Access to WASH facilities and health implications of period poverty among in-school girls in rural areas of Africa: a scoping review

Abstract

Introduction

Menstrual health is essential to adolescent well-being, yet many girls experience period poverty, an inadequate access to sanitary products, water, sanitation facilities, and menstrual education. This scoping review synthesised existing evidence on access to menstrual products, commonly described barriers and reported associations between poor health and period poverty among in-school girls in rural areas of Africa.

Methods

This study was developed in accordance with the Joanna Briggs Institute recommendations and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. PubMed, Web of Science and Google Scholar were searched for literature published in English, between 2015 and 2025. The literature must meet the inclusion criterion of being conducted among in-school girls in rural communities in Africa. Extracted data were summarised in an Excel spreadsheet, and descriptive analyses were conducted.

Results

Twenty-one (21) relevant studies were identified, of which 14 were quantitative, four were qualitative, and three were mixed methods studies. The studies were conducted across six countries, with the largest proportion from Kenya (5/21; 23%). Many of the girls were between 10 and 19 years. Period poverty was common among in-school menstruating girls in rural areas of Africa, and it negatively influenced their physical, mental, social and sexual health. Period poverty was linked to body odour, body burns, headaches, fatigue, urogenital symptoms, experience of fear, discomfort, shame, and stress. It can also lead to vulnerability to sexual exploitation, disrupted schooling, poor academic performance and school dropout.

Conclusions

Period poverty was widespread among in-school girls in rural Africa and linked to negative implications on their health. Integrated interventions that reduce girls’ vulnerability to stigma and sexual exploitation, such as free or subsidised menstrual products, gender-responsive water, sanitation and hygiene facilities, and menstrual education for boys and girls, are urgently required.

Introduction

Menstrual health is the state of complete physical, mental, and social well-being in relation to the menstrual cycle, and not merely the absence of disease or discomfort [1]. Good menstrual health practices include the use of clean menstrual absorbents (sanitary pads, menstrual cups) and hygienic disposal of the menstrual absorbents. It also includes regular changing of materials (ideally every 4–8 h) [2, 3]. Good menstrual health practices ensure that menstruation can be managed with dignity and safety. Schools with female-friendly facilities such as clean menstrual absorbents, privacy, soap, water, hygienic disposal methods, sanitation facilities, supportive environment (including sensitised teachers) and information on menstruation for both girls and boys, promote good menstrual health [4], thereby contributing to better education and health outcomes of young girls [4].

Menstrual health is essential for the well-being of women [4]. As at 2025, more than 500 million women and girls worldwide experience period poverty [5, 6]. Period poverty includes inadequate water, sanitation and hygiene (WASH) facilities: water, latrine, handwashing facilities, safe disposal or waste management system; poor menstrual health education and services [5]. Globally, the WHO and UNICEF reported that 2.3 billion people lack basic sanitation, and only 27% have handwashing facilities with soap and water [7]. In low-middle-income countries (LMICs), about 50% of the schools lack adequate water, sanitation and hygiene (WASH) facilities, which are crucial for safe menstruation management [4]. Consequently, this results in poor menstrual hygiene management during the menstrual cycle [5]. More than 50% of girls in LMICs have practised poor menstrual hygiene management, with the majority being from rural areas [8]. In many rural African schools, menstrual hygiene management is a critical issue for girls because of cultural, economic, and infrastructural challenges [9]. Period poverty is exacerbated by financial constraints and traditional cultural norms prevalent in the region. The high cost of sanitary pads prevents many rural girls from accessing, purchasing, or consistently using appropriate, hygienic, and comfortable materials [10]. This may lead to the use of unsafe alternatives [10]. Due to cultural norms and beliefs, many girls in the region also feel isolated or impure during menstruation [11].

Poor menstrual hygiene management has substantial implications for the health of girls [8]. Studies have shown that it results in both physical and psychological distress among young girls [1, 12, 13]. Unhygienic menstrual practices increase girls’ susceptibility to infections such as urinary tract infections (UTIs), reproductive tract infections (RTIs), and bacterial vaginosis. These infections are common when absorbents are reused or worn for too long without being changed or washed [13]. The UNICEF & WHO also reported the socio-economic implications of poor menstruation management on girls [7]. Poor access to affordable menstrual products and facilities affects girls’ education. School girls miss school days during menstruation due to shameful feelings from visible stains on clothing, and a lack of private space for menstrual health management [14]. In Sub-Saharan Africa, 50 to 70% of girls miss an average of 1.6–2.1 days of school every month related to menstrual issues [15]. School absenteeism is a pervasive problem with detrimental consequences for girls’ academic achievement [16]. Students who are frequently absent from school are less connected to their classmates, experience reduced participation in classroom activities and interact less with their teachers and peers [17]. Studies have shown that school absenteeism affects girls’ academic development, which negatively influences their educational attainment [18, 19].

