SPH Theses and Dissertations

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.

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.

Uterine fibroids affect up to eighty percent of women of African descent and account for 34 percent of gynecologic admissions at Sierra Leone’s national referral hospital. They appear in no national policy document, receive no dedicated financing, and generate no national data. This thesis asks how that happens and at what cost, not as a failure of any single actor, but as the outcome of how reproductive health systems across the region have been built, what they were designed to measure, and whose suffering they were structured to see. Women living with fibroids navigate delayed diagnosis, social stigma, and catastrophic out-of-pocket costs with no public support. This thesis traces how that exclusion is produced and what it means for women, households, and the health system. The study uses a convergent mixed-methods design. A retrospective chart review of 262 gynecologic admissions at Princess Christian Maternity Hospital documents clinical burden, diagnostic pathways, and treatment costs. Fifteen in-depth interviews, five focus group discussions, and seven key informant interviews explore how women interpret symptoms, seek care, and sustain their families while managing chronic illness. Fibroids accounted for 34 percent of gynecologic admissions. Most diagnoses relied on clinical examination alone because imaging was unavailable or unaffordable. Surgical care required out-of-pocket payments equivalent to several months of household income, with no cases receiving subsidy or insurance coverage. The thesis develops the Cycle of Suffering and Resilience (COSAR), an original analytic framework that traces six mechanisms, diagnostic invisibility, clinical disregard, epistemic negotiation, financial exclusion, moral surveillance, and survival labor, through which women absorb the costs of a system not designed to see them. Reproductive health frameworks across the region are built around maternity and are not structured to respond to chronic gynecologic suffering. This thesis provides the evidence and the conceptual foundation for integrating uterine health into national data systems, financing, and service delivery. Naming the wound is the precondition for rewriting the record.

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.

Local public health leaders, including community-based practitioners and local public health agencies, are integral to the public health workforce, playing a critical role in the planning and delivery of community-based public health initiatives. While capacity building programs are widely recognized as essential to strengthening the workforce and promoting evidence-based interventions, less is known about how these programs contribute to leadership development in public health.

This thesis examines the impact of Leaders in Health (LIH), a cohort-based public health capacity building program designed to strengthen community health initiatives by equipping participants with foundational skills in public health research and community-engaged approaches, while supporting the application of this learning to ongoing work. Utilizing a qualitative approach, this evaluation draws on in-depth interviews with LIH alumni, teaching fellows, and program co-directors to understand 1) how alumni leverage LIH training to advance their public health priorities and 2) how LIH supports alumni in the development and application of key leadership skills in public health.

Findings demonstrate that LIH links capacity building and leadership development by strengthening participants’ existing leadership capacity and supporting a more strategic, relational, and systems-oriented approach to advancing their community-based public health efforts. LIH strengthens applied public health leadership by building foundational knowledge and skills which enhance participant confidence and shape how alumni lead their public health initiatives. Secondly, it fosters community-centered practice by emphasizing collaboration, network-building, and participatory approaches that center community voice. Finally, LIH shapes participants’ professional trajectories and helps reframe their work through a public health lens, making explicit how their existing priorities and initiatives contribute to the broader public health system.

By centering lived experience of LIH participants, this thesis offers practice-relevant insights into how capacity building programs function as pathways for further developing public health leadership among local leaders. Ultimately, these findings underscore the potential of capacity building programs to further cultivate leadership that advances community-driven public health initiatives, contributing to more strategic and responsive local public health systems.

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.

Innovation has transformed modern health—but not equally for women. Women benefit less from medical technology than men, in part because women’s health innovations receive disproportionately little investment. This contributes to a persistent population-health gap: women spend about 25% more of their lives in poor health than men, despite living longer. This disparity is reflected in outcomes, including up to 2x higher underdiagnosis rates and delays of 7+ years for conditions such as endometriosis, decades long delays in fetal monitoring technologies, and interventions that disadvantage women. Venture capital (VC) investors heavily influence which technologies reach patients, yet only about 2% of healthcare venture funding targets women’s health, despite women representing more than half the population. Despite this gap, neither public health nor business literature examines how cognitive bias shapes VC investments in women’s health technology.

This project examines how cognitive bias and structural features of VC decision-making contribute to this disparity and identifies strategies to increase investment in women’s health innovation. Combining a multidisciplinary literature review, and 18 semi-structured interviews with investors, clinicians, and entrepreneurs, it delivers the first analysis of how cognitive bias shapes venture capital investment in the women’s health category beyond founder or investor gender. Rather than operating solely at the individual level, these biases influence how the category itself is perceived, evaluated, and prioritized by investors.

