SPH Theses and Dissertations

Climate change is increasingly being recognized as the single most significant threat facing global health. Urgency is now growing globally to address the health impacts of this threat. However, despite this momentum, existing frameworks fail to integrate climate change and health (CC&H) pathways with solutions and targets. This applied research project aimed to bridge this gap and create a solutions-focused policy tool to support global health practice.

Through a literature review and semi-structured interviews with global philanthropic organizations, the research identified key challenges and opportunities. Findings revealed that CC&H pathways can be well articulated but that a comprehensive current understanding of the burden of disease associated with CC&H pathways remains elusive. In addition, a lack of formal CC&H strategies amongst philanthropic organizations exists. Many organizations are grappling with how to define and evaluate their CC&H work while overlooking existing global development agenda goals and targets. Overall, a persistent state of confusion prevails.

Investment into the conditions for CC&H solutions to emerge independently of direct philanthropic support was identified as a major conclusion of this project. Philanthropy must invest both directly in CC&H solutions AND indirectly in the conditions that will enable CC&H innovation to occur. Investments must focus on building an understanding of the current burden of disease from climate change and identifying universally agreed-upon CC&H global goals and objectives, including the use of existing global development agenda goals and targets.

To address the state of confusion, a results-oriented novel taxonomy was developed. The Taxonomy for Climate Change and Health Solutions Pathways categorizes seven key CC&H pathways. The seven pathways are extreme temperature, food insecurity, mental well-being (encompassing forced displacement), poor air quality, water insecurity, pathogens and vectors, and health systems. Each pathway includes a description of climate change drivers, the impact of drivers on individual pathophysiology or social systems that influence health, health outcomes associated with each pathway, relevant adaptation and mitigation solutions, and Sustainable Development Goals (SDGs) targets.

As a tool, the taxonomy facilitates communication, enhances understanding of the impact of climate change on health, and can help foster collaboration amongst organizations and stakeholders. In turn, the tool can enable evidence-informed decision-making and transformative policymaking. It is believed to be the first tool to integrate CC&H pathways, solutions and metrics, thereby filling a critical gap in the literature and policy-making practice.

Our most intractable social problems—like poverty, climate change, and terrorism—are highly complex, contradictory, and cross-cutting. Often termed "wicked” or “adaptive” problems, they differ from the complicated yet resolvable nature of ordinary “tame” or “technical” issues in that there is limited consensus about the etiology of the problem, difficulty deciphering effective responses, a significant degree of overlap with other problems, and a high likelihood of conflict arising between groups trying to solve it. Using a healthcare lens, this DELTA project considers how Utah’s high rate of suicide is an example of a wicked problem, and the implications of such characteristics on efforts to reduce suffering and save lives. The qualitative methodology included: 1) interviews with 30 primary care providers to elicit their experiences, perceptions, and practices regarding suicide assessment and management at a clinical level and to compare their input to a previous study sample of 30 mental health providers; and 2) an ecosystem analysis at Intermountain Healthcare, the non-profit, integrated network that hosted this DELTA project, to understand the organizational and leadership dynamics surrounding suicide prevention at a healthcare delivery system level.
Drawing on analysis of these firsthand perspectives, the research finds that suicide is a wicked problem characterized by a high level of uncertainty surrounding the problem and solutions, a high level of interconnectedness with other problems, and high potential for social and political conflict. It identifies key areas of collaborative action needed to facilitate coherent response, and offers recommendations for the host organization as it embarks on a system-wide initiative to prevent suicide. It concludes that only by focusing the healthcare system, including primary care providers, on population-oriented and collaborative approaches—especially reductions in access to firearms—can Utah begin to move the dial on suicide. This project is the first known in-depth application of the wicked problem framework to the issue of suicide. It offers immediate opportunities for improving collaboration and problem-solving on suicide prevention in Utah, and provides a practical model for actionable applications of research to highly-complex public health problems.