There is a dearth of scoping reviews on the accessibility of menstrual products to in-school girls in rural communities of Africa, especially on the health implications of period poverty on these young girls. This scoping review addressed the evidence gap on period poverty and its health implications [10]. The study aimed to synthesise the existing evidence on the accessibility of menstrual products and the health implications linked to period poverty among menstruating girls in rural areas of Africa.

Design and methods

A scoping review was conducted to explore evidence on the accessibility of menstrual products and the health implications of period poverty. This review was developed according to the recommendations of the Joanna Briggs Institute (JBI) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA ScR) checklist [20]. JBI framework outlined the systematic approach to map the existing literature and included the following steps: (1) Determination of review question, (2) Identification of study population, (3) Search strategy for literature, (4) Selection of literature, (5) Data identification, and (6) Data extraction and collation.

Definition of terms

For the purpose of this review, (1) Period Poverty was defined as the lack of access to affordable menstrual products, adequate sanitation facilities, menstrual health education, and supportive social environments needed to manage menstruation safely and with dignity [5]; (2) Menstrual Health was defined as the state of complete physical, mental, and social well-being in relation to the menstrual cycle [4]; (3) Menstrual Hygiene Management was defined as the use of clean menstrual materials to absorb or collect menstrual blood, which can be changed in privacy as often as necessary during menstruation [14]; (4) WASH Access was defined as access to adequate water, sanitation, and hygiene services, including clean water, safe and private toilet facilities, handwashing facilities with soap, and proper waste disposal systems necessary for maintaining menstrual hygiene management [5] and (5) Rural Setting was contextualised based on how the included studies described their study area. Studies were classified as rural if they were conducted in communities, schools, or districts that the authors identified as such.

• Step 1: Determination of review questions

The following review questions were used to develop a search strategy:

1. What are the menstrual products accessible to in-school menstruating girls in rural Africa?

2. What are the health implications of period poverty?

• Step 2: Identification of study population

Based on the population, context and concept (PCC) framework, and the eligibility criteria below (Table 1), 21 relevant articles (population) were included in the review. The review included both observational and experimental studies.

Table 1.

Eligibility criteria used to select articles

Characteristics	Inclusion Criteria	Exclusion Criteria
Population	In-school girls	Populations where rural in-school girls cannot be isolated
Concept	Menstrual health, period poverty, WASH access, menstrual hygiene practices, health implications	Nil
Context	Rural areas of African countries	Mixed settings (Urban and rural)
Study Types	Quantitative, qualitative, mixed methods, controlled trials	Non-empirical articles, ongoing studies
Outcome Areas	Access to WASH/products, menstrual health management, education, and physical/ psychological /social/sexual health implications	Nil
Language	English full-text	Non-English articles
Accessibility	Full text available	Nil

• Step 3: Search strategy for literature

The search strategy was developed by AJA and OIF. After the review of literature on access to menstrual products and the health implications of menstruation, key concepts were identified (Table 2) and used to generate the search strategies appropriate for three databases (Table 3). These key concepts were combined using the Boolean operators (AND and OR). The search followed the JBI three-step process: a preliminary search, a full database search, and a reference list search [20]. Firstly, a limited initial search of PubMed, Web of Science, and Google Scholar was conducted to identify articles on menstrual health. The words from the titles and abstracts of relevant articles were used to develop a comprehensive search strategy. Secondly, the search strategy, including all identified keywords, was adapted for each included database. Thirdly, the reference lists of the same or similar topics across all included sources of evidence were further screened to identify any additional studies. The search targeted both published and unpublished studies from 2015 to 2025, aligned with the review’s focus on recent and relevant evidence from the last decade. It was limited to papers published in English. The search was done between May and December, 2025.

Table 2.

Concept of the study and search terms

SN	Concept	Search Terms
1	Period Poverty	Period poverty, menstrual hygiene, menstrual management, menstrual cycle, menstrual products, sanitary pads, menstrual hygiene management, MHM
2	WASH	WASH, water, sanitation, hygiene, water access, latrine, handwashing facilities, safe disposal, waste management
3	School Girls	Adolescent girls, schoolgirls, young women
4	Health Implications	School attendance, absenteeism, academic performance, mental health, and physical health
5	Rural Africa	Africa, SSA, Eastern Africa, Western Africa, Northern Africa, Southern Africa, Central Africa, rural, rural communities

Table 3.