The analysis identifies previously unexamined mechanisms that suppress investment in women’s health innovation. These include the “invisible patient,” whose needs are not represented in investment decision-making; the dampening effect of Medicaid-associated markets on venture capital interest; and weak OBGYN demand for innovation, shaped by prior negative experiences with legacy technologies.

Together, these factors reveal how cognitive bias and market signals interact to systematically undervalue women’s health opportunities, even when clinical need and population scale are substantial.

Closing this investment gap requires pairing cognitive-bias interventions with innovations that overcome structural barriers. Together, these approaches can realign incentives, expand investment willingness, and accelerate equitable access to medical innovation. It concludes by developing a prioritization of actionable strategies informed by the research findings, and a concrete fetal monitoring case example

Most people in Zimbabwe face financial risk when seeking healthcare. Similar to other low- and middle-income countries, the population is largely informally employed or unemployed, with only 10% covered by private health insurance or limited government programs. Without health insurance or strong financial risk pooling mechanisms, both rural and urban populations must pay out-of-pocket, and the government collects insufficient tax revenue to fund equitable healthcare and achieve its goal of Universal Health Coverage (UHC). Community-based health insurance (CBHI) has been proposed as a viable path toward providing high quality health services and financial protection for the population in low- and middle-income countries like Zimbabwe. CBHI involves forming local risk pools through community-managed insurance schemes that rely on voluntary contributions and social capital—trust and solidarity within communities. This social capital is essential for CBHI’s success. Faith-based organizations (FBOs), long trusted within communities, have been identified as well-positioned to help organize CBHI programs. This project aimed to assess the acceptability of FBO-led CBHI in predominantly rural communities near mission hospitals in Zimbabwe. The Old Mutare community, surrounding the United Methodist Church’s Old Mutare Mission Hospital, was selected for the study. Using a qualitative design, researchers conducted focus group discussions and key informant interviews. The Adapted Cooperative Healthcare framework was used to identify enablers and barriers to CBHI acceptance. Findings suggest that CBHI is indeed acceptable to the Old Mutare community. FBOs can play a critical enabling role by offering financial and technical support. However, the study found that those interviewed felt the church should not lead the initiative outright. When CBHI is perceived solely as an FBO initiative, it may trigger mistrust in the community that could undermine success. Instead, strong community ownership and oversight will be essential. Acceptability studies like this one are an important first step in CBHI development. Early community engagement and buy-in can build the foundation for long-term sustainability and contribute meaningfully to Zimbabwe’s progress toward UHC.

This doctoral thesis examines the political economy of primary health care (PHC) reforms across nine countries—the Democratic Republic of Congo, Dominica, Egypt, Kazakhstan, Kenya, New Zealand, Thailand, Tunisia, and Uruguay—which represent diverse political, economic, and health system contexts. Addressing a gap in the literature where the political economy of PHC remains underexplored, the study investigates: (1) How have political economy factors driven PHC reforms? and (2) What are the distinct political economy factors of PHC reforms, and how do they differ across different types of PHC reforms—those focusing on financing versus organization? Employing historical institutionalism alongside the Control Knob Framework, this thesis analyzes how political economy factors interact to shape reform trajectories. The research draws on primary qualitative data from 324 respondents via interviews, focus groups, and expert consultations across the sampled countries, complemented by an extensive review of literature and policy documents. Using the Framework Method, both deductive analysis for theory application and inductive approaches for theory building were applied. Process tracing provides an in-depth analyses of each reform, while the Comparative Sequential Method examines reform trajectories across health systems. The findings reveal that political economy dynamics operate at multiple interrelated levels. Temporality is critical—historical legacies and path dependencies can constrain and enable reforms, while political upheavals or economic crises create windows for transformative change. Institutional contexts—political systems, electoral rules, constitutional provisions, and bureaucracies—significantly influence reform outcomes. Interest groups such as physicians, civil society, donors, and citizens actively shape reforms, while the politics of ideas affect public support and sustainability. This research identifies six distinct domains of political economy tensions in PHC reforms: (1) public versus private sector, (2) hospital versus primary care, (3) physicians versus non-physicians, (4) centralized versus decentralized administration, (5) expanding versus limiting citizens’ choice, and (6) selective versus comprehensive changes. Moreover, the chosen reform entry point—whether financing or organization—shapes how these tensions unfold. Understanding these dynamics can help policy actors anticipate resistance and devise strategies to navigate reforms. To build resilient health systems, countries must strengthen local capacities for political economy analysis and engage diverse stakeholders.

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.