SPH Theses and Dissertations

This dissertation investigates the disease burden from coal-fired power plants from global perspective. First, the study estimated changes in national lung cancer incidence decades after building or closing coal-fired power plants. The study secondly estimated the relative risks and incident cases of cardiovascular diseases (CVD), particularly ischemic heart disease (IHD), attributable to sulfate oxide (SOx) emission from coal-fired power plants from a global perspective. Since China is one of the most greenhouse gas (GHG) emitting country, we proposed “flying S” pattern to examine and forecast carbon dioxide (CO2) emission in the next decades. For the chapter one, standardized lung cancer incidence from every country with electrical plants using coal as primary energy supply were followed from 2000 to 2016. We applied a Poisson regression longitudinal model to estimate the association between lung cancer incidence and per capita coal capacity. We fund that with 1 kilowatts (KW) increase of coal capacity per person in a country, the relative risk of lung cancer increase by a factor of 85.1% (95%CI=1.217~2.816) among males and 58.5% (95%CI=1.070~2.347) among females. Based on the model, we estimate a total of 1.41 million standardized incident cases from lung cancer were associated with coal-fired power plants in 2015. Chapter two analyzed the relative risk of CVD incidence associated with national SOx reduction for 13,581 coal-fired power-generating units in 79 countries. A 10% decrease in SOx emission was associated with 0.28% (males; 95%CI=-0.39%~0.95%) and 1.69% (females; 95%CI=0.99%~2.38%) lower CVD risk. The effects on IHD were >2 times stronger among males than females (2.78%, 95%CI=1.99%~3.57% vs. 1.18%, 95%CI=0.19%~2.17%). Further, 1.43% (males) and 8.00% (females) of CVD cases were attributable to suboptimal SOx reduction. Thus, enhancing regulations on SOx emission control represents a target for national and international intervention to prevent CVD. In chapter three, we applied mixed effect model to examine the ex post data and predict per capita emission for selected countries in the same flying geese (FG) group in Asia. The “flying S” hypothesis says the trajectories of per capita CO2 emission would just mirror each other for countries within a same FG and having relatively constant energy matrix across time, ceteris paribus.

Second-generation antipsychotics are unaffordable and inconsistently available to people with schizophrenia in Rwanda. This study conducted and assessed the health economic and market access components of an initiative to improve access to these medications in Rwanda. It was conducted in the context of a partnership between a global pharmaceutical company and a governmental agency. The study employed ecosystem analysis; health economic modeling using a cost- consequence model; and the design of a feasibility study, including the selection, development, and adaptation of scales related to health economics and other topics. Insights from the implementation and production of an ecosystem analysis, health economic model, study protocol, and scales are discussed. As a result, the partnership is well-positioned to successfully execute a health economic modeling study and feasibility study, demonstrate the health economic and social impact value of second-generation antipsychotics for Rwanda, and improve access to these medications within the country. Key enablers for increasing access to schizophrenia treatment in Rwanda are presented, related to the criteria for a committed and successful partnership, and the importance of patient perceptions, task shifting, capacity building, and the decentralization of mental healthcare into community-based primary care. Key barriers to increasing access are also presented, regarding data gaps, communication, regulatory requirements, and the persistence of stigma. Implications for the implementation science and global mental health fields are considered.

The population mental health effects of negative interactions between U.S. police and urban youth of color are becoming increasingly evident. One such effect is bidirectional distrust, which reduces policing effectiveness and increases stress in both groups. Myriad police-youth dialogue programs exist to address distrust, but most fail to engage community members in their development. Further, most programs merely measure their impact on crime and psychological risk instead of promoting positive psychosocial well-being. The main objective of this dissertation is to illustrate through three mixed methods studies the implementation and impact of a pilot police-youth dialogue program, which applied narrative-based perspective-taking to increase empathy and trust in a sample of police and urban youth (n=78) in low-resource areas of Alameda County, CA. The first study describes how stakeholder interview data (n=21), a community-academic partnership, and ethnographic observation informed the development and implementation of the intervention. Thematic analysis of interviews revealed lessons for implementation including the essentialness of community-buy in, police partners dedicated to community engagement, and ways local politics may impact community willingness to participate. The second study presents the quantitative findings of a multisite randomized pilot trial, which tested the effect of the 90-minute intervention (n=78) on self-reported trust, empathy, and social prejudice among officers and youth over a 4-week study period. Mixed effects regression models found the treatment group experienced significantly greater decreases in social prejudice (p=0.02) and higher satisfaction with local police-community relations (p=0.04) when compared to the control group. On average, treatment and youth subjects rated their study experiences higher than others. The third study uses Foucauldian Discourse Analysis to examine the discursive patterns of a subset of youth and police participants (n=36) to understand differential changes in empathy and trust. We found that control group sessions modeled after traditional police-youth dialogue sessions positioned participants to reproduce top-down hierarchical dynamics, whereas treatment group sessions positioned participants to be more trusting, vulnerable, and equitable. This is the first study of its kind to use experimental methods to test the mental health impact of storytelling in this population. Limitations and implications of this work are discussed.