Approximately 300,000 persons are infected with the causal agent of Chagas disease (CD) in the United States (US) but less than 1% of them are estimated to have been treated. In 2017, the US Food and Drug Administration approved benznidazole, a medicine for CD treatment, and Exeltis USA began supplying it commercially in May 2018. Despite this FDA approval, access to CD treatment remains limited to date. This Access Plan was developed as a Doctor of Public Health DELTA project to provide a strategic guide to expand access to benznidazole in the US. The project applies the access framework found in the public health literature to understand barriers, facilitators, and key actors that shape CD patients’ ability to obtain and use benznidazole. In addition, key barriers to CD diagnosis are also examined. The Access Plan identifies seven key barriers to benznidazole: 1) no formal structure to facilitate collaboration between key actors, 2) physician’s failure to use specific paper forms to order benznidazole, 3) lack of emergency benznidazole delivery, 4) uncertain financial sustainability of Exeltis’ drug subsidy program, 5) limited number of treaters offering CD treatment, 6) obstacles for patients seeking medical appointments, and 7) inadequate evaluation of patient eligibility for treatment. The project also found five key barriers to diagnosis: 1) limited screening opportunities at the primary care level, 2) limited access to physicians for seropositive blood donors, 3) limited physician knowledge about diagnostic procedures, 4) uncertain affordability of testing, and 5) unknown reliability of the currently used diagnostics. To overcome these barriers, the Access Plan proposes eight areas of strategic actions in which Exeltis and Fundación Mundo Sano could take actions in collaboration with other actors. These areas are intended to: 1) establish emergency benznidazole delivery, 2) ensure financial sustainability of the drug subsidy program, 3) organize and educate treaters, 4) promote patient networking, 5) implement pilot screening projects, 6) educate providers about diagnostic testing, 7) promote development of guidelines for screening, diagnosis and treatment, and 8) facilitate multi-sectorial coordination. Taking the actions proposed in this Access Plan will contribute to expanding access to CD treatment in the US.

This doctoral thesis examines how different aspects of health systems strengthening (HSS), such as human resources, supply chain, service delivery, and governance, can contribute to achieving universal health coverage (UHC). The doctoral thesis contains two key sections: the Analytical Platform, which examines key aspects of the existing literature on this topic, and the Results Summary, which presents a case study from Lesotho. The Analytical Platform consists of one narrative chapter focused on the role that values can play in setting health system priorities, and two systematic reviews which examine whether different HSS interventions - namely 1) task shifting and 2) improvements to health product procurement and supply chain - can improve health system efficiency in low- and middle-income countries (LMICs). The first review finds that substantial evidence exists for task shifting as a means to generate cost savings for care related to tuberculosis, HIV/AIDS, and various other diseases at the primary health care (PHC) and community levels. The second review finds that substantial evidence exists for pooled procurement as a means to achieve cost savings, and that a wide range of supply chain interventions can increase drug availability in different contexts. The Results Summary synthesizes Lesotho’s experience with a National PHC Reform, which sought to strengthen health systems to create universal access to comprehensive PHC and which can in turn serve as the foundation for broader UHC in the country. The Reform consisted of interventions at multiple levels, including a Village Health Worker (VHW) program, expanded services at clinics, decentralized management of the district health system, and central oversight of the Reform. Documentation of the Reform noted several key insights. First, in this model, VHWs do not simply have discrete clinical tasks, but rather have cross-cutting activities that aim to increase patient utilization of services across multiple disease areas. Second, by taking a comprehensive approach to improve population health, the Reform model specifically aims to build state capability in strengthening health systems. The findings from the Analytical Platform and Lesotho’s experiences documented in the Results Summary are relevant for policymakers, practitioners, and researchers working to achieve UHC through HSS in LMICs, especially in a post-2015 agenda.

