SPH Theses and Dissertations

Primary Health Care (PHC) is considered capable of meeting 90% of people’s health needs and fundamental to achieving the Sustainable Development Number 3 of Good Health and Well-Being. Furthermore, there is abundant evidence of PHC’s positive health, equity, and economic outcomes in countries with well-resourced and well-functioning PHC platforms. However, despite the ample evidence regarding PHC’s effectiveness, PHC has also failed to deliver on its promises in several countries, particularly in LMICs. Because of this, it is increasingly recognized that to deliver on its promises, PHC must be of high-quality and high performing itself and, consequently, redesigned and reorganized.

This thesis presents a set of themes and approaches to how the delivery of primary care can be redesigned and reorganized in LMICs to improve health outcomes based on an umbrella review of the evidence available in the peer-reviewed scientific literature on delivery arrangements, as defined by Cochrane’s Effective Practice and Organization, implemented in primary care settings and conducted in, or applicable to LMICs.

Through the umbrella review, 1269 reviews were identified, and 84 of them were included. The findings of these reviews were grouped into the main delivery arrangements of the interventions that they evaluated, as well as according to their health categories (e.g., mental health). Some of the key findings of the umbrella review are the following: Nurses can take on responsibilities currently assigned to primary care physicians for highly prevalent conditions, such as NCD and HIV care; integration or linkages of care throughout the continuum of care consistently improved outcomes for some conditions; LHWs can substitute some in-service care with at-home or in-community care, as well as support and enhance the care for several conditions; and remote consulting was found effective for NCD care and mental health disorders.

Through the analysis of these findings, it was identified that team-based delivery, proactive care, integration throughout the continuum of care, and leveraging mHealth and telemedicine for dialogue-based services were common elements of the design of highly effective interventions. Building from the findings, this project presents an approach to designing more effective PC models by using bundles of interventions, termed bundled primary care, for different conditions along the care continuum. The thesis concludes with a case study of Chiapas and Mexico City to illustrate the application and the suggested context-specific design of models of care in primary care.

This project sets forth the idea that the provision of primary care should be designed in bundles of delivery arrangements or interventions at each step of the continuum of care, based on the best available evidence, delivered by a diverse group of providers.

The United States has more mass shootings than any other developed nation worldwide. These events are of particular concern to healthcare systems because they can result in many victims with complex, penetrating injuries that require extensive, time-sensitive care. Further, the US healthcare system continues to grapple with unprecedented staffing limitations, supply shortages, and capacity issues. The current context of converging challenges within US healthcare systems impairs their ability to respond to emergencies including mass shootings, stressing a critical need to better understand how hospitals can develop adequate emergency management plans to help them effectively respond to and mitigate the effects of these disruptive events. This study aimed to address two questions: 1) What can we learn from the experiences of hospitals that have responded to recent mass shootings in the US? 2) What unique challenges do community hospitals, whose experiences with mass shootings have not been studied, face in preparedness, response, and recovery for mass shooting incidents? These questions were explored with a series of qualitative interviews with first responders to six mass shootings and one mass casualty event across the US, as well as analysis of five incident preparedness toolkits developed by national expert organizations. Five major needs were identified that must be addressed when planning for, responding to, and recovering from mass shootings: 1) engaged leaders who advance preparedness; 2) mass casualty plans based on realistic assumptions and that consider the current healthcare system; 3) timely and consistent communication to combat misinformation during a hospital’s response and recovery; 4) rapid regional coordination for family assistance and reunification centers; and 5) robust support and mental health services for patients and staff. Adequate and realistic planning at organizational and regional levels is essential to optimize and coordinate response to unexpected mass casualty events. An appropriate preparedness plan ensures that responsibility, accountability, and roles are clarified in advance and facilitates efficient communication, resource utilization, and safety of staff and patients—helping hospitals and healthcare systems better respond to and mitigate the effects of emergencies such as mass shooting events.

The demands of modern life are eroding the quantity and quality of people’s sleep, causing a significant public health problem. Circadian Positioning Systems (CPS), a startup headquartered in Newport, RI, has developed a sleep and circadian-rhythm-targeted platform technology that enhances circadian alignment. It is a potential solution for lifestyle-related sleep deficiency that impedes productivity and performance, increases our risk of accidents, and can lead to chronic health conditions. Startups like CPS require funding and resources to develop and scale their products. One strategy for acquiring resources is to collaborate with other companies. This qualitative study explores strategic alliance opportunities in healthcare for CPS to make their sleep technology accessible to the general public.