Search strategies for individual databases

Databases	Search Terms
PubMed	(Africa[tiab] OR “Africa“[Mesh] OR “Sub-Saharan Africa“[tiab])) OR ((“Menstrual Hygiene Management“[tiab] OR “menstrual hygiene“[tiab] OR “menstrual health“[tiab] OR menstruation[tiab] OR “Menstruation“[Mesh] OR “Menstrual Hygiene Products“[Mesh]) OR (rural[tiab] OR “rural areas“[tiab] OR “Rural Health“[Mesh] OR village[tiab]) AND (“WASH“[tiab] OR “water sanitation hygiene“[tiab] OR sanitation[tiab] OR “Sanitation“[Mesh] OR toilets[tiab] OR latrines[tiab] OR “Hygiene“[Mesh] OR “sanitation facilities“[tiab] OR “school sanitation“[tiab]) AND (“school girls“[tiab] OR schoolgirls[tiab] OR “in-school girls“[tiab] OR adolescents[tiab] OR “Adolescent“[Mesh] OR “female students“[tiab])
Web of Science	((“Rural Africa” AND (“school girls” OR “schoolgirls” OR “in-school girls” OR “adolescents”) AND “period poverty” OR “menstrual poverty” OR “menstrual hygiene management” OR “menstrual hygiene” OR “menstruation” OR “menstrual health”) AND (“WASH” OR “sanitation” OR “toilets” OR “latrines” OR “wash facilities” OR “school sanitation” OR “health outcomes”) AND (“rural” OR “rural areas” OR “village”) AND (“Africa” OR “Sub-Saharan Africa only”))
Google Scholar	((“Rural Africa” AND (“school girls” OR “schoolgirls” OR “adolescents”) AND “period poverty” OR “menstrual poverty” OR “menstrual hygiene” OR “menstruation” OR “menstrual health”) OR (“WASH” OR “sanitation” OR “toilets” OR “latrines” OR “wash facilities” OR “school sanitation” OR “health outcomes”) AND (“rural” OR “rural areas” OR “village”) AND (“Africa” OR “Sub-Saharan Africa only”))

• Step 4: Selection of literature

Following the literature search, all identified citations were collated and uploaded into a referencing software (Zotero). Duplicate records were removed. Titles and abstracts of articles were screened by two independent reviewers, using the inclusion criteria for the review. The full text of selected literature was also screened using the inclusion criteria. The reasons for exclusion of literature after reviewing the full text were recorded and reported in the scoping review.

• Step 5: Data identification

The process of identification of relevant studies was systematically divided into three phases: identification, screening, and inclusion.

• Step 6: Data extraction

A data extraction form was used to extract the following data from each article: author(s), publication year, study aim, study location, study setting/area, study design, sample size, participant characteristics, accessible menstrual products/tools/facilities and health implication indicators. The extracted data were presented in tables and charts.

• 7) Data charting

Summarisation and reporting of results.

Results

1. Collation of Studies

During the data the identification phase, a total of 3,812 records were retrieved through database searches and reference listing. Database search identified 1,313 records, comprising 1,296 records from PubMed and 17 records from Web of Science. Additional sources retrieved 2,499 records, which included 2,470 records from Google Scholar and 29 records through reference list screening. For PubMed, the search results were sorted by relevance, and the first 130 pages of results were screened. For Google Scholar, results were also sorted by relevance, and the 247 pages of results were screened.

More than half (2,523) records remained after duplicates were removed. In the screening phase, titles and abstracts of all 2,523 records were assessed independently by two reviewers, based on predetermined relevance and eligibility criteria, of which 2,490 records were excluded. Consequently, 33 full-text records were reviewed for eligibility; however, 22 were excluded for various reasons, including being irrelevant (n = 11) and ongoing study (n = 1). In the final inclusion phase, 21 studies were selected for data extraction. Selected studies included 15 quantitative, four qualitative and three mixed-methods studies. There were no disagreements during the title/abstract screening or full-text review stages. The results of the search and the study inclusion process are presented in a PRISMA flow diagram in Fig. 1.

Fig. 1.

PRISMA flow diagram of the literature search

• 2.Characteristics of included studies

As shown in Table 4, the review included 21 studies published between 2016 and 2025. The studies were conducted across 9 African countries, with the largest proportion from Kenya (5/21; 24%), followed by Ghana (4/21; 19%), while Rwanda had the least of studies conducted (1/21; 5%). All the studies were conducted in rural settings.

Table 4.