This thesis explores the political economy of health care reform in Malaysia by examining two policies in depth: first, transformation from National Health Service towards social health insurance, known as 1Care; and second, an incremental step in the form of non-profit, socially-oriented voluntary health insurance (VHI). The Analytical Platform proposes the following problem statement: there is an insufficient understanding of the institutional and political barriers to health care reform in Malaysia. The chapter presents a literature review to provide the conceptual and scientific foundation of knowledge for the thesis. Next, the chapter describes Malaysia’s political environment and health system in detail, including previous attempts at reform. Results Statement Part I presents a retrospective political analysis of Malaysia’s 1Care reform, which investigates the fundamental causes of the reform’s failure. This is achieved by conducting a stakeholder analysis using Reich’s PolicyMaker tool and methodology, to elucidate interest groups’ power and position on the reform; then by applying Kingdon’s multiple streams framework to provide context for the reform’s failure within the agenda-setting process. The overarching conclusion of this analysis is that, although opposition groups made considerable efforts to derail 1Care, the underlying cause of the reform’s failure was the lack of continuous and demonstrable political support by the Prime Minister and ruling coalition. Results Statement Part II seeks to provide relevance to the current policy environment by extracting lessons learned from 1Care that can be applied to the ongoing non-profit VHI scheme. Where comprehensive reforms failed, this chapter examines whether a relatively small-scale, incremental step such as VHI can be leveraged towards achieving longer-term goals. The findings from this analysis highlight the inherently political nature of health care reform and reinforce the crucial need to conduct political economy analysis to develop reforms that are both technically optimal and politically feasible.

Lead and Methylmercury are environmental neurotoxicants known to interfere with neurodevelopment. Some neurodevelopmental consequences associated with lead and methylmercury exposure include intellectual deficits, behavioral and motor deficits, and impaired visuospatial performance. Several neuronal circuits associated with cognitive function and neurodevelopment can be probed with simple physiological behavioral paradigms, potentially serving as a marker of neurotoxicant effects. One such paradigm is pre-pulse inhibition (PPI), a sensorimotor gating process that indicates adequate organization of human cognitive processes. PPI deficits have been proposed as a neurobiological marker for pathologies indicative of inadequate motor or sensory gating such as observed in psychosis, schizophrenia, and other neurodevelopmental disorders. Although PPI’s relevance for neurodevelopmental disorders has been established in clinical, cross-sectional settings, its relationship with environmental neurotoxicants has not been epidemiologically explored. Additionally, PPI’s potential utility as a biomarker of neurotoxicant effects has not been established. Yet, by probing underlying neurobiology, PPI offers the potential to identify neurological deficits associated with neurotoxicants earlier and more objectively than current methods in environmental epidemiology. To our knowledge, no studies have examined the association between heavy metals and PPI deficits in human populations. We aimed to evaluate the utility of PPI as a biomarker of neurotoxicant effects by 1) identifying socio-demographic predictors of PPI using a data-driven prediction model, 2) estimating the causal effect of prenatal lead exposure on PPI deficits, and 3) estimating the association between methylmercury exposure and PPI deficits in children and adolescents 8-17 years of age using the Early Life Exposures in Mexico to Environmental Toxicants (ELEMENT) birth cohort. In this body of work, we identified new predictors of PPI, found that prenatal lead may cause PPI deficits, and found an association between methylmercury exposure and PPI deficits. Our results suggest that PPI may be useful as an objective biomarker of neurotoxicant effects and an adjunct screening tool for neurodevelopmental disorders associated with sensory gating deficits.

