize its connection to menstrual stigma.

Methods: The database search was conducted on March 14, 2024. Given that the search is now over a year and a half old, I recommend updating it to ensure that more recent studies are captured.

Further clarification is needed regarding the rationale for selecting the six databases used. Were any date limits applied to the search and which study designs were eligible for inclusion?

A limitations section should be added following the discussion. Section 2.3 would be more appropriate within this new limitations section.

Additional attention is warranted regarding how the exclusion of gray literature and non-English publications may have narrowed the scope of the findings, particularly given that relevant interventions may be documented in gray literature sources and that Hindi is one of India’s official languages.

A summary of each study included should be provided in a table format.

On page 7, line 292, the phrase “as well as any recommendations from the authors” requires clarification. Please elaborate on what is meant by this and specify the type of information extracted.

A description of the data analysis and synthesis processes is missing. The authors should clearly outline how the data were coded, categorized, and organized for synthesis. This should include a description of the steps taken to chart the data, the criteria used to group findings (e.g., intervention types), and how consistency in the interpretation of data was ensured. How did the authors move from individual study findings to broader synthesized conclusions? Additionally, please indicate whether any theoretical or methodological frameworks were used to guide the analysis and structure the presentation of results. This level of detail is essential for establishing methodological transparency and rigor.

Results: The results section provides a clear overview of the interventions described in the included studies. However, adding subheadings within Section 3.1.1 would help improve the organization and readability of this section. Additionally, Section 3.1.2 should be reworded, as the current phrasing makes it unclear whether the perspectives presented reflect the authors of the manuscript or the authors of the studies included in the scoping review. Consider adopting a more descriptive heading such as “Strategies to Address Menstrual Stigma” or “Recommended Approaches for Reducing Menstrual Stigma.”

Discussion: The discussion section requires substantial revision. Much of the current content restates the results or includes material that would be more appropriately placed in a limitations section. The discussion should move beyond summarizing findings to interpret them in the context of existing literature, highlight their implications for practice, policy, and future research, and situate the study within a broader theoretical, cultural, or systemic framework. The first paragraph, which primarily summarizes the results, could be removed or condensed, with the focus shifted toward interpretation. The discussion of knowledge, attitudes, and practices (KAP) is important but could be expanded to explain how KAP manifests in the context of menstrual stigma and to identify practical opportunities for intervention. Similarly, the study found that nearly all interventions targeted adolescents, which is a critical observation; the discussion should address the implications of this focus, including gaps for adult women or other populations (thank you for including pre-menarche) and how future interventions might be broadened. Some content, such as paragraph 2 and lines 506–531, lacks sufficient interpretation or is more appropriately categorized as study limitations. These sections could be condensed and relocated to a formal limitations section, allowing the discussion to concentrate on synthesis, interpretation, and implications. Overall, the discussion should situate the results within the broader literature, highlight gaps, and suggest directions for future research, rather than reiterating findings or presenting limitations.

The limitations section should acknowledge the potential for selection bias, which is inherent in scoping reviews. Decisions regarding databases, search terms, and inclusion criteria may have excluded relevant studies, which could influence the comprehensiveness of the findings.

Conclusion: The conclusion effectively summarizes the research and highlights its implications. To strengthen this section, the authors should assert their contribution more confidently. For example, reword “We hope that this scoping review…” (line 589) to clearly convey the study’s significance and the authors’ meaningful contribution to the field.

Comments on the Quality of English Language

Overall, there are some grammatical errors and instances of awkward phrasing throughout the manuscript, and I recommend an external editorial review to improve clarity and readability.

Author Response

Reviewer 3

[Thank you for the opportunity to review the article titled: “Addressing Menstrual Stigma: A Scoping Review on Menstrual Health Interventions in India.” This study offers important insights into interventions that reduce menstrual stigma experienced by girls and women in India. The review underscores persistent gaps that must be considered to effectively address the pervasive menstrual stigma in India, highlighting a critical area for ongoing research and intervention. Please find my review below with suggestions aimed at strengthening the overall clarity and presentation of the study.

Abstract: Effectively summarizes the study.

