Browsing by Department "Global Health Institute"

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Open Access
A Cost-Effectiveness Analysis of Timely Otitis Media Treatment through a Community Health Worker Delivered School Screening Program
(2023-04-19) Johri, Mohini
In certain settings, otitis-media related hearing loss forms a large proportion of total hearing loss cases. Delays to timely otitis media diagnosis and appropriate treatment leads to more serious otitis media cases, sometimes chronic suppurative otitis media, which may lead to a permanent hearing loss. A primary driver in the delay to diagnosis and treatment is a lack of easily accessed, trained healthcare workers in the identification and treatment of otitis media. We used an exemplar setting, Zambia, to understand the costs and potential effects of community health worker-delivered screening program for school-age children. The goal of this analysis was to highlight otitis media as a driver of hearing loss and understand the cost-effectiveness of timely diagnosis/treatment to prevent downstream hearing loss. The treatment pathway for otitis media treatment was identified using a cascade of care framework, as well as the effects of increased otitis media treatment access though stakeholder engagement metrics. The treatment for otitis media in this analysis was conservative treatment, aural toileting and topical antibiotics. Additionally, the costs of otitis media and chronic suppurative otitis media and the proportion of both metrics treated in Nigeria were found. Training costs of a program were included in the treatment pathway to adequately model the scale-up strategy. Simulated persons experience yearly age- and sex- specific probabilities of acquiring hearing loss, the prevalence of which is 3.6% in Nigeria. The population of interest was six-year-old children in Nigeria suffering from otitis media across their lifetime. Strategies for comparison to increase appropriate treatment of otitis media included current care and the implementation of a community health worker-delivered screening program. Main measures included lifetime undiscounted and discounted (3%/year) costs and QALYs and incremental cost-effectiveness ratios (ICERs) by Nigerian standard (<3x $2,097.09 was considered cost-effective). Current detection (CD) resulted in 19.22 discounted average person-years of otitis media treatment compared to 19.23 discounted average person-years with implementation of a CHW delivered screening program. Lifetime total per-person undiscounted costs were $64.26 USD for CD and $62.26 USD with the screening program intervention, indicating that the screen is both less costly and more effective than not screening. Results were most sensitive to variations in cost of screen, cost of CSOM, rAOM, pOME resolution from screening, and CI device cost. Limitations included input uncertainty given limited data sources for similar settings. Additionally, we had to use a utility decrement for moderate hearing loss since there is not one in the model that we identified specifically for CSOM. We project that a community health worker delivered screening program is cost-effective by US standards. Further research is needed to determine whether screening at younger ages or different treatments for otitis media is cost-effective.
Open Access
A Policy Analysis of No Hit Zones: What are barriers to No Hit Zone implementation?
(2018-12-05) Mastrangelo, Madison
No Hit Zones (NHZs) represent a new policy to prevent corporal punishment and to ensure healthy environments for children and their families. NHZs designate spaces where no hitting of any kind is tolerated and serve as an intervention to shift cultural norms away from physical discipline, starting at the institution-wide level. This mixed-methods thesis is divided into two studies that address the substantial research gap in this nascent field. Study 1 provides an overview of the approximately 50 NHZs nationwide and answers the research question, “What are the barriers to No Hit Zone implementation in institutions, such as hospitals and District Attorney’s offices?” Through the analysis of qualitative data from 44 interviews with professionals involved in NHZ implementation, this thesis establishes a comprehensive list of NHZs and their distribution across states and institution types. Study 1 identifies four central barriers to NHZ implementation: social norms surrounding corporal punishment, framing of the NHZ policy, resource issues, and lack of data surrounding training initiatives. Based on Study 1’s identification of the training barrier, Study 2 analyzes quantitative data from surveys administered before and after NHZ training at Children’s Hospital New Orleans and provides preliminary evidence that training programs can impact healthcare professionals’ views about the use of corporal punishment and increase their perceived ability to intervene when they witness hitting.
Open Access
Analyzing the Connections Among Water Access, Sanitation, Malaria and Diarrhea Outcomes in Rural Central Uganda
(2016-04-22) Hu, Michael
Access to safe water and sanitation around the world has increased significantly in the past few decades. The United Nations claims that 91% of the world’s population has access to safe water, exceeding the Millennium Development Goal for water access. Yet, some evidence in the literature suggests that safe water and sanitation access is overestimated, as the common indicator used to estimate safe water is infrastructural. The usage of water, behaviors surrounding water acquisition and storage, and possible contamination along the source to point-of-use continuum is poorly understood. This cross-sectional epidemiological study used a combination of surveying, mapping and bacteriological water testing to identify some of the possible factors in water contamination, and relationships with malaria and diarrhea burden, in a parish in Central Uganda. Secondary goals included assessing the burden of malaria and diarrhea in the parish, and assessing the use of mapping and water testing as field research tools. The survey included questions on water acquisition and usage behavior, sanitary conditions, knowledge of diarrhea, and malaria and diarrhea burden. In this parish, 126 households across 9 villages were randomly chosen to be surveyed, mapped and water tested. All water sources in the parish were additionally mapped and water tested. Across all water sources, including piped water, the water quality at the household point-of-use level was drastically worse than quality measured at the source. In fact, among all water sources, piped water recipients showed the highest average bacterial loads, despite the clean quality of the source itself. Possible factors in lowering or raising contamination, as displayed by regression results, include the frequency of obtaining water and distance from the water source respectively. The malaria and diarrhea case sample size proved smaller than expected, and challenges remain in using mapping and water testing in the field. These results support the theories that the amount of people with access to safe water is overestimated, and that contamination exists along the source to point-of-use continuum. More research is needed to investigate the exact points of contamination in the spectrum and possible contaminating factors.