While it is a good thing that modern medicine allows people to live longer and postpone disability due to chronic illness, there has been a relative lack of focus on how to support patients as their underlying illnesses become the source of biological, psychological, sociological, and spiritual (bio-psycho-socio) suffering, and impacts quality of life. One type of program that is designed to address these needs is known as advanced illness support (AIS). Although there is growing need for AIS programs, they remain difficult to access for the more than forty million Americans with serious illnesses and functional dependency. This Doctoral Project focused on evaluating a home-based palliative care pilot called the “Advanced Illness Support Program” (AISP) that was specifically designed and implemented by Blue Cross Blue Shield of Massachusetts to support the commercially insured population in Massachusetts with advanced illnesses. The evaluation sought to better understand the needs of this population, the challenges of identifying and recruiting appropriate patients into the program, and, ultimately, to continue to improve the design of the AISP program. The framework of Adaptive Leadership was used to conceptualize, study, and evaluate the pilot to address the challenges and propose new areas for research and practice. The evaluation included in-depth qualitative interviews with pilot program stakeholders to assess barriers, challenges, and successes of the pilot. The issues identified during the pilot require a mix of both “technical” and “adaptive” solutions. The pilot highlights the adaptive challenges of having a clear and consistent method of defining and identifying seriously ill patients, and an understanding of the holistic services that patients, caregivers, and families need. Many technical solutions can help improve advanced illness support, but the work will require mobilizing frontline clinical staff to test out iterative improvement processes to refine the program, including developing more effective patient identification and outreach approaches. The lessons learned from the pilot can help to guide the continuing efforts to care for this vulnerable population and provide insights into next steps in the evolution of the Advanced Illness Support Program – and community-based palliative care services in general.

This doctoral thesis, Advancing Health Equity Through Multi-Sector Collaboration, highlights the need for multi-sector collaboration to address current health inequities. It is focused on three separate projects based in three distinct sectors, which included: local government, a primary care association, and a collaborative focused on creating partnerships and elevating data, policies and practices that promote health equity. The methods employed to better understand the difficulty of facilitating a cohesive multi-sector collaboration and achieving successful outcomes included a survey, a set of interviews, and an assessment of the literature on the effectiveness of policies and programs to improve health opportunity. Although the project goals for each organization differed, collectively they provided insights into the challenges presented when building a multi-sector collaboration, and allowed for the identification of the necessary elements that enable the success of multi-sector collaboration to advance health equity. This doctoral thesis highlights current knowledge on multi-sector collaboration in policy and in public health, delineates the goals, methods and findings based on the three projects and concludes with considerations towards achieving multi-sector collaboration to advance health equity.

Entrepreneurship plays a major role in developing innovative medical technologies that contribute to better public health; however, most entrepreneurs fail to scale their innovations. One of the most commonly cited reasons for startup failure is the lack of customer need. Therefore, during the early stages of the startup lifecycle, entrepreneurs must focus on achieving product-market fit by developing robust value propositions that will enable early market success. The goal of this Doctor of Public Health (DrPH) thesis is to assess the challenges and opportunities associated with a host organization’s value proposition for its product offering. The host organization for this project, UrSure, Inc., is an early-stage startup established at the Harvard Innovation Labs seeking to improve adherence to HIV pre-exposure prophylaxis (PrEP) medications through the use of a novel diagnostic test. As part of this doctoral project, I took a full-time position as Director of Business Development at UrSure from June 2018 to March 2019. This experiential learning, combined with an interdisciplinary review of entrepreneurship and public health literature, informed the development of a qualitative research protocol to understand the needs, opportunities, and purchasing behaviors of customers in a key market segment, 340B clinics. I interviewed thirteen health care providers at 340B clinics that offer PrEP services and used thematic analysis to uncover three global themes that provide insight on UrSure’s customer value proposition. From the global themes, I distilled implications for practice in the form of three strategic recommendations to help UrSure improve its chances of achieving entrepreneurial success. The first recommendation is to conduct ongoing customer discovery research. The second recommendation is to consider reframing the value proposition to more aptly meet the unmet needs of potential customers. The third recommendation is to continue generating evidence on the efficacy and utility of PrEP adherence testing. This thesis also presents important lessons learned that can inform customer development strategies at other health care startups to increase the likelihood of successfully commercializing impactful public health interventions.

With a continued focus on the UN Sustainable Development Goals, we recognize the impact of poor ocean environments on human health. This is particularly relevant given the large number of weather-related disasters along the increasingly dense coastline. In order to ensure continued access to vital ocean resources, we need to develop early warning triggers to alert for potential issues before they become unmanageable. The Ocean’s “Canary” is the Shark; who serves as an integral part of the ecosystem by ensuring the entire ocean remains balanced. Specifically, my Doctoral Engagement in Leadership and Translation for Action (DELTA) project was to create translational knowledge to support the global effort in policy change, specifically related to shark conservation. Utilizing the Kingdon “Multiple Streams Policy Framework,” I offer Shark Angels, a non-governmental organization focused on shark conservation, with a method of preparing to more adeptly influence policy change at any level. By delving into each aspect of the framework, and specifically applying it to the issue of shark conservation, Shark Angels can now better assess their internal organizational gaps and prepare for a future window of opportunity to open. In addition, my work offered me a unique perspective into Shark Angels’ internal processes. This provided me with some insights that may be hindering their organizational capacity, but may also be adapted to a variety of other organizations. The result is to offer Shark Angels with some areas for consideration, which have the potential to greatly enhance their organization’s capacity for future growth and subsequently improve their ability to influence policy change.