Summary of the reviewed literature

S/N	First Author (Year)	Country	Setting	Study Design	Target Population	Sample Size	Methodology	Data Collection Techniques	Age Range	Sex
1	Kitesa (2016)(21)	Ethiopia	Rural	Cross-sectional	Adolescent school girls	430	Mixed	Survey/FGD	Grade 9–12	Female
2	Pokharel (2018)(22)	Kenya	Rural	Cross-sectional	Rural school girls	902	Quantitative	Survey/checklist	Not stated	Female
3	Manyara and Okube (2023)(23)	Kenya	Rural	Cross-sectional	Primary school girls	111	Quantitative	Questionnaire	10–19	Female
4	Method et al., (2024)(34)	Tanzania	Rural	Cross-sectional	Adolescent students	400	Quantitative	Questionnaire	10–19	Female
5	Shah et al., (2022)(24)	Gambia	Rural	Cross-sectional	Primary & secondary students	561 girls surveyed; 155 qualitative participants	Mixed	Survey & Interviews, checklist	≥ 13	Female & Male
6	Mutunda and Stern (2017)(25)	Zambia	Rural	Explorative	Secondary school girls	51	Qualitative	Interviews	13–20	Female
7	Kumbeni (2021)(26)	Ghana	Rural	Cross-sectional	Junior high girls	705	Quantitative	Questionnaire	12–19	Female
8	C (2025)(27)	Ghana	Rural	Analytical cross-sectional	Basic school girls	318	Quantitative	Questionnaire	10–19	Female
9	Chidakwa (2022)(28)	South Africa	Rural	Critical emancipatory	Rural adolescent girls	10	Qualitative	Interviews	13–19	Female
10	Phillips-Howard (2015)(37)	Kenya	Rural	Cross-sectional	Menstruating females	3418	Quantitative	Survey	13–29	Female
11	Biljon and Burger (2019)(36)	South Africa	Rural	Cross-sectional	School girls	1,849,935	Quantitative	Survey	6–17	Female/male
12	Montgomery P. (2016)(39)	Uganda	Rural	Quasi-experimental	School girls	1,124	Quantitative	Attendance records	10–13	Female
13	Benshaul-Tolonen (2019)(11)	Kenya	Rural	RCT	School boys/girls	6,000	Quantitative	Attendance records	8–18	Female & Male
14	Gbogbo et al., (2025)(29)	Ghana	Rural	Qualitative narrative design	Senior high girls	60	Qualitative	FGD/Interviews	15–19	Female
15	Gutema (2023)(38)	Ethiopia	Rural	Cross-sectional	High school girls	577	Quantitative	Questionnaire	18–22	Female
16	Monica (2018)(30)	Uganda	Rural	Cross-sectional	Primary & secondary girls	100	Quantitative	Questionnaire	Not stated	Female
17	Nabwera et al. (2021)(35)	Gambia	Rural	Cross-sectional	School girls	358	Quantitative	Questionnaire	15–21	Female
18	Austrian et al., (2021)(40)	Kenya	Rural	RCT	Primary school girls	3,489	Quantitative	Attendance records	Mean age − 14.4	Female
19	Asumah et al., (2020)(31)	Ghana	Rural	Analytical Cross-sectional	Basic school girls	13	Quantitative	Questionnaire	Not Stated	Female
20	Chiyanma et al., (2019)(32)	Zambia	Rural	Qualitative	Rural school community	Not stated	Qualitative	Interviews & FGDs	14–18	Female & Male
21	Janoowalla et al., (2020)(33)	Rwanda	Rural	Cross-sectional	School girls	240	Mixed	Survey & Interviews	18–24	Female

As regards, data collection methods, the majority (14/21; 67%) of the studies used quantitative methods. Qualitative methods, including interviews and focus group discussions, were used in 4 studies (19%), while mixed-method approaches were used in 3 studies (14%). Surveys and questionnaires were the most commonly used data collection tools across the studies. The majority (14/21; 67%) of the studies adopted a cross-sectional study design, including analytical cross-sectional studies. Other study designs included randomised controlled trials (2/21; 10%), quasi-experimental, explorative, qualitative narrative, critical emancipatory, and qualitative designs.

The primary population across most studies was adolescent school girls in primary and secondary schools. A few studies also included boys, mixed student populations, and rural school communities. The reported age range of participants varied across studies, with most participants being adolescents, although some (4/21; 19%) studies did not specify participant ages.

• 3.Reporting of results

Figure 2 shows the number of studies and countries in rural areas of Africa where WASH assessments in schools and the health implications of period poverty among in-school girls have been conducted. Evidence on WASH assessment in rural schools was available only in three [3] countries: Ghana, Kenya, and Gambia, with 3, 3, and 2 studies, respectively. Also, only 6 countries had conducted studies [14] on the health implications of period poverty. Of the five countries, South Africa, Ethiopia and Uganda had three studies each, while Rwanda (1/28) had the fewest.

