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Exploring Variations and Decision-making Processes of the Utilization of Modern Contraceptive Methods During Protracted Violence and Political Instability in Rural Haiti
No full textBackground
Haiti's protracted sociopolitical instabilities greatly impact healthcare delivery, leading to low family planning coverage of 35%. Short-term contraceptive methods are predominant, making frequent and expensive visits to healthcare facilities necessary. These instabilities also cause disruptions in healthcare services, potentially resulting in missed follow-ups and unintended pregnancies ultimately.
Methodology
We investigated family planning utilization trends and decision-making in four Haitian communes during prolonged sociopolitical instabilities through a convergent mixed-method study. Secondary quantitative data on family planning service usage from healthcare facilities were collected, alongside data on major sociopolitical events from online newspapers. Linear regressions were employed to analyze the impact of these events on family planning usage. Qualitative data were gathered from in-depth interviews and focus group discussions across the communes. Then inductive content analysis was performed using Dedoose.
Results
During the study period, 163,179 women aged 15 to 49 utilized the six most common contraceptive methods across four healthcare facilities. Simultaneously, 188 sociopolitical events were recorded, with 80% being national, 10% local, and 10% regional events.
In bivariate analysis, we found a negative correlation between stockout of common contraceptives and family planning service utilization -0.64 (95%CI: -0.79, -0.49), p.001. Strikes reduced family planning utilization -0.63 (95%CI: -2.6, 1.35) but, their effect was not statistically significant, p=0.53. Having more than two trained providers was positively correlated with family planning utilization, 1.99 (95%CI:1.8, 2.0). Surprisingly we found an increase in family planning service utilization during gang clashes 1.94 (95%CI: -0.02, 3.9), police-gang clashes 1.8 (95%CI:0.64, 2.9), and gang violence 1.8 (95%CI:0.68, 2.9). After controlling for confounders, the relationship between health facilities characteristics and family planning service utilization remained statistically significant.
Inductive qualitative analysis revealed six main themes representing three barriers: 1) accessing healthcare facilities, 2) family planning side effects, and 3) workforce challenges. Additionally, three facilitators for family planning utilization emerged: 4) integrated services, 5) interpersonal influences, and 6) socio-economic challenges.
Conclusion
Prolonged sociopolitical events impact family planning access, creating both barriers and opportunities. These events may hinder the movement of people and goods, prompting proactive strategies by healthcare professionals and family planning users. Our recommendations include expanding storage capacity, promoting long-acting contraceptives, and improving community-based distribution. The observed positive correlation between family planning service utilization and sociopolitical instabilities suggests increased demand during crises. This highlights the need for timely provisioning of FP supplies to empower communities to navigate ongoing crises effectively.Graduate Educatio
Remarcation: Redefining, Remaking, and Reclaiming Disability in Public Space
No full textDespite legislation to ensure that disabled people have access to public space, like the Americans with Disabilities Act (ADA), many disabled people are still unable to access public spaces and services. Though this is in part due to a culture of minimum compliance in architecture, it also stems from the false belief that when a building is labeled as “accessible,” it is accessible to everyone. However, because many accommodations that help some disabled people harm others, there is no such thing as universal access as people would like to believe. By examining the intersection of the objective, static nature of physical architecture with the personal, ephemeral experience of the user, this thesis attempts to create a more realistic understanding of what accessibility can and should look like in public space. Through the exploration of common spaces at Harvard University with individuals of diverse physical, mental, and sensorial disabilities, this thesis has produced a set of guidelines and assessment tools to map the plethora of factors that influence the accessibility of a space. This framework aims to help end modern segregation of the disabled community from the broader public by giving educators, designers, developers, lawmakers, and others who have jurisdiction over shared spaces the tools they need to prioritize accessibility and ensure that everyone has access to a beautiful world.Department of Architectur
Transforming Capacity into Impact: New Systemic Pathways to Realizing the Vision of National Public Health Institutes
No full textBACKGROUND
Numerous publications and frameworks have described health systems and public health responsibilities of countries, often focusing on clinical care while neglecting the need for population-centered approaches to achieve public health impact. Meanwhile, recent crises (e.g., Ebola, COVID-19) have highlighted the importance of strengthening public health capacities, pushing countries to recognize the value of robust systems to prevent, detect, and respond to health threats.