Currently, there is a lack of global health education and research opportunities in low- and middle-income countries in comparison to high-income countries. There is a critical need to address this gap because of the current intractable health problems — like climate change, antibiotic resistance, noncommunicable diseases (NCDs) and infectious outbreaks — which disproportionally affect more poor people in any country, but especially those living in low- and middle-income countries (LMICs). These global health problems tend to be the result of complex and unprecedented global forces such as globalization, ageing populations, and capitalism that require creative, transdisciplinary, and trans-sectoral responses. In response to these problems, “Global Health Education” (GHE) and “Global Health Research” (GHR) were developed as part of the global citizenship education movement. GHE and GHR aim to aid students in understanding global forces affecting their communities and encourage them to adopt a self-critical approach and use their agency to achieve equity and mitigate national and transnational risks through a health and research lens. However, while LMICs account for 84% of the world’s population, only 19% of the 195 affiliated global health institutions within the Consortium of Global Health Universities are located in LMICs. Likewise, only 10% of health-related research addresses problems faced by 90% of the world’s population – a phenomenon known as the 10/90 gap. Therefore, there is a need for more institutions promoting GHE and GHR in LMICs to equip local professionals with the tools they need to address global health challenges. The purpose of this doctoral project was to address the gap in global health education and global health research in LMICs by generating the theoretical bases and momentum for launching an Institute of Global Health Equity (IESG in Spanish) in a well-renowned university in México, a middle-income country experiencing myriad global health challenges like NCDs, infectious outbreaks, and climate change effects and with only one formalized academic global health institution. The aims of this doctoral thesis were to:

1. Assess the internal and external conditions and forces that enable, restrict, or facilitate the creation of a global health institution in Latin America, with a focus on México.
2. Codify the strategy, structure, pedagogy, resources, and processes for the IESG.
3. Develop and implement a community organizing effort and strategic action plan for the IESG that resulted in a proof of concept. To achieve these aims, I drew on a 10-month full-time immersion in my host institution as an academic professor, coordinator, and researcher. During my time there, I performed a critical analysis of the literature to assess the need and value of GHE and GHR, conducted qualitative research to explore and understand the perceptions of key stakeholders, interviewed and gathered advice from managers of other global health institutions, designed and taught global health courses, organized students and professors to convince the host institution leadership, and developed a summarized business plan for the IESG. This project is the first known in-depth application of research methods, full immersion and community organizing practices to create the basis to launch a global health institution in a LMIC. Furthermore, it provides a roadmap to advocates, students, professors or administrators interested in launching institutions to promote GHE and GHR in LMICs.

Background: Cervical cancer is a main cause of female cancer death worldwide; however,cervical squamous cell carcinoma (CSCC) is vaccine-preventable and curable if detected early. The fact that 348,000 women died from the disease, with 94% of deaths occurring in low- and middle-income countries (LMICs) in 2022, reflects the urgent need to integrate the multi-step continuum of care required for secondary prevention to increase coverage. Screening coverage across LMICs remains low, despite widespread national policies making cervical cancer screening a priority.

Methods: This study used an explanatory mixed-methods design combining a quantitative survey phase (Phase 1) with a qualitative, multi-country interview phase (Phase 2) to explore how cervical cancer screening and treatment services are integrated into health systems in GFF partner countries.

Results: Phase 1 demonstrated that screening coverage varies from 1% to 26% across GFF countries, with over 75% below 15%. A structural imbalance emerged: countries with the
highest HPV vaccination rates had the lowest screening coverage. A tiered country classification was designed to group partner countries into three tiers based on policy commitment, funding availability, and disease burden to guide tailored program support. Phase 2 qualitative analysis explained the mechanisms underlying the quantitative results, focusing on participants’ experiences during the implementation of HPV DNA testing. Participants described that HPV DNA testing requires women to interact with the health system multiple times, increasing the risk of an incomplete healthcare cascade. A causal loop diagram synthesized from both phases makes this structural logic clear and highlights where governance and financing investments are needed to break the cycle.