Fig. 2.

Countries where WASH assessment and health implications of period poverty have been conducted in rural area of Africa

Access of menstruating in-school girls in rural Africa to menstrual products

Thirteen of the reviewed papers showed limited access to menstrual products among in-school girls in rural Africa [21–33]. These are cross-sectional and mixed-methods studies conducted among in-school girls in Ethiopia, Tanzania, Kenya, Ghana, Uganda, and South Africa, which reported that a large proportion of girls lacked adequate sanitary products during menstruation [21–33]. For example, a study in Ethiopia showed that girls in some of the schools lacked menstrual hygiene management facilities, including sanitary napkins, a private place to change napkins and an ample water supply [21]. Another study in Ghana showed that, although most of the schools had toilet facilities, they lacked clean water, soap, privacy and dustbins, which were necessary for their menstrual hygiene management [16]. Also, a study in Kenya showed that there was no running water and soap near the latrines for hand washing after using or changing the menstrual materials [23]. It was reported that even where menstrual products were available in schools, access was often unreliable and mediated through school authorities, which discouraged the use of menstrual products [23]. Sanitary pads were sometimes kept in school offices rather than made freely accessible [23, 31].

Negative implications of period poverty among in-school girls in rural Africa

This review identified negative physical, social, mental, sexual, and economic health implications of period poverty among in-school girls in rural areas of Africa (Table 5).

Table 5.