Sustainable and equitable population health improvement is a goal not all public health approaches can deliver on. Public health outcomes emerge from multiple unpredictable, dynamic, adaptive, and interconnected factors. There is a growing demand for public health interventions that align with the unique characteristics of complex systems rather than applying methods rooted in the linear cause-and-effect relationships of clinical interventions (Rutter et al., 2017). The danger of the continued use of reductionist approaches to address complex public health issues is sustained poor health outcomes and the perpetuation of inequitable system functioning (Kania et al., 2018).
This paper contributes to the growing field of complex systems-informed practice in public health and the operationalization of systems leadership as a practice approach. First, the foundational concepts for this initiative are presented, including complex adaptive systems, systems thinking, and systems leadership. This project then examined the application of these concepts during the early stages of a large-scale systems change initiative to improve eye health in Bangladesh. An action research case study methodology was employed to reflectively examine the early efforts to define the critical intervention points, communicate higher-level systems concepts across cultures, sectors, and practitioners, iteratively adjust the approach, and engage non-traditional stakeholders. Multiple data sources contributed to the development of the case study, including 25 semi-structured qualitative interviews with Sylhet and Dhaka practitioners engaged in this initiative through local workshops. The data was analyzed and organized to advance our understanding of the systems leadership approach in this context. The results from this project stage summarize several learning points, including the importance of early emphasis on communicating the concepts across all involved partners and redefining knowledge to include context expertise about local system dynamics from regional leaders. Two significant practice shifts related to this approach are centering the beneficiary’s experience to drive solution generation and reliably capturing learning and insight as an intentional outcome that must be disseminated and fed back into planning. Lastly, an adapted action research framework is proposed to guide an iterative, collaborative, and reflective approach to systems thinking and systems leadership in complex public health environments.

Neglected tropical diseases (NTDs) represent a major disease burden in sub-Saharan Africa and among the poorest of the poor in other regions around the world. A significant global effort is underway to deliver preventive chemotherapy (PC) medicines via mass drug administration (MDA) to people at risk the five PC-NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths, and trachoma. Despite the existence of an effective, low-cost, and seemingly simple solution of MDA aided by donations of free drugs, most countries will fall far short of the ambitious global NTD control and elimination goals targeted to be achieved by 2020. The host organization for this DELTA project, the END Fund, is a private philanthropic initiative that pools and directs resources to PC-NTD programs. This project used a systems thinking approach to better understand the complex challenges around addressing NTDs in order to make recommendations to the END Fund on how it can catalyze NTD systems change. The mixed-methods approach included 1) a quantitative survey with social network analysis of global NTD stakeholders and 2) in-depth interviews at the global level and in Nigeria to develop a qualitative model of the NTD system. A parallel work stream involving a group-based systems thinking process was facilitated with END Fund staff in order to inform the research component and help generate actionable recommendations. The research uncovered a number of structural issues impeding progress on NTDs and identified five key leverage points for systems change: 1) clarify potential for and assess progress towards elimination, 2) increase support for interventions besides drug delivery, 3) reduce dependency on donors, 4) address the issue of health worker incentives, and 5) create a more inclusive global NTD community. Each of these areas was accompanied by recommendations for how the END Fund and NTD community can influence each lever. The project is an example of using rigorous research methods in a practical, applied way to bridge the gap between the academic and practice sectors. This model also points to the need for more documented evidence of successful and failed attempts to use systems thinking to make progress on complex social problems.

Disasters negatively impact lives and livelihoods, and over the last two decades of 2000 to 2019, they have cost the global economy approximately US$3 trillion (CRED (Centre for Research on the Epidemiology of Disasters) & UNDRR (United Nations Office for Disaster Risk Reduction), 2020). The field of disaster management has grown over this same period. Still, efforts towards improving long-term aspects of disaster management like mitigation and recovery have been relatively limited. These aspects of disaster management necessitate a holistic view and long-lasting foresight into ways in which the interconnectedness of diverse components of the system, including climate change, inequity, capabilities, training, and economic volatility, could influence the overall system, its outcomes, and the eventual impact on communities.