Conclusion: These findings reveal a gap between national commitments and operational realities, indicating that health systems are not yet structured to support the multi-step care pathway required by HPV DNA testing. Scaling up screening is not a technical challenge but requires a system level intervention. For those countries, this means tailoring support to each health system's readiness level, prioritizing government ownership and domestic co-financing, and viewing cervical cancer secondary prevention as an opportunity to strengthen the health system.

A child’s first few years are a critical developmental period that has enduring health effects, and children living in poverty are particularly at risk. The Rhode Island Department of Health (RIDOH) implements three evidence-based home visiting programs to ensure children have opportunities to thrive. These programs have demonstrated positive outcomes for children and families. However, RIDOH has been experiencing challenges in engaging families to enroll and participate in these programs. This DELTA project aims to: (1) identify factors that influence enrollment and participation across three home visiting programs for birth cohorts 2014-2016 in the four core cities where most disadvantaged families reside; (2) understand barriers in delivering and accessing home visiting programs. A mixed methods approach was taken. To assess factors thought to be associated with family enrollment and participation, bivariate and multivariate analyses of data were performed. Potential engagement factors included characteristics of child (disabling condition, low birth weight), family (maternal age, marital status, health insurance, language, and prenatal visits; and parental education, race/ethnicity, and social-behavioral factors) and other (participation in short-term home visiting program). To provide more context for these results, focus groups and interviews were conducted with 45 home visitors and other staff as well as 40 families with young children to understand barriers in delivering or accessing home visiting services.
Though RIDOH was successful in targeting high-risk population, there was low enrollment—28% to 64% of eligible children across the four core cities. However, once enrolled participation was high with over 90% having more than 4 visits. Lack of awareness or understanding of home visiting programs and indicators of greater vulnerability appeared to contribute to low enrollment rates. Young maternal age, public insurance, <12th grade maternal education, minority race/ethnicity, social-behavioral factors (e.g., substance use, involvement with foster care), and prior contact with short-term home visiting program were significantly associated with lower enrollment. Only language (non-English) was correlated with higher participation. Recommendations for RIDOH to increase family enrollment and sustain participation in home visiting programs are: (1) conduct outreach to increase awareness of programs; (2) support home visitors; (3) use an integrated home visiting – mental health model approach; and (4) involve families to identify needed community resources.

Gavi, the Vaccine Alliance, has been critical in improving immunization coverage and equity in low- and middle-income countries (LMICs) since its inception in 2000. Based on Gavi’s unique transition model, 19 countries have transitioned from Gavi’s support and become “Gavi graduates,” expecting to sustain their immunization performance as a self-financing country. However, the COVID-19 pandemic tested the resilience of these countries' immunization systems and raised concerns about their sustainability after graduation. This study evaluated whether Gavi’s past investments contributed to building resilient immunization systems in former Gavi-supported countries (FGCs) and what systemic challenges they faced.

This study applied a mixed-methods approach by integrating Difference-in-Differences (DiD) analysis and key informant interviews (KIIs). The quantitative analysis compared immunization performance trends in 19 FGCs and 26 never-Gavi-supported LMICs (NGCs) during the pandemic, focusing on DTP3, DTP1, and MCV1 coverage using WHO-UNICEF Estimates of National Immunization Coverage (WUENIC) data. The qualitative component consists of 20 semi-structured interviews with policymakers, global health experts, and immunization program managers to explore systemic factors affecting immunization sustainability in FGCs.

The DiD analysis revealed that FGCs experienced 3.74 (95% CI -4.92, -2.56) percentage points greater decline in DTP3, 3.85 (95% CI -4.78, -2.93) percentage point in DTP1, and 5.7 (95% CI -6.72, -4.69) percentage points in MCV1, compared to NGCs by 2023. The decline of DTP1 coverage in FGCs is equivalent to 371,000 to 430,000 additional zero-dose children. Qualitative findings revealed systemic gaps in vaccine procurement capacity, budget constraints, and governance systems. Stakeholders noted that graduation criteria may not fully capture a country’s readiness to sustain immunization performance, and the lack of tailored transition support limits the sustainability of immunization programs in FGCs.