As such, the acceleration and growth of national public health institutes (NPHIs) has been a welcome response to the persistent threats to the health and well-being of populations. As their capacity increases, however, most still compete with a myriad of other government programs and agencies to define their distinct and critical role, garner funding, and build a sizable, highly capacitated workforce that will allow them to successfully sustain their missions. Even when the functions of an NPHI (generally associated with the 12 Essential Public Health Functions, as defined by WHO) are cultivated and supported, the competencies that these public health institutions must have to successfully translate these functions into successful performance and demonstrable impact is unclear. Given the limited resource environments and complex contexts of public health, particularly in low- and middle-income settings, understanding the pathways that successful public health systems have followed to achieve positive outcomes and impact could be critical to the future success and sustainability of public health institutions worldwide.
AIMS
This project aims to develop an operational framework that describes the complex adaptive pathways linking inputs to functional ability and, more importantly, the pathways from function to meaningful public health impact. The project has three key objectives. First, to initiate a new dialogue in public health around defining and achieving impact, with a focus on structuring capacity-building efforts to support these goals, particularly in national public health institutes and government health systems. Second, to explore how non-technical capacities and competencies contribute to public health success and impact. Third, to realign global health capacity-building efforts to more directly advance public health practice, improve quality, and enhance the measurable impact of public health initiatives.
METHODS
This study employed three complementary qualitative research methods: a literature review, key informant interviews, and exploratory case studies in Bangladesh and Jordan. The literature review synthesized existing research on National Public Health Institutes (NPHIs) and their roles in global health. Key informant interviews were conducted with experts from the global health ecosystem, including those with significant involvement in NPHIs in various countries. Exploratory case studies involved in-depth interviews with individuals both within and outside the NPHIs studied, observational data collection, and a document review.
Data collection efforts were designed to address the following research questions:
1. Given the positionality and authority of NPHIs in low- and middle-income countries, which essential public health functions are they best positioned to perform?
2. Based on the essential public health functions identified, what additional capacities are needed for NPHIs to functionally succeed or achieve demonstrable public health impact?
3. What factors enable or inhibit NPHI efforts to:
- build the capacity to perform essential public health functions?
- build additional capacities necessary to achieve functional success or demonstrable public health impact?
FINDINGS
The study finds that, while the implementation of the 12 Essential Public Health Functions provides value to populations served by government health systems, responsibility for their execution does not need to rest solely with the NPHI. In many cases, shifting these functions entirely to the NPHI can disrupt the system and overwhelm the institution. A more effective approach may involve focusing on a “Core 4” or “Core 5” set of data-driven functions while coordinating with other entities to perform additional functions.
Furthermore, while technical capacities and tools—such as those supporting surveillance, emergency response, public health research, and disease prevention—are critical, non-technical “strategic accelerators” that also play a significant role in achieving public health impact. Using retrospective outcome analysis four strategic accelerators enable NPHIs to progress beyond functionality to impact were identified: Systems Awareness and Collaboration, Adaptive Capacity, Sustainability Thinking, and Population Engagement and Prioritization. The constructs and sub-constructs of these strategic accelerators were further defined based on the analysis of qualitative data collected. However, it is notable that these accelerators have been largely overlooked in public health capacity-building efforts in the past.
Finally, this study identifies a hypothesized pathway linking institutional functions to measurable public health outcomes to impact. This proposed pathway provides a new approach to understanding NPHI success and impact but also underscores the need for operational frameworks that consider both direct and systemic contributions to health. By taking a more holistic approach to capacity building and NPHI development that integrates technical acumen with strategic and structural expertise, future approaches to public health capacity building, systems change, and population impact may be demonstrably improved moving forward. Moreover, this more robust approach may prove invaluable to the support and sustainment of national public health institutes in the future.Public Healt
Xenogeneic collagen matrix loaded with recombinant human platelet-derived growth factor vs autogenous connective tissue graft for the treatment of peri-implant soft tissue dehiscences: A randomized, controlled, clinical, trial
No full textBackground and Object: Patient’s demands have progressively increased over the last decade that esthetic concerns related to anterior dental implants are not uncommon. Several techniques have been attempted for the treatment of peri-implant soft tissue dehiscences/deficiencies (PSTDs), mostly employing the use of autogenous connective tissue graft (CTG).
