PROJECT SUMMARY/ABSTRACT Despite being a natural physiological process, menstruation is often associated with health and safety challenges, especially in low-resource settings. In Nepal, 90% of women and girls follow at least one menstrual restriction. The most extreme is chhaupadi, a social-religious tradition in which women live in isolation during menstruation, exposing them to harmful health consequences. There is a dearth of evidence regarding effective approaches to address chhaupadi, which remains widespread. Research: This community-engaged study aims to rigorously review extant intervention evidence, as well as co-design and pilot a culturally relevant chhaupadi intervention to ultimately improve women’s health in Nepal. The study aims are as follows: Aim 1 - Conduct a Realist Synthesis to elucidate the mechanisms of success or failure of chhaupadi interventions to date, including key-informant interviews (KIIs) (n=35). Aim 2 - Co-design a chhaupadi intervention with women (n=30) in three districts using participatory, human-centered design activities. The intervention will be refined via community meetings (n=6) and KIIs (n=25). Aim 3 - Pilot test the intervention in two matched communities (intervention and control, n=45). Surveys with standardized measures and focus group discussions (n=6) will be conducted to assess feasibility, acceptability, and changes in health attitudes and behaviors expected to be impacted by the intervention. Candidate: Dr. Sara Baumann is an Assistant Professor at the University of Pittsburgh School of Public Health, Department of Behavioral and Community Health Sciences with extensive previous training in community-engaged research and women’s reproductive health in Nepal. Training: Four training goals will support Dr. Baumann’s trajectory toward becoming an independent investigator: 1) Acquire skills in Realist Synthesis to identify underlying causal mechanisms and reasons for intervention success or failure; 2) develop expertise in intervention development and assessment, as well as implementation science; 3) attain new skills in clinical trial design applicable to low- and middle-income countries (LMICs); and 4) gain essential skills in leadership, mentorship, grant writing, and study management. Mentors/Environment: Dr. Baumann will be supported by an exceptional team of international and multidisciplinary experts including a diverse mentorship team, advisory board, consultants, and collaborating organizations in Nepal. Her mentorship team has expertise in essential content and methodological areas such as intervention development, evaluation, clinical trials, and statistical analyses. Her comprehensive career development plan includes substantial mentorship, didactic training, and experiential learning at the University of Pittsburgh (US) and Tribhuvan University (Nepal). By successfully completing these rigorous career development and research plans, Dr. Baumann will be fully prepared to transition into a successful independent global health researcher and interventionist who harnesses community-engaged approaches to improve women’s reproductive health in LMICs.

PROJECT NARRATIVE Harmful menstrual practices, such as chhaupadi (menstrual seclusion) in Nepal, are an urgent threat to women’s health, wellbeing, and development. This study will investigate underlying mechanisms of promising aspects of chhaupadi interventions to date and build upon these findings to co-design and pilot test a context- specific intervention in partnership with community members. In the short-term, outcomes from this proposal will advance the field by resulting in 1) a pilot tested intervention that can be further tested in a future randomized controlled trial, 2) a refined approach for engaging communities in sustainable and contextually appropriate intervention co-design that is expected to be applicable to other low- and middle-income country contexts, and 3) in the longer-term support public health efforts aiming to reduce the negative health effects of harmful menstrual practices on women in Nepal.