Open Access
Assessing the Health Needs and Barriers to Accessing Health Care in a Predominantly Latinx Immigrant Community in North Florida
(2020-04-18) Sharma, Anu
On average, the Latinx population in the US has a higher rate of being uninsured and faces numerous social determinants, such as lower educational attainment and lower income, which can impede access to healthcare services. In addition, the passage of recent targeted immigration policies in Florida raise concerns over a possible chilling effect on health services utilization in this population. While previous research has indicated higher prevalence of chronic diseases in the predominantly rural areas of North Florida, the health concerns and barriers to accessing care of Latinx immigrants in these regions have been largely understudied. The goal of this thesis is to understand the healthcare context of a Latinx immigrant population in North Florida by using programmatic data collected by the Rural Women’s Health Project (RWHP), a health justice nonprofit based in Gainesville, FL. One of RWHP’s programs, Project SALUD (PS), is a community-based patient navigation program active in three counties in North Florida which improves linkage to care for participants. This study examined the data collected on participant intake forms during the PS registration process and included demographic measures, as well as information on the participant’s greatest health concerns and barriers to accessing care. Chi-squared analyses were conducted using R Studio. The study demonstrated that PS has catered to a predominantly female population (75.6%) who are by and large working age adults, with a median age of 37. Participants most commonly list their region of origin as Mexico, followed by Central America. The overwhelming majority speak little to no English (87.0%) and are medically uninsured (87.2%). PS has been most commonly accessed to address a need for dental care (30.4%). In terms of differences by gender, female participants were more likely to indicate a need for cancer screening or general health when compared to males. Insurance status also generally increased by age as did English proficiency. Participants from Central America were significantly more likely to indicate that cost was a barrier to accessing healthcare. This data will enable RWHP to evaluate the impact of the program from 2016 to present and can serve as baseline data for future studies to longitudinally monitor the programmatic goals of PS. It may also guide PS to reach communities that were previously not participating in the program, offer more services tailored to specific needs, and collaborate with community partners to increase the accessibility of health care and social services to address health disparities in North Florida.
Open Access
Augmenting Research on South Asian and South Asian Women's Health in America: The Case for Data Disaggregation
(2023-04-19) Meesa, Priyanka
South Asian Americans are a rapidly growing ethnic group in the United States. They experience an array of health disparities that are not well-understood or addressed partially due to a lack of research on the health of this population. There are many factors that contribute to this paucity of research, one is the lack of data disaggregation within the Asian demographic category in U.S. health research datasets. Data disaggregation allows a finding to be analyzed in more granular way. This may help uncover differences that were invisible in the aggregated data. In the context of this paper, data on Asians is often aggregated into one “Asian” category, so it cannot be broken down into East, South, etc. Asian, making the health differences of these populations challenging to identify. This paper provides a deeper understanding of the complex issues surrounding data disaggregation (scientific, technical, regulatory, and ethical), from the perspectives of thought-leaders and subject matter experts informed by their real-world experiences of conducting precision and biomedical research. In this study, participants concurred that data disaggregation is essential to understanding South Asian American health disparities and that aggregation can be harmful. They also noted barriers to and risks of disaggregation. These barriers and risks can start to be addressed with increased funding and researcher awareness of South Asian health disparities. Furthermore, informants highlighted methodological challenges, such as defining what it means to be South Asian and capturing culture in data. This is especially important for understanding the health of women in the community, as South Asians have gendered practices and health behaviors as a result of their cultural and religious beliefs. Participants agreed that country of origin is a good starting point for disaggregation, but more information, such as immigrant status, acculturation, and religion, is important to truly understand health and develop interventions. More research is needed to 3 understand perspectives of community partners, members of the South Asian American community, policymakers, and research funders on augmenting research on South Asian American health to address health disparities. Increased data disaggregation facilitated by greater funding and awareness among those conducting and participating in research is an important first step to improve the ability of researchers to identify the health needs or outcomes specific to the South Asian population in the United States.