Disasters strain the already under-resourced public health systems, along with other essential public services like public safety, public education, public transport, public utilities, and infrastructure, among others. To closely understand the nuances of the interconnectedness of efforts in preparation for and during disasters, I undertook a case study at a mid-sized United States city-county public health department. The case study, while not generalizable or representative of the entire country, was indicative of how systems-based thinking and approaches can be used for efficient and effective disaster management.

The study validated the complex interconnected and dynamic nature of inter-and intra-organizational work, highlighting the need for robust collaboration, relationship-building, and communication plans to be in place and functional much in advance of any crisis and the inherent systemic biases that need to be overcome to make such efforts successful.

The Iceberg Model, a systems thinking tool, was used to understand disaster management. It enabled the identification of the mental models or systemic barriers that are the root causes of the underlying structures and patterns of events seen over and over during different crises. Experts have advised lessons on the importance of cross-sectoral collaboration, information sharing, and capacity-building for out-of-the-box scenario planning for decades. Yet, it is by understanding and addressing the complex mental models that influence explicit and implicit structures that might enable these lessons to be implemented. Furthermore, even such deeper dives should not be siloed analyses. Stakeholders should be careful not to identify root causes within their respective areas and presume that addressing those alone will change outcomes. To understand the full extent of the issues and fully manage them, they will need to work as a part of a bigger system, and efforts will need to be made across the spectrum.

Keywords: Systems thinking, Disaster Management, Crisis leadership, Emergency Management, Preparedness, Mitigation, Resilience, Risk Reduction, Pandemic, Collaboration, Coordination, Communication, Leadership, Management, Innovation, Public Health Systems Research, inter-disciplinary, inter-sectoral, cross-sectoral, organizational behavior

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.

Despite the fact that existing dietary scores that capture the overall healthiness of the diet have extensively been used to study associations with risk factors for cardiovascular disease, it is questionable whether these scores are appropriate for the Hispanic/Latino U.S. population, since these metrics may not accurately capture the diet habits of ethnic/racial minority groups. In chapter 1, we adapted a traditional Mexican diet score (tMexS) based on an existing non-validated score, and we assessed its reproducibility and validity among U.S. adults of Mexican heritage in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). The tMexS had satisfactory reproducibility and moderate validity correlations with nutrient intakes and biomarkers. Since the purpose of dietary scores is to assess and guide an individual’s dietary intake for the prevention of disease, the utility of the tMexS needed to be evaluated with disease endpoints. In chapter 2, we examined the association between the tMexS and risk of hypertension and changes in blood pressure (BP) among participants of Mexican heritage in HCHS/SOL. Greater adherence to a traditional Mexican diet was associated with a reduction of 0.21±0.11 mmHg in diastolic BP during a mean follow-up of 6 years, but not with the risk of hypertension. However, for tMexS components, we found 18% higher hypertension risk for each serving per day of red and processed meats, and 12% lower hypertension risk per serving per day of corn tortilla and 29% lower hypertension risk for grains. Associations between tMexS and BP were stronger among men and participants with overweight or obesity. To our knowledge, no studies have compared a diet score that measures adherence to a traditional diet against prevailing diet quality scores. In chapter 3, we compared the tMexS against three diet quality scores: the Mediterranean diet score (MeDS), the Alternate Healthy Eating Index 2010 (AHEI-2010), and the Dietary Approaches to Stop Hypertension (DASH) score in association with risk of hypertension and change in BP among U.S. adults of Mexican heritage in HCHS/SOL. We found that higher scores on AHEI-2010, but not DASH, MeDS, or tMexS, were associated with lower hypertension risk; however, tMexS reduced diastolic BP.

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.