Suggestion 1: Introduction: Overall, the introduction provides a comprehensive discussion of key concepts, such as MHM, period poverty, menstrual stigma, and the scope and impact of stigma in India, drawing appropriately on relevant literature. There are, however, several areas where further refinement could strengthen this section. The opening paragraph presents the global prevalence of menstruation and introduces it as a stigmatized topic. Expanding and further unpacking this discussion would offer a more robust foundation and better situate the issue of stigma globally for readers. Figure 1 is not explicitly referenced in the text. While it is implicitly connected to the content being discussed, it should be formally introduced to guide readers more clearly, or alternatively, removed.

Answer 1: Thank you for taking the time to review our paper. We have made sure Figure 1 is better incorporated into the text, by referencing it in section 1.2., Menstrual Stigma in India Please see our edits for lines 112-175.

Suggestion 2: The lengthy discussion of school absenteeism related to menstruation could be condensed to improve clarity and more directly emphasize its connection to menstrual stigma.]

Answer 2: We thank Reviewer 3 for this suggestion. We have condensed the discussion around absenteeism and highlighted the importance of future scholarship and intervention focusing on the effect of stigma (please see lines 202-217):

Suggestion 3: [Methods: The database search was conducted on March 14, 2024. Given that the search is now over a year and a half old, I recommend updating it to ensure that more recent studies are captured.]

Answer 3: Thank you for this suggestion. As this is a scoping review, there is typically more flexibility on the date of last search. Furthermore, this is not a rapidly evolving field, and so the “answer” to the review question is not likely to change based on the incorporation of a few more studies. For this reason, and because we were issued ‘minor revisions’ with a relatively short turnaround date, we assumed the editor was OK with the search date and not expecting a search update during this revision.

Suggestion 4: [Further clarification is needed regarding the rationale for selecting the six databases used. Were any date limits applied to the search and which study designs were eligible for inclusion?]

Answer 4: thank you for this question. We selected scholarly databases for their multidisciplinary coverage, health-focus, population focus, and regional focus (see insert below). We have made this clear by editing lines 232-242 and Table 1.

Eligibility criteria are specified in 2.2. To make them clearer, We split section 2.2. into 2.2., Inclusion and exclusion criteria and 2.3 study screening. Please see lines 263-289.

Suggestion 5: [A limitations section should be added following the discussion. Section 2.3 would be more appropriate within this new limitations section.]

Answer 5:  We have made a new ‘Limitations’ section after the discussion, please see lines 540-551.

 

Suggestion 6: [Additional attention is warranted regarding how the exclusion of gray literature and non-English publications may have narrowed the scope of the findings, particularly given that relevant interventions may be documented in gray literature sources and that Hindi is one of India’s official languages.]

Answer 6: Please see our answer to Suggestion 5.

Suggestion 7: [A summary of each study included should be provided in a table format.]

Answer 7: Each study is summarised in the scoping table, please see Table 2.

Suggestion 8: [On page 7, line 292, the phrase “as well as any recommendations from the authors” requires clarification. Please elaborate on what is meant by this and specify the type of information extracted.]

Answer 8: thank you for this suggestion. We have clarified the meaning of the sentence, i.e., that the studies’ authors’ recommendations were also extracted (see lines 298-299). 

Suggestion 9: [A description of the data analysis and synthesis processes is missing. The authors should clearly outline how the data were coded, categorized, and organized for synthesis. This should include a description of the steps taken to chart the data, the criteria used to group findings (e.g., intervention types), and how consistency in the interpretation of data was ensured. How did the authors move from individual study findings to broader synthesized conclusions? Additionally, please indicate whether any theoretical or methodological frameworks were used to guide the analysis and structure the presentation of results. This level of detail is essential for establishing methodological transparency and rigor.]

Answer 9: Our data extraction methods are described in Section 2.5 Data Extraction. The methodological framework guiding this review is the Joanna Briggs Institute (JBI) Scoping Review Methodology. The use of a theoretical framework to guide the coding and synthesis of evidence is not expected, please refer to the JBI methodology for scoping reviews: https://jbi-global-wiki.refined.site/space/MANUAL/355862791/10.2.8+Analysis+of+the+evidence

Suggestion 10: [Results: The results section provides a clear overview of the interventions described in the included studies. However, adding subheadings within Section 3.1.1 would help improve the organization and readability of this section.]

