Perceived affordability, knowledge and ritual restriction: a multidimensional assessment of menstrual health vulnerability among adolescent schoolgirls in government schools of Ladakh, North India-a cross-sectional comparative study

Menstrual health among adolescents in India’s high-altitude trans-Himalayan region is almost undocumented. This study examines menstrual-health disadvantage as a multidimensional condition among schoolgirls in Ladakh’s two districts, Leh and Kargil, which differ in geography, religion, livelihood and service access. A cross-sectional survey of 310 post-menarcheal girls in grades 8–12 was conducted between 22 April and 25 May 2026 in nine accessible government schools selected by convenience, the sample is not probability-based. An exploratory composite Menstrual Health Vulnerability Index (0–100) was built from four a priori domains: knowledge deficit, product access and perceived affordability, hygiene-practice gap, and ritual and behavioural restriction. Item wording, coding and thresholds are given in an additional file. District differences were tested with Mann–Whitney U tests, reported with effect sizes and bootstrap confidence intervals and re-estimated with school-clustered standard errors. Mean index score was 27.4 (SD 14.0, median 25.0). Disadvantage concentrated in two domains: ritual and behavioural restriction (52.7) and product access and perceived affordability (44.8), knowledge deficit (3.7) and practice gap (8.5) sat near the floor (90.0% and 66.1% scoring zero). Leh scored higher than Kargil on the composite (30.0 vs 25.0, difference 5.0, 95% CI 2.0–8.1, d = 0.36, p = 0.002), but this did not survive adjustment for clustering ( p = 0.19) and reversed when the restriction domain was excluded. Compositional differences were larger: restriction was higher in Leh (64.7 vs 41.6, d = 0.61) and the practice gap wider in Kargil (11.6 vs 5.2, d = -0.56), both surviving correction for multiplicity and clustering. Domains were not independent, access and restriction correlated ( ρ = 0.30), a pair accounting for 145 of 147 participants with two deficits. Measured disadvantage was dominated by ritual restriction and perceived cost rather than ignorance or poor technique. The districts differed more in the composition of disadvantage than its level, though this contrast was sensitive to weighting and clustering and should be treated as a hypothesis. Because household income was largely unavailable, the access domain reflects perceived affordability and product access, not economic poverty. Findings do not extend to out-of-school, nomadic, private-school or remote adolescents.