The objective of this study was to assess the effectiveness of combining recombinant human platelet-derived growth factor (rhPDGF)-BB with a xenogeneic “volume-stable” collagen matrix collagen matrix (VCMX) compared to the gold standard CTG for the treatment of peri-implant soft tissue dehiscences PSTDs at anterior implant sites.
Methods: Twenty-eight subjects with isolated PSTDs were enrolled and randomized to receive a prosthetic-surgical approach involving either VCMX + rhPDGF-BB or CTG. The treatment protocol involved a presurgical prosthetic phase, with the removal of the pre-existing crown and the fabrication of a temporary crown. After 1 month, the surgical procedure for the correction of the PSTD was performed via soft tissue augmentation (VCMX + rhPDGF-BB or CTG, based on the randomization). After a provisional phase with the creation of an adequate emergence profile, a new definitive crown was made. The primary outcomes of interest in this study were the mean PSTDs coverage between the two treatment groups at 1 year. Additional outcomes of interest included: i) volumetric changes; ii) assessment of modifications in the peri-implant soft tissue phenotype; iii) ultrasonographic tissue perfusion-related outcomes; iv) ultrasonographic tissue elasticity-related outcomes: v) assessment of patient-reported outcomes during the first post-operative month; vi) evaluation of patient-reported outcomes at the last study visit and their changes compared to baseline. Optical scanning and the superimposition of the digital models were employed to evaluate volumetric changes at the treated areas. High-frequency ultrasonography was executed at different time points over 12 months to assessed changes in the peri-implant soft tissue phenotype, as well as tissue perfusion, and strain elastography. Multilevel linear mixed models were used to assess the study outcomes, accounting for repeated measures with random effects for time and subject, and fixed effects for potential confounders.
Results: The preliminary findings from the randomized clinical trial depicted a mean follow-up period of 7.6 months. No statistically significant differences were observed for the primary outcome (mean PSTD of 94% for CTG, and 87% for VCMX + rhPDGF-BB, p>0.005). CTG-treated sites showed significantly higher KMW changes (2.9 mm vs 0.6 mm, p.01), MT gain (1.6 mm vs 0.9 mm, p=0.02) and Vol gain (114 mm3 vs 81 mm3, p=0.04) compared to VCMX + rhPDGF. On the other hand, the patients allocated to CTG reported significantly greater post-operative morbidity (20.9 VAS vs 5.5 VAS, p.01) and time for recovery (8.3 days vs 4.1 days, p.01) than the subjects that received VCMX + rhPDGF-BB. No significant differences were found between the groups for patient-reported treatment satisfactions and esthetic assessment (p.05).
Conclusion: Treatment of PSTD with CTG or VCMX + rhPDGF-BB resulted in similar mean PSTD coverage. CTG resulted in a significantly greater KMW, MT, and Vol gains, while it also caused significantly higher post-operative pain and time to recover than VCMX + rhPDGFPeriodontolog
A Multilevel Investigation of Transgender and Nonbinary Adolescent and Young Adult Mental Health: Classification and Assessment of Structural and Interpersonal Determinants
No full textMental health disparities, including depression and suicidality, among transgender and/or nonbinary (TNB) youth and college students are of high public health concern. Understanding the risk factors and population patterning of mental health disparities can shape intervention efforts at various levels to improve the mental health of TNB individuals. Caregivers of TNB youth have the ability to provide emotional support and access resources that are key to reducing disparities in TNB mental health. Colleges too have the ability to provide unique forms of institutional support to TNB students to facilitate reductions in mental health outcomes. Despite this, little is known about caregiver experiences of parenting TNB youth, the policy environments experienced by TNB college students, or the intersectional disparities in TNB college student mental health outcomes. This dissertation explores these key risk factors and disparities with the goal of informing intervention development for TNB youth and college students.