A history of child abuse (CA) is associated with a number of leading causes of death and disability in adulthood, and an important mechanism linking CA to such outcomes is the hypothalamic pituitary adrenal (HPA) axis. Biomarkers of its activity are cortisol and its antagonist dehydroepiandrosterone (DHEA), both detectable in hair and saliva, with hair reflecting long-term secretions and saliva reflecting short-term secretions. A commonly cited limitation for the use of hair is the washout of such biomarkers over time in distal segments (>6cm from the scalp). Therefore, in Chapter 1, we evaluated the impact of such washout by comparing distal and proximal segments reflecting the same time period in pregnancy. We found that distal HCC were significantly lower and poorly concordant with proximal HCC, which has methodological implications for researchers interested in using distal hair segments at delivery for their associations with CA history and pregnancy-related outcomes. In Chapter 2, we used non-distal hair segments to evaluate the association between HCC from preconception to the third trimester and measures of stress, including a history of CA. Using linear mixed models, we found no differences in HCC or its patterns according to CA history and observed few differences in HCC across the stress measures overall. Findings suggest that CA may not impact cortisol as measured in hair, or that CA-related dysregulations may be obscured by naturally occurring increases in hair cortisol during pregnancy. In Chapter 3, we examined the relationship between a history of CA and salivary rhythms of cortisol and DHEA in postmenopausal women using piecewise linear mixed models. We found that a history of CA was more consistently associated with dysregulations in DHEA than cortisol, suggesting that CA may impact health in older women via DHEA dysregulations. Ultimately, we hope that the research undertaken in this Dissertation will contribute to the literature attempting to explain the underlying mechanisms linking CA and adverse health outcomes across the life course, and that it be used to advocate for survivors of child abuse and their families.

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.

Access to reproductive health services, including abortion services, is essential to the health of women and families. While existing literature has documented the influence of demographic factors (‘who you are’) on access to abortion in the United States, exploration of the influence of place of residence (‘where you live’) is limited. Evidence on the relationship between rurality and access to abortion is notably incomplete, despite the assertions in the public discourse that women living in rural communities have worse access to care than their urban peers. This dissertation addresses this gap via qualitative and quantitative research in the Central Appalachian region. The qualitative study explores rural women’s reproductive health needs and experiences via in-depth interviews. Paper 1 analyzes the variability of experiences related to accessing a range of reproductive health needs, including abortion. This critical formative research is needed not only to replace assumptions with evidence, but also to contextualize access to abortion within reproductive health access broadly. Paper 2 focuses on rural women’s experiences related to abortion services. It explores how perceived feasibility of obtaining abortion care influences pregnancy decision-making. Paper 3 explores the relationship between gestational age at time of abortion and county-level factors, adjusting for individual characteristics and distance traveled to care, using a three-level hierarchical model. The dissertation results suggest that reproductive health services are not uniformly difficult for women in rural communities to access. Instead, experiences accessing services vary as a result of the nature of the health need, with barriers to obtaining highly specialized and/or stigmatized services. Abortion services are both specialized and stigmatized, thus these services are uniquely challenging to access for women in rural communities, which influences women’s pregnancy decision-making. When women assess pregnancy as unacceptable but abortion services as unfeasible, they adjust their emotional orientation towards continuing pregnancy, casting ongoing pregnancy as acceptable. Finally, place of residence, specifically county of residence, is relevant to gestational age at time of abortion. Residing in a nonmetropolitan county is associated seeking abortion later, even after controlling for miles traveled and county-level poverty.

My research examines the adoption and implementation processes involved in transferring a global health policy into national-level practice. More specifically, I consider how high-level stakeholders adopted and street-level, private-sector retailers implemented the Phase I pilot of the Affordable Medicines Facility- malaria (AMFm) between mid-2009 and end-2011. The AMFm — a large-scale program housed at the Global Fund to Fight AIDS, TB and Malaria — sought to improve access to high-quality malaria treatment through financing and delivery strategies using the public and private sectors. To date, the median implementation outcomes have been considered in the Independent Evaluation commissioned by the Global Fund but country-level processes and nuanced considerations of outcomes have gone unexplored. To better understand the AMFm pilot in Ghana, I collected both quantitative and qualitative data between August and December 2011.