Summary of the study findings

S/N	Reference	Aims/objectives	Key findings
1	Kitesa (2016) [21]	Assessed knowledge and practice of adolescent school girls towards menstrual hygiene management and determining factors	More than half, of girls were absent from school during their menstrual period from one to seven days per month. all the schools lack MHM inclusive sanitation facilities (including sanitary napkins, private place to change napkins and ample water supply).
2	Pokharel (2018) [22]	Assessed the availability of WASH facilities for Kenyan school girls for the management of menstrual hygiene	WASH facilities (water supply, sanitation and personal hygiene conditions) were inadequate for the rural Kenyan girls to effectively manage their menstruation.
3	Manyara and Okube (2023)[23]	Assessed the challenges associated with menstrual hygiene among adolescent girls attending Bocharia Primary School in Nyamira County, Kenya.	There was no running water and soap near the latrines for washing hands after using or changing the menstrual materials. Some sanitary towels were available in the school office. However, there was no disposal bins, and the girls threw the used menstrual absorbents in the latrines. Moreover, no girl was putting on a stained dress.
4	Method et al., (2024) [34]	Responds to the call for evidence sensitive to local barriers and challenges to inform successful strategies in MHM.	School absenteeism among adolescent girls during menstruation was significantly associated with a headache and abdominal waist pain. Girls also experienced psychological disturbances such as anxiety and embarrassment that resulted into absenteeism. They also experienced fear from soiling and discomfort.
5	Shah et al., (2022)[24]	Explored how menstrual hygiene management practices and related factors influence school absenteeism and drop-out among primary and secondary school girls in rural Gambia	Menstrual pain, cultural beliefs, fear of peers knowing menstrual status, and poor school WASH facilities led to school absenteeism, however, they had no impact on school drop-out. Both qualitative and quantitative findings show that menstrual pain, inadequate school WASH facilities, cultural beliefs of restricted movement or fear of people ascertaining their menstrual status, or symptoms of urogenital infection were the main drivers for school absenteeism.
6	Mutunda and Stern (2017)[25]	Explored the factors influencing the understanding, experiences and practices of menstrual hygiene among adolescent girls in Mongu District, Western Province of Zambia.	Girls suffer from poor menstrual hygiene, originating from lack of knowledge, culture and tradition, and socio-economic and environmental constraints, leading to inconveniences, humiliation and stress. This leads to reduced school attendance and poor academic performance, or even drop outs.
7	Kumbeni (2020) [26]	Investigated menstrual hygiene management among adolescent girls in junior high schools in rural northern Ghana	Although most of the schools had toilet facilities, they lacked clean water, soap, privacy and dustbins which are necessary for menstrual hygiene management. Absenteeism from school during menstruation was significantly related to menstrual hygiene management. The prevalence of menstruation-related school absenteeism was 27.5%. School absenteeism ranged from one to seven days during the menstrual period
8	Bonsu (2025)[27]	Accessed the enabling environment necessary for effective menstrual hygiene practices among adolescent girls in basic schools in Fodome Township.	The variation in MHM across regions was attributed to socioeconomic conditions, educational programs, and the availability of WASH facilities, which are often inadequate in certain areas.
9	Chidakwa (2022)[28]	Examined the menstrual health challenges and hygiene that were faced by vulnerable rural adolescent schoolgirls in South Africa,	The research findings reflected that the gaps in menstrual information, restricted availability and the use of sanitary products, conformity of cultural norms and inadequate amount of WASH facility helped creating considerable barriers for many rural adolescent schoolgirls, thereby compelling them to miss school during their menstruation
10	Phillips-Howard (2015) [37]	Examined sanitary products used, provision of products from sexual partners or from transactional sex, and demographic and sexual exposures.	Two-thirds of pad users received the pads from sexual partners; The odds of having transactional sex for pads was higher among females having two or more partners in the past 12 months
11	Biljon and Burger (2019) [36]	Examined if girls absent from school during their periods, If so, how large is the effect of menstruation on absenteeism, the effects differ by socio-economic status	Menstruation caused absenteeism for young girls (12–13 year olds in the poorest 60% of schools and 10–11 year olds in the richest 40%), but that older girls do not have a higher probability of being absent during their menses. These results imply that encountering menstruation for the first time presents challenges for girls in relation to school attendance.
12	Montgomery P. (2016) [39]	Assessed the impact of providing reusable sanitary pads and puberty education on girls’ school attendance and psychosocial wellbeing outcomes.	At follow-up, school attendance had worsened for girls across all conditions. Per-protocol analysis revealed that this decline was significantly greater for those in the control condition d = 0.52(95%CI0.260.77), with those in control schools having a 17.1% (95%CI: 8.7–25.5) greater drop in attendance than those in any intervention school.
13	Benshaul-Tolonen (2019)[11]	Examined if biological processes hinder girls in developing countries from participating in school to a greater extent than boys	Absenteeism is higher at endline than at baseline. Girls that received the sanitary pads were 5.4% points less likely to be absent at endline, illustrated by the interaction effect
14	Gbogbo et al., (2025)[29]	Investigate menstrual hygiene practices, including disposal methods and the influence of ritualistic beliefs on adolescent girls in selected high schools.	Observations of WASH facilities revealed an inadequacy in meeting the population’s needs. Available facilities, mainly cemented and wooden pit latrines, were few, and the few flushing toilets lacked running water and were poorly maintained.
15	Gutema (2025) [38]	Assess the magnitude of school absenteeism during menstruation and associated factor among high school female students in Basho district, Ethiopia	School absenteeism was associated with menstruation among three in four students female students.
16	Monica (2018)[30]	Identified the menstrual management practices by school girls, the effects that are caused by menstruation cycle in relation to attending the classes.	Young girls look at menstruation as shocking and cause stigmatisation. It is as well costly they therefore end up using unhygienic items such as clothes and even news papers while a way from school.
17	Nabwera et al. (2021) [35]	Described MHM practices among schoolgirls from rural Gambia and assess risk factors associated with urogenital infections and depressive symptoms.	Heavy menstrual bleeding was associated with depressive symptoms (adjusted prevalence ratio, aPR 1.4 [95% CI 1.0, 1.9]), while extreme menstrual pain (aPR 1.3 [95% CI 1.2, 1,4]), accessing sanitary pads in school (aPR 1.4 [95% CI 1.2, 1.5]) and less access to functional water source at school (aPR1.4 [95%CI1.3,1.6]) were associated with UTI symptoms. More attention is also needed to support girls with heavy menstrual bleeding and pain symptoms.
18	Austrian et al., (2021) [40]	Assessed effects of sanitary pad distribution and reproductive health (RH) education on girls in primary grade 7 in Kilifi, Kenya.	Neither sanitary pad distribution nor reproductive health (RH) education, on their own or together, were sufficient to improve primary school attendance. However, as the RH education intervention improved RH outcomes, the evidence suggests that sanitary pad distribution and RH education can be positioned in broader RH programming for girls.
19	Asumah et al., (2020)[31]	Assessed determinants of menstrual hygiene practices among adolescent girls in Basic Schools in the West Gonja Municipality of the Savannah Region of Ghana.	Majority (68.2%) of the schools did not have supportive hygiene infrastructure for the practice of menstrual hygiene management. The Ministry for Sanitation and Water Resources should fit in menstrual hygiene and its management into the National Sanitation and Hygiene Strategy.
20	Chiyanma et al., 2019 [32]	Explored girls’ experiences of MHM in rural schools of Zambia from the perspectives of schoolgirls, schoolboys and community and school-based adults key to MHM for schoolgirls	School toilets did not have soap and water or doors and locks for privacy and had a bad odor. Girls’ school attendance and participation in physical activities was compromised when menstruating due to fear of teasing (especially by boys) and embarrassment from menstrual leakage. When menstruating, schoolgirls in rural Zambia would rather stay home than be uncomfortable, inactive and embarrassed due to inadequate MHM facilities at school. A friendly and supportive MHM environment that provides education, absorbent sanitary materials and adequate WASH facilities is essential to providing equal opportunity for all girls.
21	Janoowalla et al., (2020)[33]	Determined the rates of urinary tract infection in adolescent users of menstrual pads versus non-users in a rural area of Rwanda.	More than half of the girls reported to have been absent from school during their menstruation period. Those who did not use sanitary napkins were more likely to be absent from school [AOR-95% C.I: 5.37 (3.02–9.55)]. 58% of girls reported that their school-performance had declined after they had menarche. In addition, the qualitative study indicated that school-dropout was common among girls who experienced teasing and humiliation by classmates when their clothes were stained with blood as they do not use sanitary napkins.

