Harvard T.H. Chan School of Public Health

This study examined the feasibility of implementing an organizational intervention to improve worker safety, health, and well-being in a Chilean transportation company. The project brought workers, supervisors, and leaders together to identify concerns and develop sustainable solutions to improve working conditions. Rather than relying exclusively on outside consultants, the intervention provided guidance to the company as it developed the internal skills, teams, and processes needed to develop a sustained capacity to improve working conditions. Because this intervention was implemented during social and political unrest in Chile and the COVID-19 pandemic, the researchers also noted how capacity-building approaches can help companies become more adaptable and responsive to worker and productivity concerns during periods of disruption.

This study examined how working conditions shaped the safety, health, and well-being of professional drivers in a Chilean transportation company. Researchers used interviews and focus groups with drivers, supervisors, union representatives, safety staff, and company leaders to understand how scheduling, communication, and work organization affected drivers’ health and safety. The study showed how structured input from workers and managers can reveal specific pathways linking working conditions to health and safety risks in a particular workplace. These insights informed the design of a targeted organizational intervention to improve worker safety, health, and well-being, guided by information from workers and managers about their working conditions.

The Thriving from Work Questionnaire (TfWQ) was developed by the Harvard T.H. Chan School of Public Health Center for Work, Health, and Well-being to measure the positive contribution work can play on a worker’s overall well-being. It is a 30-item long survey instrument covering six domains and an 8-item short form drawn from those same items.

This guide describes how to produce a translated version that is defensible, publishable, and — critically — comparable to the existing English, Spanish, and German versions. It draws on our experiences of translating and validating two published TfWQ translation/validation studies (Spanish for Peru/Mexico; German), the Questionnaire’s User Manual, and best practice cross-cultural adaptation methodology.

The central principle: translation is the less time-consuming part of the job. The more demanding part is demonstrating that the translated items still measure the same latent construct in your population. A linguistically flawless translation with no content validation may not be a valid instrument.

Economic uncertainty negatively impacts employment and production. However, little is known about the associations between uncertainty shocks and health over time. We employ a time-series econometric model to analyze the propagation patterns of uncertainty shocks on mortality, using daily data from the Economic Policy Uncertainty Index and the UK national death registry. We observe immediate increases in suicide, drug poisoning deaths, and in cardiovascular mortality at weekly horizons. Suicide and drug poisoning deaths rise by up to 2.3%, with the positive association persisting for three weeks before returning to baseline by week six. Cardiovascular mortality rises by 0.9%, persists for one week, and increases modestly again during weeks five and six. Our results demonstrate transmission patterns of uncertainty shocks across causes of death, reflecting both individual and systemic responses during uncertain times.

Our workplaces shape our health, whether through the stress of our workloads, pay and benefits we receive, interacting with physical surroundings, or obtaining support from colleagues and supervisors. This is as true for addiction treatment organizations as it is for any other workplace. However, the implications of working conditions in these settings are wider since how these workplaces shape worker health also impacts the health of clients seeking addiction treatment. Creating working conditions that support the health and wellbeing of the addiction treatment workforce is therefore central to providing consistent and effective addiction treatment for clients.

The considerable rise in substance use disorders has strained addiction treatment services across the United States, and this strain can be noticeably felt in organizations operating across Massachusetts—a state with one of the highest rates of overdose deaths in the country. The addiction treatment workforce has long been characterized by high rates of turnover and attrition, but with the rising rates of addiction, workforce shortages have greater implications for people seeking addiction care. This may be particularly true for residential addiction treatment facilities, which provide 24/7 care for individuals as they move into recovery.

The Substance Use Provider Occupational Wellbeing (SUPOW) Study aimed to understand how working conditions and larger socio-political influences impact the health and wellbeing of Massachusetts residential addiction providers working in state-funded facilities. This study also sought to identify how the health and wellbeing of providers impacted the organizations at which they worked and client care. As part of this community-initiated study, frontline providers, supervisors, and executive leaders participated in interviews and focus groups to share their perspectives and observations working in residential treatment across Massachusetts regions. As such, all analyses presented in this report are from the perspective of providers and leaders with first-hand experience working in residential addiction treatment.

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.