The first study (Chapter 2) utilizes the social ecological model to contextualize experiences of 48 caregivers of TNB youth in semi-structured interviews using thematic analysis and immersion crystallization. Chapter 3 utilizes quantitative intersectional modeling to characterize the population patterning of mental health outcomes among US college students across intersections of gender identity, race/ethnicity, and socioeconomic status. Finally, Chapter 4 empirically classifies the distribution of 12 TNB-supportive policies across 311 US colleges using latent class analysis.
Among caregivers, we found opportunities for gender affirmation and social connections, stressors between youth and caregivers, and associations between caregiver labor and stress. Among college students, we found first generation biracial Black and Indigenous TNB students had the poorest predicted mental health outcomes. Lastly, in examining college campus policy environments, we found associations between the probability of having a more supportive policy environment for TNB students and indicators of a college’s access to resources.
This dissertation discusses opportunities and recommendations for intersectional interventions across levels of the social ecological model, especially interventions at the community, organizational, and societal levels.Population Health Science
From Silos to Systems: A Qualitative Analysis of Braiding Funds for HIV and Syndemic Service Delivery in the United States
No full textThis doctoral project explores the practice of braiding funds as a strategic approach to improving the coordination and integration of public health funding streams—specifically within the U.S. Centers for Disease Control and Prevention’s National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP). With growing attention to syndemic conditions that intersect with HIV, there is an urgent need to align categorical funding in ways that enhance service delivery, reduce fragmentation, and improve outcomes for disproportionately affected communities. Braiding funds offers a promising solution, allowing public health agencies to coordinate multiple funding sources while maintaining accountability to each.
Using a qualitative design informed by implementation science, this study employed 19 key informant interviews with CDC officials and leaders from state and local health departments across the United States. A stratified purposive sampling approach was used to ensure geographic, epidemiological, and jurisdictional diversity. Data were analyzed using a hybrid coding framework, themes were identified to highlight facilitators, barriers, and opportunities in implementing braided funding. The project was guided by three conceptual frameworks: the EPIS (Exploration, Preparation, Implementation, Sustainment) framework, the Positive Deviance model, and Kotter’s Eight Steps for Leading Change.
Findings underscore the administrative complexity of managing multiple funding streams and the tension between flexibility and compliance. Participants identified both structural and cultural challenges, as well as innovative strategies used by jurisdictions to align resources. The study concludes with a set of targeted recommendations to strengthen braided funding efforts within CDC’s NCHHSTP and lays the groundwork for broader adoption across federal public health initiatives.Public Healt
Rhythms in Motion: A Biofeedback-Driven Vibrotactile Wearable for Gait Entrainment Rooted in Polyrhythmic Analysis of Afro-Diasporic Music
No full textStudies have demonstrated that synchronized auditory and tactile cues can support motor coordination through neural entrainment.[1] Emerging research suggests that rhythm-specific entrainment influences distinct aspects of gait such as stride symmetry, cadence, and joint coordination. [2] This thesis introduces a culturally grounded, rhythm-driven therapeutic device that leverages vibrotactile rhythmic stimulation for gait modulation and neurorehabilitation. While vibrotactile cueing and rhythmic auditory stimulation have been utilized for gait training purposes, these studies rely on binary and ternary rhythmic patterns. [3], [4] There are no studies that make polyrhythmic analysis the basis of the rhythmic framework utilized to deliver these therapeutic modalities.