The study proposed prioritized recommendations: refining graduation criteria to assess country readiness in the short-term, establishing a post-transition technical assistance mechanism in the mid-term, and institutionalizing the MICs Approach for tailored support in the long term. As Gavi enters its 6.0 strategy cycle (2026–2030), there is a window opportunity to implement these recommendations and strengthen the sustainability of immunization systems in FGCs and transitioning countries.

The United States (U.S.) is the country with the highest per-capita spending on healthcare services, but ranks near the bottom among peer countries for social services spending. This underinvestment in social services has been theorized to be a factor for why the U.S. healthcare system ranks among the bottom on access, quality, and population health outcome indicators. While improvements in medical care quality could prevent 10-15% of premature deaths, the remaining root causes include genetics, and the social, economic, and environmental determinants of health. Policy and program interventions to improve social and economic disadvantage, reduce poor social behaviors, and enhance built environments, could reduce population health inequities and improve health status overall. Yet, healthcare systems do not yet know how to translate this research evidence into effective and equitable interventions to improve population health and reduce health inequities. Stronger evidence of intervention effectiveness is needed, with accompanying implementation and dissemination research, to guide decision-making and secure funding for social determinants of health interventions in clinical settings. This DELTA Project fills a gap in the literature by providing an in-depth, qualitative case study on the implementation of a Clinic-to-Community (CCI) integration strategy to intervene on one specific socio-economic determinant: food insecurity. In Part 1: Analytical Platform, I first provide a brief overview of the U.S. healthcare system performance and social determinants of health drivers contributing to poor healthcare access and status. Second, I conduct a comprehensive assessment of food insecurity, including definitions, burden, risk factors, and associated health outcomes. Third, I provide a review of government policies and healthcare system programs to address food insecurity. Finally, I introduce the program design for the CalFresh Enabled Enrollment Pilot Program, with special focus on the theoretical framework and implementation strategy. In Part 2: Results Statement, I utilize the descriptive case study methodology to assess the DELTA residency along the following stages: on-boarding months, planning months, and implementation months. In the concluding section, I articulate key learnings, including critical reflections on the original project theory and strategy, and discuss future directions.

Introduction: Prediabetes (intermediate hyperglycemia) is a high-risk state that is defined by glycemic variables that are higher than normal, but lower than the diagnostic threshold for Type 2 Diabetes Mellitus (T2DM). Nutu, a mobile application developed by Willow Laboratories, provides daily nudges to help users monitor their lifestyle and adopt healthier behaviors to reduce their risk for prediabetes. Willow Laboratories plans to expand into the Saudi market and is interested in understanding the current regulatory and policy infrastructure to support the launch of Nutu.

Objectives: To identify the key factors under which a digital prediabetes prevention platform can achieve successful adoption, scaling, and sustainability within the Saudi healthcare system, thereby addressing the disparity between policy ambition and implementation.

Methods: This study used a qualitative, exploratory research design with semi-structured interviews conducted with 35 senior leaders across the health care system, including policymakers, industry leaders, clinicians, and academics. The data were analyzed using a two-stage approach: Framework Analysis and NASSS (Nonadoption, Abandonment, Scale-up, Spread, and Sustainability)- structured synthesis.

Results: Prediabetes is a condition of public health importance that is not currently prioritized in National Clinical Guidelines and Care Pathways. From a policy perspective, the regulatory environment for new products or services aimed at the prevention and management of obesity and diabetes is considered positive, with strong political commitment to meeting Vision 2030 targets. However, several issues need to be addressed, including over-regulation, limited capacity to conduct clinical trials, poor health information systems, a price-oriented procurement system of health products, and the general lack of dialogue and coordination among stakeholders.

Conclusion: Even though Vision 2030 has made a huge difference in how the Saudi Healthcare system and innovation are changing, my assessment of the Saudi Ecosystem found that the majority of the NASSS domains will need significant work to deliver an effective prediabetes intervention. However, with the right engagement with regulators, a culturally relevant value proposition for the Saudi market, and the right partnership, I believe that Nutu can be successfully adopted, validated, and scaled for the Saudi market and for sustainable impact.

