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Access, Knowledge and Taboos: Assessing Period Poverty and Menstrual Hygiene Among Adolescents in Ladakh, North India

This study reveals that period poverty among schoolgirls in Ladakh is a heterogeneous, multidimensional issue with distinct district-specific patterns—characterized by sociocultural restrictions in Leh and hygiene deficits in Kargil—necessitating targeted, localized interventions rather than uniform approaches.

Original authors: Mohd Rafee

Published 2026-07-24

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Mohd Rafee

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

The Invisible Backpack

Imagine you are packing for a long hike. You know you need water, a map, and warm clothes. But what if, halfway up the mountain, you realize your backpack is actually made of four different, heavy straps? One strap is made of heavy rocks (money), another is tangled with thick vines (rules and traditions), a third is a loose knot you don't know how to tie (knowledge), and the fourth is a broken zipper that won't hold your gear (hygiene tools). If you only fix the loose knot, you might still get stuck because the rocks are too heavy. If you only carry the rocks, the vines might still stop you from moving forward.

This is the world of "period poverty." For a long time, people thought this was just one big problem: not having enough money to buy pads. But scientists are now realizing it's more like that invisible backpack. It's a mix of things: can you afford the products? Do you know how to use them safely? Are you allowed to talk about them? And are you restricted from doing normal things, like cooking or praying, when you have your period? Understanding this mix is crucial because if we try to solve the problem with just one tool—like handing out free pads—we might miss the heavy rocks or the tangled vines that are actually stopping girls from living their lives with dignity.

The High-Altitude Mystery: Two Districts, Two Different Backpacks

A researcher named Mohd Rafee from the University of Ladakh decided to test this "backpack" idea in a very specific, rugged place: Ladakh, a high-altitude region in North India. This area is cold, dry, and scattered across deep valleys. Rafee looked at two neighboring districts, Leh and Kargil. Even though they are close neighbors, they are quite different: Leh is mostly Buddhist and connected to tourism, while Kargil is mostly Muslim and more focused on farming.

Rafee asked 310 schoolgirls (ages 12 to 21) to fill out a survey. Instead of just asking "Do you have pads?", the researcher built a special "Menstrual Health Vulnerability Index" (MHVI). Think of this index as a scorecard that measures how heavy the girl's invisible backpack is. The score goes from 0 (light as a feather, no problems) to 100 (super heavy, struggling on all fronts). The scorecard checked four specific straps:

Knowledge: Do they know how periods work?
Access & Poverty: Can they get products, and do they feel they are too expensive?
Practice: Do they wash hands and dispose of pads safely?
Sociocultural: Are they restricted by rules, taboos, or shame?

The Big Surprise: The Backpacks Look Different

The study found that, on average, the girls' backpacks weren't crushing heavy. The average score was 27.3 out of 100. Most girls (about 65%) were in the "low vulnerability" zone. This sounds like good news, right? But when Rafee looked closer at what was inside the backpacks, the story changed completely.

The biggest weight in everyone's backpack wasn't ignorance or bad hygiene. It was sociocultural restriction (rules and taboos) and the feeling that products are too expensive. The girls knew what to do and mostly did it, but they were held back by shame, silence, and the fear of cost.

Here is where it gets really interesting. The two districts had very different backpacks, even though their total scores were similar.

In Leh: The girls carried a much heavier load of sociocultural restrictions. Their score for this was 65.3, compared to 40.0 in Kargil. They knew more about periods and felt more comfortable talking about them, but they still faced strict rules about where they could go or what they could do during their period.
In Kargil: The girls had a different problem. Their practice gaps were much larger (11.6 vs 5.2 in Leh). This means they were less likely to change pads frequently or wash hands perfectly. However, they felt they had better support from their schools.

The "One-Size-Fits-All" Trap

The most important discovery is that these four straps of the backpack are independent. They don't move together. A girl can be super smart about periods but still be banned from the kitchen. Another girl might have plenty of money for pads but still not know how to dispose of them safely.

Because these problems don't travel together, fixing one doesn't fix the others. The study found that 38.1% of the girls were struggling with two or more of these problems at the same time. It's like having a backpack with both a broken zipper and a heavy rock; fixing the zipper doesn't make the rock disappear.

What This Means for the Future

The paper suggests that we can't just use one plan for the whole region. If we send the same "solution" to both Leh and Kargil, we will get it wrong for both.

For Leh: The priority should be breaking the silence. We need to tackle the taboos and build better places to throw away used pads.
For Kargil: The priority should be teaching practical hygiene skills and making sure products are affordable.

The researcher concludes that period poverty in Ladakh isn't one single monster to be defeated. It's a collection of different challenges that look different depending on which valley you are in. To help these girls, we need to look inside their specific backpacks and untangle the specific knots they are facing, rather than just handing out a generic map.

