School-based WASH facilities and menstrual hygiene management: a systematic review of impacts on adolescent girls in South Asia, Sub-Saharan Africa, and Southeast Asia

Abstract Background Menstrual health and hygiene are crucial for achieving Sustainable Development Goals, such as SDG 3 (Good Health and Well-being), SDG 4 (Quality Education), SDG 5 (Gender Equality), and SDG 6 (Clean Water and Sanitation), yet they remain underprioritized in global health and education agendas. Millions of school-going girls, particularly in low- and middle-income countries, continue to lack access to accurate information, affordable products, safe facilities, and stigma-free environments for managing menstruation with dignity. The inequities are rooted in structural, cultural, and institutional barriers and underscore the need for multilevel, system-oriented approaches to menstrual health. Methods This systematic review aimed to synthesise evidence on how school-based Water, Sanitation, and Hygiene (WASH) facilities influence menstrual hygiene management among adolescent schoolgirls in South Asia, Sub-Saharan Africa, and Southeast Asia. Studies were identified through PubMed, Scopus, Web of Science, JSTOR, and grey literature searches. Eligible primary studies focused on adolescent schoolgirls (10–19 years) and school-based Water, Sanitation, and Hygiene (WASH) environments. Findings were thematically synthesised across five Social Ecological Model (SEM) levels: individual, interpersonal, organisational, community, and policy. Results Across settings, menstrual health was shaped by a complex interplay of cognitive, social, infrastructural, and policy determinants. At the individual level, awareness has improved, yet biological understanding remains limited by affordability and stigma. Interpersonal dynamics were dominated by mothers and constrained by silence among fathers, and how teachers mediate girls’ comfort and coping. Organisational barriers, reported inadequate WASH, privacy, and disposal facilities, form the primary bottleneck linking knowledge to behaviour. Community norms of pollution, shame, and restriction reinforce secrecy and absenteeism, while policy frameworks remain fragmented, underfunded, and poorly monitored, with weak integration of Menstrual Hygiene Management (MHM) into education systems. Cross-level analysis revealed that knowledge gains fail to translate into practice without enabling infrastructure, supportive social networks, and institutional accountability. Conclusion Menstrual health inequities among adolescent girls are ecological rather than individual. Sustainable progress requires rights-based action across SEM levels: inclusive policy and financing; gender-sensitive, well-maintained school WASH; trained and empathetic educators; community norm transformation; and psychosocial well-being integrated into monitoring frameworks. Only through such system-wide alignment can menstrual health become a public guarantee of dignity, equity, and educational opportunity.