Creating large-scale health system change requires a combination of technical solutions and political skills, analysis, and strategies. Understanding the political context of health reform is crucial to improving the chances of effectively designing, adopting, and implementing health policies that can achieve their intended objectives. Applied political analysis has been used to support health reform in diverse national contexts in low- and middle-income countries for different purposes. However, there are few published accounts of the process of conducting applied political analyses, let alone evaluations of the outcomes of political strategies. This gap in the literature hampers the development of the field of applied political analysis for health reform. A proper understanding of what works and what does not in doing applied political analysis is required to support health reform processes. This DELTA thesis examines the process of conducting an applied political analysis to inform the development of policy proposals to improve the performance of the health system in Odisha, India. An applied political analysis of the position, power and interest of the stakeholders involved in health policy changes helps to understand their role in promoting, resisting, or blocking implementation, and the dynamics of their interactions (Reich, 2002). I followed the Six Steps for Applied Political Analysis (Reich & Campos, 2019): 1) Define the audience (client) and the problem; 2) Identify the policy to promote; 3) Describe the context of the policy; 4) Conduct a stakeholder analysis; 5) Design a set of political strategies; and 6) Assess the impacts of your political strategies. A purposive sample of stakeholders was selected to represent five different groups in the health policy ecosystem in Odisha: interest groups, bureaucrats, financial decision-makers, leaders, and beneficiaries (Campos & Reich, 2019). Applied political analysis does not guarantee success in policy reform or implementation. Policy processes are often unpredictable, and the context may change from one day to the next. However, being prepared to manage the political dimensions of health policy processes can increase the likelihood that the changes will be adopted and will achieve the desired outcomes. The role of applied political analysis is to help reformers engage effectively with the political context to create political feasibility for health reform. I offer four key lessons on how to improve the process of conducting a stakeholder analysis: 1) Purpose and framing: having a clear purpose for the analysis, a clear problem, and an engaged audience; 2) Timing: harmonized timelines and workplans of the technical and political analyses teams are needed; 3) Organizational context: a team of internal and external analysts, and regular communication with the client are essential; 4) Methods: the choice of the methods will depend on the purpose of the analysis and on the resources available to conduct it. Repeating the analysis over time as the policy process unfolds, and keeping track of stakeholders and strategies, can increase the chances of successful reform.

Value-based health care (VBHC) is a critical approach that ties physicians’ incentives to patient outcomes. Several high-income countries proved that VBHC improves overall patient outcomes without raising costs. However, lower- and middle-income countries (LMICs) are left behind due to barriers such as immature health financing systems and the lack of health information technology (HIT) infrastructure to collect information on costs and patient outcomes. The most practical starting point for LMICs is to develop a HIT system that collects reliable data on cost and patient outcomes to guide the transformation towards VBHC. This doctoral project demonstrates that a cloud-based electronic health record (EHR) is a feasible solution to collect data points required for VBHC, even in low-resource settings. Embedding components of VBHC into the EHR also reveals positive effects that extend beyond capturing data, such as inspiring teamwork between caregivers, encouraging positive doctor-patient relationships, and promoting excellent patient satisfaction. The outcome of this doctoral project helps to prove that HIT can be an enabler for VBHC in low resource settings. Hence, VBHC should be advocated as a key to improving outcomes and value to patients in LMICs just as it is in high-income countries, and providers should focus on HIT as a starting point to collect reliable data on cost and patient outcomes to start the journey towards VBHC.

Drowning is the leading cause of death among children aged 1–4 years in the United States, a pattern that has persisted despite decades of evidence-based prevention strategies. Childhood drowning mortality is concentrated in early childhood, marked by persistent racial disparities, and strongly shaped by the environments in which children encounter water. This study examines national patterns of childhood drowning mortality alongside a detailed environmental case study in Texas to better understand how drowning risk varies across age, race and ethnicity, and drowning environment. National mortality data were analyzed in combination with Texas setting-specific fatality data to characterize patterns by age and environmental context. Findings demonstrate a clear developmental pattern in drowning risk. Bathtub and container drownings occur primarily during infancy, residential swimming pool drownings predominate during early childhood, and natural water environments increasingly account for deaths during adolescence. Drowning deaths among young children were overwhelmingly concentrated in residential backyard pools. Persistent racial disparities further reflect differences in access to swimming skills, water safety resources, and safe aquatic environments. These findings indicate that childhood drowning risk is age-specific, environmentally patterned, and shaped by structural inequities. Prevention strategies must therefore be aligned with the environments in which children are exposed to water at different stages of development.