Technical Summary: Access, Knowledge and Taboos: Assessing Period Poverty and Menstrual Hygiene Among Adolescents in Ladakh, North India

Problem Statement
Menstrual health among adolescents in India's high-altitude trans-Himalayan region remains poorly understood, particularly regarding the multidimensional nature of "period poverty." While national surveys indicate improvements in hygienic practices, they often fail to capture the specific stratifications of remote, frontier populations. Existing literature frequently treats menstrual disadvantage as a binary condition (adequate vs. inadequate) or aggregates diverse burdens into a single composite outcome, obscuring the distinct economic, informational, behavioral, and cultural drivers that vary by location. This study addresses the gap in disaggregated data for Ladakh, a region characterized by extreme geography and cultural diversity, to determine whether menstrual vulnerability is a uniform deprivation or a locally patterned bundle of independent burdens.

Methodology
The study employed a cross-sectional, school-based survey design across 13 administrative blocks in the two districts of the Union Territory of Ladakh: Leh (predominantly Buddhist, tourism-connected) and Kargil (predominantly Muslim, agrarian).

Participants: The sample comprised 310 post-menarcheal schoolgirls (150 from Leh, 160 from Kargil) enrolled in government secondary or higher-secondary schools.
Instrument: Data was collected via a structured questionnaire adapted from validated menstrual-health surveys, covering nine thematic areas. A specific 18-item attitudinal battery using a five-point Likert scale was utilized.
Measurement Innovation: The authors constructed a composite Menstrual Health Vulnerability Index (MHVI) ranging from 0 to 100. This index aggregates four distinct domains:
1. Knowledge Deficit: Awareness of physiology, hygiene, and infection risks.
2. Access and Poverty: Hardship markers including lack of reliable product access, resorting to cloth due to cost, and school absence.
3. Practice Gap: Shortfalls in product choice, change frequency, safe disposal, and handwashing.
4. Sociocultural Restriction: Reported restrictions, discomfort in discussion, and ritual exclusion.
Analysis: Statistical analysis utilized Mann-Whitney U and Welch's t-tests for district comparisons, Spearman correlation for domain interdependence, and ordinary-least-squares regression to identify adjusted predictors. Internal consistency was measured via Cronbach's $\alpha$ .

Key Results

Overall Vulnerability: The mean MHVI was 27.3 (SD 14.3), with 64.8% of participants falling into a "low-vulnerability" category. However, 38.1% of girls experienced deficits in two or more domains simultaneously.
Domain Decomposition: The composite index masked a lopsided reality. The Sociocultural restriction domain (mean 52.3) and Access and poverty domain (mean 44.8) were the primary drivers of vulnerability. Conversely, Knowledge deficit (mean 3.7) and Practice gap (mean 8.5) were minimal, indicating that most girls possessed adequate knowledge and basic hygiene techniques.
District Divergence: While the overall vulnerability was only modestly higher in Leh (30.2) than in Kargil (24.6) ( $p=0.001$ $p = 0.001$ ), the composition of vulnerability differed sharply:
- Leh: Characterized by significantly higher sociocultural restrictions (65.3 vs. 40.0 in Kargil) despite higher knowledge scores.
- Kargil: Characterized by significantly larger practice gaps (11.6 vs. 5.2 in Leh) and knowledge deficits, despite reporting better school support.
Independence of Burdens: The four domains were largely uncorrelated (Spearman $\rho$ values were weak, e.g., access vs. sociocultural $\rho=0.31$ ). This indicates that burdens are orthogonal; a girl with high knowledge can still face severe cultural restrictions, and affordability barriers do not necessarily correlate with poor hygiene practices.

Key Contributions

Multidimensional Indexing: The study operationalizes period poverty not as a single metric but as a composite index that can be decomposed. This allows for the identification of specific "local balances" of burden rather than relying on a single headline figure.
Revealing Heterogeneity: By disaggregating data across two contrasting districts within a small geographic region, the study demonstrates that uniform territorial programs may be ineffective. It highlights that two areas with similar overall vulnerability scores can have diametrically opposed primary drivers (cultural vs. practical).
Methodological Refinement: The paper challenges the binary "adequate/inadequate" approach common in menstrual health surveys, preserving gradation and capturing the cumulative nature of multiple, independent deficits.

Significance and Claims
The paper claims that period poverty in Ladakh is heterogeneous and locally patterned, driven by distinct combinations of cultural and economic factors rather than a uniform lack of resources or knowledge.

Policy Implication: The authors argue that "one-size-fits-all" interventions are inefficient. The study concludes that district-specific interventions are required: Leh requires focus on taboo reduction and disposal infrastructure, while Kargil needs affordability support and hands-on hygiene education.
Strategic Shift: The findings suggest that because the four domains are independent and cumulative, interventions must be modular and multi-component. Addressing one domain (e.g., education) does not automatically resolve others (e.g., cultural restriction or cost).
Tool Transferability: The MHVI is presented as a practical, transferable scaffold for planners in other remote or frontier regions to allocate scarce resources based on disaggregated local data rather than aggregate assumptions.

The study maintains a modest tone, acknowledging limitations such as the exclusion of out-of-school adolescents, the lack of household income data, and the reliance on self-reported cross-sectional data. It positions the MHVI as a construct for further validation and empirical re-weighting rather than a finalized standard tool.