Answer 10: Thank you for this suggestion. Section 3.1.1. has been split into two sections, called “study characteristics and assessments criteria” and “study findings”. Please note that while the edits look major when using the track and trace function in the reviewed article, they are in fact minor, as text has only been moved around, not altered (see lines 365-461).

Suggestion 11: Additionally, Section 3.1.2 should be reworded, as the current phrasing makes it unclear whether the perspectives presented reflect the authors of the manuscript or the authors of the studies included in the scoping review. Consider adopting a more descriptive heading such as “Strategies to Address Menstrual Stigma” or “Recommended Approaches for Reducing Menstrual Stigma.”]

Answer 11: Thank you for this reflection. We have edited section 3.6 (lines 463-488) to clarify that it concerns the scoped studies’ recommendations, not the recommendations of the authors of this paper.

Suggetion 12: [Discussion: The discussion section requires substantial revision. Much of the current content restates the results or includes material that would be more appropriately placed in a limitations section. The discussion should move beyond summarizing findings to interpret them in the context of existing literature, highlight their implications for practice, policy, and future research, and situate the study within a broader theoretical, cultural, or systemic framework. The first paragraph, which primarily summarizes the results, could be removed or condensed, with the focus shifted toward interpretation. The discussion of knowledge, attitudes, and practices (KAP) is important but could be expanded to explain how KAP manifests in the context of menstrual stigma and to identify practical opportunities for intervention. Similarly, the study found that nearly all interventions targeted adolescents, which is a critical observation; the discussion should address the implications of this focus, including gaps for adult women or other populations (thank you for including pre-menarche) and how future interventions might be broadened. Some content, such as paragraph 2 and lines 506–531, lacks sufficient interpretation or is more appropriately categorized as study limitations. These sections could be condensed and relocated to a formal limitations section, allowing the discussion to concentrate on synthesis, interpretation, and implications. Overall, the discussion should situate the results within the broader literature, highlight gaps, and suggest directions for future research, rather than reiterating findings or presenting limitations.]

Answer 12: We thank the reviewer for their thorough review of our discussion and recommendations for improvements. We have made substantial revisions to refine the text, including removing summaries of our findings that may be redundant to reports in previous sections, centreing our discussion to high level findings in the context of other studies in the majority world and global trends in addressing menstrual stigma, and positioning the importance of this topic in the context of cultural shifts aimed at reducing access to sexual and reproductive health education resources. Additionally, study limitations have been consolidated and moved to a separate subsection (4.1 Methodological Limitations), with recommendations and directions for future research moved to Section 5. Conclusions.

Suggestion 13: [The limitations section should acknowledge the potential for selection bias, which is inherent in scoping reviews. Decisions regarding databases, search terms, and inclusion criteria may have excluded relevant studies, which could influence the comprehensiveness of the findings.

Answer 13: Please see our answer to suggestion 5. 

Suggestion 14: [Conclusion: The conclusion effectively summarizes the research and highlights its implications. To strengthen this section, the authors should assert their contribution more confidently. For example, reword “We hope that this scoping review…” (line 589) to clearly convey the study’s significance and the authors’ meaningful contribution to the field.]

Answer 14: We have edited the conclusion to be more action-oriented, and to convey the study’s contribution to the field. Please see lines 552-581.

Reviewer 4 Report

Comments and Suggestions for Authors

This is a very well written important article focused on better understanding interventions to reduce menstruation stigma among girls and women in India. 

Line 12 – There is no H in Joanna.

Line 167 – Should be “one’s”.

Line 524 – There is a double N in national.

Author Response

Reviewer 4:

Suggestion 1: [This is a very well written important article focused on better understanding interventions to reduce menstruation stigma among girls and women in India.]

Answer 1: Thank you for your review of our paper. We appreciate your attention to detail. We have edited the paper according to your suggestions below:

Suggestion 2: [Line 12 – There is no H in Joanna.]

Answer 2: We corrected this spelling mistake, please see line 12.

Suggestion 3: [Line 167 – Should be “one’s”.]

Answer 3: please see line 180

Suggestion 4: [Line 524 – There is a double N in national.]

Answer 4: This line was deleted as part of another revision.

Notes for the editor:

While editing the paper, we found a few typos that we have corrected.