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A Visual, Community-Engaged Exploration of Menstrual Practices and Motivations Among Title Page A Visual, Community-Engaged Exploration of Menstrual Practices and Motivations Among Adolescent Girls in Far-West Nepal by Sara Elizabeth Baumann BA in Sociology of Health & Aging, Minor in Peace & Social Justice, University of Michigan, 2008 MPH, BRAC University, Bangladesh, 2010 Submitted to the Graduate Faculty of Behavioral and Community Health Sciences Graduate School of Public Health in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2019 Committee Membership Page UNIVERSITY OF PITTSBURGH GRADUATE SCHOOL OF PUBLIC HEALTH This dissertation was presented by Sara Elizabeth Baumann It was defended on July 18, 2019 and approved by Shalini R. Ayyagari, PhD, Assistant Professor, Department of Music Kenneth P. Dietrich School of Arts and Sciences, University of Pittsburgh Müge Kökten Finkel, PhD, MA, Assistant Professor Graduate School of Public and International Affairs, University of Pittsburgh Marni Sommer, DrPH, MSN, RN, Associate Professor, Sociomedical Sciences Mailman School of Public Health, Columbia University, New York Martha Ann Terry, PhD, Associate Professor, Department of Behavioral and Community Health Sciences Graduate School of Public Health, University of Pittsburgh Dissertation Advisor: Jessica G. Burke, PhD, MHS, Professor, Department of Behavioral and Community Health Sciences Graduate School of Public Health, University of Pittsburgh ii Copyright © 2019 Sara Elizabeth Baumann. All Rights Reserved. iii A Visual, Community-Engaged Exploration of Menstrual Practices and Motivations Among Adolescent Girls in Far-West Nepal Sara Elizabeth Baumann, PhD University of Pittsburgh, 2019 Abstract Menstrual health, a growing global public health issue, refers to social, political, structural, educational and environmental factors that affect experiences of menstruation and impact health. Challenges associated with menstruation include the lack of access to materials and sanitation facilities, low knowledge about menstruation, and taboos and stigma that perpetuate unsafe practices. In Nepal, menstrual restrictions are widespread, putting menstruators at risk for poor health outcomes. Menstrual health research and interventions in Nepal must thoughtfully examine practices and beliefs, and propose solutions considering social values and the health and development context. Arts-based methods and community-engaged approaches are particularly appropriate for investigating sensitive topics such as menstrual health. This dissertation first reviews studies that have applied film methods in public health research. It then introduces a novel, visual, community-engaged research method called Collaborative Filmmaking. Finally, it presents the results from applying Collaborative Filmmaking to study menstruation in Nepal. Results from the review identified 15 film methods used in public health, which offer numerous methodological strengths such as providing rich descriptions, capturing emic perspectives, increasing comfort in participation, and empowering participants. Collaborative Filmmaking is a six-step method that builds upon these strengths. Adopting a community-engaged approach, participants of Collaborative Filmmaking are trained to create, analyze, and screen their own films in the community. Piloting Collaborative Filmmaking in far-west Nepal provided nuanced, sensory insight into menstrual practices and motivations among adolescent girls. An array of menstrual practices related to cleansing, cooking, iv eating and drinking, touching, worshipping, sleeping, and maintaining physical distance were uncovered. The practices fell along a continuum and varied by caste/ethnic and religious background. Motivations for following menstrual practices included religious and spiritual beliefs, family tradition, negative consequences, and social pressure. This dissertation contributes to both visual methods and menstrual health scholarship. Collaborative Filmmaking is an effective method for engaging participants in exploring a sensitive topic, generating nuanced data, and is powerful for disseminating results. In terms of menstrual health, this dissertation extends the literature by describing key differences in menstrual practices among girls from different caste/ethnic and religious groups in Nepal for consideration in future interventions and polices. v Table of Contents Preface ........................................................................................................................................... xi A Note from the Author ............................................................................................................. xv 1.0 Introduction ............................................................................................................................. 1 1.1 Introduction to Dissertation Approach and Specific Aims......................................... 1 1.2 Menstrual Health Background and Significance ......................................................... 4 1.3 Nepal Context ................................................................................................................ 11 1.4 Menstrual Health in Nepal .......................................................................................... 15 1.5 Theoretical Framework ............................................................................................... 29 1.6 Menstrual Health Interventions and Studies in Nepal .............................................. 33 1.7 Opportunities for Menstrual Heath Research in Nepal ............................................ 34 1.8 Visual Methods Background ....................................................................................... 36 2.0 Is Film as a Research Tool the Future of Public Health?: A Review of Study Designs, Opportunities and Challenges .................................................................................... 40 2.1 Abstract ......................................................................................................................... 40 2.2 Introduction .................................................................................................................. 40 2.3 Methodology .................................................................................................................. 42 2.4 Results ............................................................................................................................ 46 2.5 Discussion ...................................................................................................................... 51 2.6 Conclusion ..................................................................................................................... 53 2.7 Acknowledgements ....................................................................................................... 53 2.8 Tables and Figures ....................................................................................................... 53 3.0 Collaborative Filmmaking: A Participatory, Visual Research Method .......................... 61 3.1 Abstract ......................................................................................................................... 61 3.2 Introduction .................................................................................................................. 62 3.3 Collaborative Filmmaking Research Method ............................................................ 64 3.4 Collaborative Filmmaking Steps: Maya’s Menstrual Health Film as an Example 69 3.5 Discussion ...................................................................................................................... 84 3.6 Conclusion ..................................................................................................................... 92 3.7 Acknowledgements ....................................................................................................... 92 4.0 Beyond the Chhaupadi Shed: Exploring a Continuum of Menstrual Practices in Nepal using Collaborative Filmmaking .................................................................................... 94 4.1 Abstract ......................................................................................................................... 94 4.2 Introduction .................................................................................................................. 95 4.3 Methodology ................................................................................................................ 100 4.4 Results .......................................................................................................................... 102 4.5 Discussion .................................................................................................................... 122 4.6 Conclusion ................................................................................................................... 131 4.7 Acknowledgements ..................................................................................................... 132 5.0 Dissertation Discussion ....................................................................................................... 133 5.1 Future Directions for Research ................................................................................. 134 5.2 Dissertation Conclusions ............................................................................................ 139 vi Scoping Review Search Terms Developed with HSLS Librarian
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