Physical implications

Four studies reported that period poverty was associated with physical discomfort such as body odour, body burns, fatigue, and urogenital symptoms [24, 32, 34, 35]. For example, a study in Zambia reported that girls complained of friction burns on their inner thighs during their long journey to school due to chaffing of wet non-absorbent material used to make menstrual cloth [32]. Another study in Tanzania showed that during menstruation, some girls had physical: discomfort as a result of soiling from using improper MHM absorbent materials [34], while another study in Gambia found that heavy menstrual bleeding and extreme pain were associated with symptoms of urogenital infection [35].

Social and mental implications

Five studies showed how school girls were emotionally and socially affected [24, 25, 32–34]. These girls experienced fear, anxiety, shame, and stress during menstruation, especially when their menstrual status was known to male peers or teachers [24, 32]. The study in Tanzania showed that girls also experienced psychological disturbances such as anxiety and embarrassment from period poverty. Findings showed that teasing and bullying by boys affected the girls’ emotional well-being, and sometimes resulted in girls’ avoidance of social interactions during menstruation [28, 32]. According to the study in South Africa, the onset of menstruation results in gender inequities that disproportionately affected younger girls, especially those who are menstruating for the first time [36].

Sexual implications

Only one study identified sexual risks associated with period poverty [37]. The study among menstruating girls in rural Kenya found that two-thirds of pad users received the sanitary product from sexual partners. Also, some relied on transactional sex for menstrual products, which was also associated with having multiple partners [37].

Economic implications

Thirteen studies consistently associated period poverty with disrupted schooling, poor academic performance, and increased risk of school dropout [11, 21, 24–26, 28, 32, 33, 36, 38–40]. For example, the study in Zambia reported that girls who suffered from poor menstrual hygiene had reduced school attendance, poor academic performance, and even dropouts [25]. Similarly, Kumbeni study in South Africa reported recurrent absenteeism, reduced concentration in class, and avoidance of participation in class as a result of period poverty [26]. The study in Rwanda showed that more than 50% of girls reported having been absent from school during their menstruation. and that school dropout was common among girls who had experienced teasing and humiliation by classmates when their clothes were stained with blood [33].

Discussion

This scoping review synthesised evidence from 21 primary studies that explored the accessibility to menstrual products and the health implications of period poverty among in-school girls in rural Africa. These primary studies employed qualitative, quantitative, and experimental designs and was conducted across Eastern, Western, and Southern Africa. Evidence showed that period poverty was a challenge among in-school menstruating girls in rural Africa [21, 28], and linked with negative implications for their health [15].

Findings from this review showed that period poverty was highly prevalent among in-school girls in rural areas of Africa, with reports of inadequate access to menstrual products, lack of privacy and unsafe sanitation facilities [21, 26, 38]. This is similar to the findings of Crankshaw (2020) in South Africa, which identified period poverty as a major problem among school girls. In the Northwest of England, a HIC, period poverty was often contextualised around affordability, homelessness, and stigma [41]. This is unsurprisingly due to differences in gross income power relative to the geographical context of this review. In rural areas of Africa, lack of menstrual products often overlaps with poor WASH infrastructure, limited access to pain management, long distances to school, and minimal school support [22, 31]. Consequently, the health and dignity of young girls are compromised.