Mental health care is often characterized by coercion, abuse and ill-treatment. At the same time, there has been increasing interest in rights-based approaches to health. However, it is not always clear what the actual meaning of a rights-based approach is. This is particularly true in the field of mental health, and the dearth of scholarly research on this subject is especially pronounced in poorly resourced settings in low and middle-income countries. In the context of the Doctoral Engagement and Translation for Action (DELTA) project of my Doctor of Public Health degree, I engaged with the Open Society Foundations to research the content of rights-based approaches to mental health and psychosocial support services in Kenya, where a significant amount of the organization’s work on community-based mental health is located. I interviewed ten key stakeholders, including service providers and service users, to ascertain what they perceived to be rights-based approaches to mental health in terms of content and in terms of the potential contribution of these approaches to mental health systems. I also asked about the supports and barriers to implementing rights-based approaches to mental health and psychosocial support services. Using an interpretivist methodology, I organized the interview data into three categories, namely: Key components of a rights-based approach to mental health; the contribution of a rights-based approach; and key barriers and supports related to implementation of a rights-based approach. Central principles of rights-based approaches were identified and these principles inform the interventions that might be said to embody a rights-based approach, thus aiding in the key challenge of implementation. Participants noted some challenges to implementation, while also highlighting supportive factors. Questions remain around the role of traditional healers and the acceptability of coercive practices, but this research highlights the central components of a rights-based approach that can guide interventions, facilitate standardization and inform future research. Moreover, in keeping with the goals of the DELTA, it provides a platform for further work on rights-based approaches to mental health at the Open Society Foundations, which hopefully will lead to better resourcing and increasing attention to these models.

Infertility carries substantial psychological burden, yet psychosocial support remains limited, particularly outside active treatment. Meta-analytic effect sizes for expressive writing on quality of life in infertile populations remain negligible to small (g = 0.00 to 0.05). No study has evaluated structured expressive writing among women experiencing infertility outside treatment settings. INSPIRE is a single-blinded randomized controlled trial among women trying to conceive for over two years, not undergoing stimulated or medicated fertility treatment, with moderate to high infertility-related distress. Exclusions included active suicidal ideation, current psychotherapy, and recent pregnancy loss. Participants were randomized 1:1 via blocked randomization to structured expressive writing or matched neutral journaling delivered over four consecutive days via hybrid Zoom and REDCap. Recruitment used paid social media. The primary outcome is change in FertiQoL. Secondary outcomes include a five-item distress composite assessed at baseline, post-intervention, and four-week follow-up. Models adjusted for baseline FertiQoL. Twenty-nine participants (15 control, 14 intervention; mean age 39.7 years, 72.4% US-based, trying to conceive over two years) were analyzed from a target of 220. Baseline FertiQoL was comparable between groups. Adjusted between-group difference in FertiQoL Overall was 5.55 points (95% CI: -1.56, 12.67) at follow-up. The Emotional subscale showed an 11.30-point improvement at follow-up (95% CI: 0.89, 21.71; d = 0.59), a clinically meaningful effect exceeding prior benchmarks. The distress composite difference was -1.86 (95% CI: -3.75, 0.03) at follow-up. Emotional intensity was consistently higher in the intervention group at baseline and across all writing sessions, with greater Day 4 relief. These preliminary findings require confirmation in the fully powered sample. Preliminary findings suggest structured expressive writing may improve fertility-related quality of life, with clinically meaningful effect sizes. If confirmed, this intervention may offer scalable psychosocial support for individuals experiencing infertility outside active treatment.

This work was undertaken to critically examine whether and how a managed care organization can address the social determinants of health for vulnerable Medicaid populations. Unprecedented changes are taking place in the U.S. health system, and more scrutiny has been devoted to publicly financed healthcare spending and outcomes. Fostering and funding efforts that find innovative ways to meet the distinct needs of Medicaid populations have risen to the top of state and federal policy agendas. Complementary to this shift, the broader social conditions and the social determinants of health (SDoH) that structurally influence the health outcomes of populations are receiving increasing attention.