This thesis makes two key contributions. First, it introduces a novel method for modeling and applying complex polyrhythmic musical structures—drawn from Afro-diasporic music—that diverge from conventional binary and ternary rhythmic patterns typically used in existing interventions. Second, the system integrates real-time gait adaptation through embedded force sensitive resistors, enabling personalized rhythmic synchronization. By integrating polyrhythmic analysis, real-time gait adaptation, CAD-informed wearable design, and multisensory feedback, this work establishes a novel framework for personalized, culturally resonant neurorehabilitation strategies— with potential applications for individuals with neurodegenerative or motor disorders.Biomedical Engineering A
Immune Landscape and Differential Gene Expression in Hepatocellular Carcinoma: A Comparative Transcriptomic Analysis of Murine Models and Human TCGA Data
No full textHepatocellular carcinoma (HCC) remains a major global health challenge, exhibiting poor prognosis and limited therapeutic options. Although programmed death receptor 1 (PD-1)-based immunotherapy can extend survival in some patients, its overall response rates in HCC are modest. To elucidate mechanisms underlying immunotherapy resistance, we studied transcriptomic data from RNA-seq analyses of two orthotopic murine HCC models—RIL-175 (responsive, “immunologically hot” tumor) and HCA-1 (resistant, “immunologically cold” tumor)—and 369 human HCC samples from The Cancer Genome Atlas (TCGA-LIHC). We used bulk RNA-seq deconvolution and differential gene expression analysis (DGEA) to examine how TP53 mutation influences immune infiltration and the potential effect of immune checkpoint blockade on the TME. Our findings reveal that only high-impact TP53 mutations aligned with reduced immune effector cell infiltration, implicating dysfunctional p53 in fostering an immunosuppressive microenvironment. Furthermore, our evaluation of differentially expressed genes highlighted E2F1 as a key factor enriched in the resistant HCA-1 model. Elevated E2F1 expression correlated negatively with cytotoxic T-cell presence in murine tumors and was associated with significantly poorer survival in TCGA-LIHC patients. These data suggest that reactivating p53 (e.g., via mRNA nanoparticle delivery) could synergize with PD-1 blockade, whereas E2F1’s central role in immunoevasion makes it a compelling therapeutic target. Collectively, this study underscores how careful mutation stratification and targeted immunomodulatory strategies hold promise for improving clinical outcomes in advanced HCC.Graduate Educatio
Learning Low-Dimensional Structures in High Dimensions
No full textAlthough researchers nowadays deal with increasingly high-dimensional datasets, lower-dimensional structures often exist and learning them effectively play a crucial role. This dissertation contributes to this effort by developing theories and methodologies for learning low dimensional structures in high dimensions, developed by the author and collaborators. The first two chapters focus on learning one-dimensional functionals in the proportional asymptotics setting, where the number of observations grows proportionally with the number of features. The theories developed in this asymptotic regime reveals surprising new phenomena and exhibit remarkable accuracy in finite samples of high dimensions, where classical theories fail. Chapter 1 investigates heritability estimation under this framework. We study the joint distribution of debiased Lasso and Ridge estimators under proportional asymptotics, and consequently propose a heritability estimator that features an adaptive tuning procedure. Empirical studies confirm its efficiency and robustness compared to previous methods. Chapter 2 focus on transfer learning in linear models. Within proportional asymptotics framework, we precisely characterize the generalization error of min-norm interpolators under both design and model shifts, and confirm the finite sample accuracy via simulations. This analysis identifies regimes where transfer learning is beneficial, and provides relevant guidelines for practitioners. Chapter 3 shifts focus to unsupervised learning of high-dimensional Poisson process arrival data. We propose an end-to-end pipeline that not only reconstructs underlying (inhomogeneous) rate functions of Poisson processes, but also learns low-dimensional representations that are valuable for downstream learning tasks.Statistic
Essays on the Labor Market
No full textThis dissertation studies how firms set wages. The first essay, coauthored with Corey Allan, studies the restrictions that governments place on migrants' job options. We find that firms account for migrants' weaker job options when setting wages. However firms don't specifically discriminate against migrants, but rather pay lower wages to all their workers. As such, restrictions on migrants' job options also reduce the wages of many non-migrants. The second chapter, coauthored with Jesse Silbert, is theoretical. We study a labor market in which firms do not price discriminate among their workers. We characterize when and how such a labor market will allocate workers inefficiently, and we show who benefits from these inefficiencies. The third chapter, also coauthored with Jesse Silbert, studies wage inequality within occupations. Every occupation in our data exhibits substantial wage inequality. By studying how firm profits are affected by the separation of individual workers, we show that much of this inequality cannot be explained by productivity differences between workers.Business Economic