This review found that period poverty among rural schoolgirls was linked with physical, mental, sexual, and economic health outcomes simultaneously [24, 34, 35]. The negative physical health outcomes included inner thigh burns, headaches, fatigue, heavy bleeding, and symptoms of urogenital infection, which were exacerbated by a lack of water, soap, and private changing spaces [22, 26]. Mental health outcomes such as anxiety, stress, shame, and depressive symptoms were related to fear of leakage/stain, teasing, and menstrual stigma [15]. When girls did not have access to period products during menstruation, they experienced fear and harassment [24, 32]. This corroborates UNICEF global reports on the experience of fear and harassment by girls who had period poverty [42]. Similarly, a study conducted in Nepal reported negative implications of period poverty on physical health. Emotional distress was also linked with period poverty in this region [43]. The pronounced poor physical health of girls observed in rural areas of Africa may be due to structural challenges, which include inadequate WASH facilities, poverty, and limited access to menstrual care or services. These findings suggest that period poverty is pervasive, and consequential where material, infrastructures, and social supports are weak. Addressing period poverty requires a multi-dimensional approach that goes beyond the provision of menstrual products to include gender-responsive WASH infrastructure, comprehensive menstrual health education, pain management, and broader poverty-alleviation strategies.

Beyond the physical and mental distress, this review also highlights the inter-connection between mental, social and economic consequences of period poverty that are experienced by in-school girls. Our reviews reported girls withdrawing from social interaction during menstruation due to fear of being teased, embarrassment from possible leakage, and lack of privacy in school sanitation facilities [23, 29, 32, 34]. The absence of doors, locks, water, soap, clean toilets and disposal bins in school latrines created an environment where girls felt exposed and unsafe while managing their menstruation. As a result, many preferred to remain in solitude, avoid participation in classroom discussions, physical activities, or peer engagement, and be absent from school. The social withdrawal negatively affected their confidence and educational engagement [25, 44]. These findings is similar to the results of a systematic review of qualitative studies in HICs, which found that menstrual stigma and negative social norms caused embarrassment and avoidance of social activities among menstruating adolescents [45]. Another study by Akerman (2024) in Sweden, an HIC, showed how menstrual stigma limited young women’s everyday lives and social relationships, including participation in social activities [46]. Policymakers and practitioners must recognise menstrual health as both a public health and gender equity priority, essential to safeguarding girls’ wellbeing, educational continuity, and human rights.

Sexually high-risk behaviours were associated with period poverty. The sexual dimension of period poverty that is not often discussed. Dependence on male partners for menstrual products increases girls’ vulnerability to coercion, exploitation, multiple sexual partnerships, and exposure to sexually transmitted infections and teenage pregnancy [47]. Therefore, period poverty is not only a hygiene or educational issue, but also a sexual and reproductive health risk concern. The implication of this is that a lack of access to basic menstrual products can promote risky sexual behaviour [47, 48].

A major strength of this scoping review is the comprehensive mapping of evidence across many African countries, different study designs, and multiple outcome domains. The review described the complexity of menstrual health challenges among rural in-school girls by including qualitative, quantitative, and intervention studies. It not only captured access of school girls to menstrual products, but also the interconnected physical, mental, social, economic, and sexual health implications. However, there exist some limitations. The heterogeneity of study designs and outcome measures limits direct comparability across studies. Many of the studies relied on self-reported data, which may be influenced by recall bias or social desirability bias. Also, although the primary population was adolescent school girls, a few studies included boys, teachers, parents, school administrators, policymakers, and wider school communities as study participants. This limitation was addressed by including only studies in which girl-specific findings related to menstrual health, menstrual hygiene management, period poverty, or WASH access were available. Also, the synthesis and interpretation of the findings were primarily focused on adolescent girls. Despite these limitations, the review provides valuable insights for research, policy, and practice. It highlights the multidimensional nature of period poverty in rural contexts and underscores the need for interventions that address access to menstrual products.

Conclusion

Period poverty is widespread among in-school girls in rural areas of Africa and has been linked to negative implications for health, education, dignity, and safety. Yet, there exists limited data on access to menstrual products and the health outcomes of period poverty among girls from areas of Africa. This gap underscores the need for future research to explore access to WASH and long-term outcomes among rural girls in Africa.

Authors' contributions

AJA developed search strategy, screened the literature and wrote the first draft of the manuscript. OIF developed search strategy, supervised screening of literature and improved the first draft of the manuscript.

Funding

This review received no funding.

Data availability

All data supporting the findings of this study are available within the paper. Outputs from all reviewed papers are provided in Tables 4 and 5.

Declarations

Ethics approval and consent to participate

No ethics approval is required. Findings will be disseminated via publications, presentations, stakeholder meetings, and policy briefs.

Consent for publication

Authors gave consent for publication.

Competing interests

The authors declare no competing interests.