Twenty semi-structured interviews were conducted with stakeholders and experts in healthcare from the public health, health and wellness, health insurance, and pharmaceutical sectors. Qualitative thematic analysis was used to identify and examine patterns emerging from the data. Most participants were enthusiastic about the potential for the wearable patch component of the platform to provide more accurate measures of sleep during continuous monitoring for up to six weeks. Viable strategic alliance opportunities exist across all sectors with the lowest barrier to entry and greatest potential to partner with health and wellness-related organizations.

The post-COVID-19 digital health revolution has contributed to increased interest in emerging digital health technology for monitoring, diagnosing, and treating adverse health conditions. The CPS platform technology has the potential to make an impact in health and wellness, patient monitoring, clinical care, health insurance, and pharmaceutical settings.

Background: US healthcare systems have begun establishing and expanding supplier diversity and local purchasing programs, in response to an increasing focus on equity and the role of hospitals as anchor institutions. The literature contains multiple lists of best practices and recommendations but does not contain an analysis of the complexities that stymie successful implementation.

Aims: This thesis provides a framework to understand the complexities of impact purchasing and offers some recommendations based on that framework.

Methods: The analysis relies on three primary sources of qualitative data: semi-structured interviews with 20 healthcare purchasing experts; insights from five reports highlighting healthcare impact purchasing case studies; and the author’s observations and conversations with colleagues while working at UMass Memorial Health. Structuring the analysis around Bolman and Deal Reframing Organization’s Four Frames, these data sources were coded to identify key themes.

Results: Through decades of pressure to reduce costs and respond to increasing quality standards, contracts with vendors in the healthcare sector have grown in scale, complexity, and specificity, limiting the ability of small businesses to respond competitively to bids. The reduced capacity to compete has also been driven by unequal access to capital and rising local labor costs. Common approaches to supplier diversity in healthcare rarely acknowledge or address the historical origins that have created the current purchasing system in healthcare, limiting the health system’s ability to create the desired economic growth impacts.

Recommendations: Healthcare leaders should update purchasing processes, ensure adequate staffing to handle the relationship-intensive work of connecting with local and diverse businesses, and build data systems that enable decision-making. Leaders should empower and incentivize staff at multiple levels (within supply chain and the departments making purchasing decisions) to make changes. Senior leaders must link supplier diversity to business strategy, and leaders at all levels should negotiate with vendors and others to create innovative solutions and multiply impact. Finally, by continuously telling stories, leaders can position local and diverse supplier efforts as an important symbol of the organization’s commitment to diversity, equity, and inclusion, likely increasing the interest of local and diverse vendors in doing business with system.

Musculoskeletal Disorders are the leading cause of pain and disorder in the United States and globally. Of all musculoskeletal disorders, back pain is the most prevalent, with a lifetime prevalence of 84% for any form of back pain and a prevalence of 23% for chronic low back pain. This burden of pain has led to calls for a cultural shift in how pain is diagnosed and treated in the United States by the Institute of Medicine and National Institute of Health, and other Federal and State agencies. The IOM and the NIH's central recommendation is to design new pain care models that rely on individualized, multimodal, multidisciplinary care, centered on establishing a patient-clinician therapeutic alliance and shared-decision making. The doctoral project involved 15 semi-structured patient interviews and 10 physical therapist interviews to assess therapeutic alliance and patient experience in the MSK rehab and pain care context to inform a startup organization looking to remodel MSK pain care through telehealth. Themes identified under the therapeutic alliance fell under a Goal, Task, and Bond conception. Themes identified for patient experience fell under the categories of Barriers, Adherence Determinants, and Patient Pleasers. Finally, the thesis presents recommendations to the startup on translating the learning on the therapeutic alliance and patient experience into a consumer-focused strategy. The recommendations aim to guide the startup on strengthening the alliance and improving the patient experience through telehealth. Furthermore, it addresses relevant considerations regarding the forces of structure, financing, public policy, technology, consumers, and accountability that healthcare innovators are bound to experience.