To consider adoption, I first use a grounded, qualitative approach to address: What explains the stands taken by national stakeholders towards and against participating in the AMFm’s Phase I? I generate explanatory categories about the different views — stands — key stakeholders in Ghana took about joining Phase I. Public health goals; indirect policy goals; and concerns about personal, organization, and national reputation help to explain the views of different high-level stakeholders. Second, I consider the actions taken by different stakeholders: To what extent can a multiple-streams approach to policy adoption help clarify Ghana’s decision to join in the AMFm’s pilot? I find the Multiple-Streams Approach cannot be used to explain adoption of the AMFm pilot in Ghana. However, a modified version accounting for the global and national levels simultaneously can explain this case.

To consider implementation, I ask: Do retailers in Northern Region comply with Ghana’s the advertised AMFm Recommended Retail Price among for-profit, private-sector retailers? And, does non-compliance vary systematically with features of retailer structure or conduct? I find high compliance based on reported retail prices. I also find that neither measures of spatial competition nor having seen regulation enforced in the past explain the pattern of non-compliance. Rather, variation in the terminal supply price is highly associated with a retailer’s decision to charge at or above the RRP.

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.

Women from communities of color (WOC) in the United States are more likely to die from childbirth or pregnancy-related causes or experience severe maternal morbidity (SMM). The disparities faced by these WOC are driven by race/ethnicity, socioeconomic status, and environmental disadvantages. Social support can help women navigate the physiological, psychosocial, and environmental stressors that may arise during pregnancy and postpartum. With a goal to improve maternal health outcomes and reduce the disparities between WOC and their counterparts in other racial and ethnic groups, this thesis generates evidence on the effect of social support on maternal health outcomes, assesses the capacity and resources of Community-Based Organizations (CBOs) to provide social support services, and identifies the gaps faced in supporting WOC during pregnancy up to one year postpartum. A conceptual framework illustrates the determinants of maternal health outcomes and potential pathways of influence for social support. An analytical framework examines the effect of social support on SMM and pregnancy-related rehospitalizations. Surveys and semi-structured interviews conducted in 20 CBOs identify the gaps in social support provision.
Findings show a 78% decrease in the adjusted odds of SMM in hospital encounters for women with partner support (adjusted odds ratio [AOR] = 0.215; P .001) compared to encounters without support. In addition, ten support service gaps were identified among CBOs, along with gaps in implicit bias training programs, employee diversity, and community involvement. Informed by the gaps, recommendations call for significant investments in additional social support services, partnerships with public, private, academic and community stakeholders, and prototyping alternative delivery methods, including task shifting and technology platforms.

Obesity is a risk factor for several cancers, including colorectal cancer (CRC). I and my colleagues investigated adulthood weight change and body fat distribution and its change in relation to CRC risk in the Nurses’ Health Study and Health Professionals Follow-up Study. We also identified distinct trajectories of body fatness across the lifespan using a group-based modeling approach and then compared cancer risk across these trajectories. We found that weight gain from early adulthood to baseline was associated with an increased risk of CRC, whereas weight loss was associated with a lower risk. The association was stronger in men than in women. High waist circumference, hip circumference and waist-to-hip ratio were all associated with a higher risk of CRC in men, even after adjusting for body mass index. The associations were weaker in women. Ten-year gain of waist circumference, independent of weight change, was positively associated with CRC risk in men, but not in women. We identified 5 distinct adiposity trajectories across the lifespan: lean-stable, lean-moderate increase, lean-marked increase, medium-stable, and heavy-marked increase. Compared to women in the lean-stable group, those in the lean-marked increase and heavy-marked increase groups had a higher risk of esophageal adenocarcinoma and cancers of the colorectum, pancreas, kidney, and endometrium. Postmenopausal breast cancer risk was inversely associated with early-life adiposity, but was positively associated with late-life adiposity. In men, increased body fatness at any life period was associated with a higher risk of esophageal adenocarcinoma and colorectal cancer; compared to men in the lean-stable group, those in the heavy-marked increase group had a higher risk of pancreatic cancer, but lower risk of advanced prostate cancer. The trajectory-cancer associations were generally stronger for non-smokers and women who did not use menopausal hormone therapy. In conclusion, weight gain from early to middle adulthood was positively, and weight loss was negatively associated with CRC risk. Abdominal adiposity was positively associated with CRC risk and this association was stronger and independent of overall obesity in men than in women. Adiposity trajectories throughout life were associated with cancer risk and the pattern of associations varied by sex and cancer site.

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.