Open Access
Beyond Polio in Pakistan: Understanding the Development and Consequences of Eradication Strategies
(2024-04-18) Sheikh, Shanzeh
This thesis seeks to understand how the strategies of polio eradication and the development of the healthcare environment in Pakistan have led to the continued presence of polio in the country, despite its elimination in nearly every other country besides neighboring Afghanistan. Often the literature, focused on the execution of programs, overlooks the program design that in many ways occurs outside of Pakistan. I use a critical historical analysis to identify root causes of international and national stakeholders’ eradication strategies and rationale, paying close attention to how Pakistan’s history has shaped its perspectives and possibilities. I review archival sources from the Pakistani government, physicians, and international organizations, as well as research papers and reports on polio eradication and health infrastructure. I also conducted nine interviews with Pakistani physicians, researchers, and public health workers. Colonial medical interests have shaped international health regulations and Pakistan’s health system such that they are largely focused on combatting single diseases rather than investing in basic healthcare. The Pakistani state has created gaps in healthcare delivery that military conflict in the region has exacerbated, and that physicians struggle to fill within the politicized health environment. The failure to address community demands for other health services leads to mistrust and vaccine refusals, but international health organizations continue to focus efforts on disease-targeted strategies due to concerns about cost-effectiveness and sunk investments. Efforts to eradicate a disease like polio would be better served by a focus on basic health services. International organizations must re-evaluate what programs they prioritize to control diseases, center investment in public and primary health care as opposed to selective and targeted interventions, and empower the voices of those in marginalized communities to develop programs that respond to their needs, rather than the needs of high-income countries.
Open Access
Bringing Care to Patients: Evaluation and Implications of an Outreach Mobile Clinic Model in Rural North Carolina
(2024-04-08) Haddad, Nicholas
The goal of the DGHI and Hope Clinic partnership has evolved over time but has centered around understanding the services Hope Clinic offers to its patients, especially those with chronic conditions, and their access to care. Hope Clinic is a free and charitable clinic in Bayboro, NC that serves about 300 patients. Following previous studies that have highlighted the clinic’s current building constraints and patients’ transportation difficulties, an outreach care pilot was developed. This model rests on two pillars: “outreach locations” (six community sites where patients could go for clinic appointments) and community health workers. Using patient geospatial and clinical data, Duke students identified six community sites that would theoretically reduce the travel burden patients with chronic conditions currently face in making it to Bayboro. Second, a partnership with a now defunded community health worker program aimed to provide personalized check-ins for patients outside of clinic hours (e.g., calling to ensure that patients are taking their medications). The community health worker program lost its funding before this pilot began in its entirety; while specific data and implications from this portion of the program won’t be considered, the incorporation of community health workers will be considered in recommendations and when addressing current gaps in care that emerge from this analysis. Over the course of 2023, Hope Clinic has been holding quarterly clinics at five outreach locations. A joint pilot evaluation plan was developed at the forefront of this project. This study aims to evaluate this pilot from January 2023 through December 2023 by: analyzing qualitative and quantitative patient satisfaction data (survey and interview data from 2023), demographic and diagnosis data taken from the clinic’s health records (from 2023), clinic encounter and appointment adherence data (from 2022 and 2023), and interview data from other free and charitable clinics (collected November and December 2023); future implications of a program like this for similar clinics and recommendations for Hope Clinic’s existing program will be offered. Collected data includes patient encounter statistics (e.g., completed appointments, cancellations, and no-shows), pertinent demographic data (e.g., gender, age, race/ethnicity) pulled from Hope Clinic’s electronic health records system, conversations with patients and providers (e.g., satisfaction, travel time to locations, qualitative suggestions). This data paints a vivid picture of who is coming to outreach locations, their health status (e.g., vital signs, hypertension and/or diabetes diagnosis, frequency of appointments, prescription status), and how the program is impacting adherence to appointment times and patient maintenance of health conditions. Interviews with other free and charitable clinics are used to better understand their strategies addressing barriers to health care access for their most vulnerable clients with an eye towards identifying possible solutions for Hope Clinic. Overall, findings from Hope Clinic’s first year of piloting their outreach care model are overwhelmingly positive. With higher completion rates, fewer cancellations and no-shows, and shorter travel times to outreach sites than to the normal Bayboro location, staff have reduced barriers to access that patients have previously expressed in interviews. Talking to other free and charitable clinic leadership across the state has highlighted similar transportation and resource constraints that make it difficult for patients to receive care and has showcased strategies used to address those challenges. While implementation of this model has led to reductions in the number of completed patient appointments (down roughly 6% from 2022), the benefits of this model seem to outweigh this challenge, and recruiting another provider (given space exists at community sites) may increase capacity.
Open Access
Caregiver Perspectives on Social Support for Individuals Living with Psychotic Disorders in Tanzania
(2021-04-20) Desjardins, Monica
In low-resource settings like Tanzania, individuals living with psychotic disorders must rely on their families for much of their financial and social support, thus leading family members to informally become their primary caregiver. Therefore, how relatives understand, think about, and implement their caregiving roles can have a profound impact on the recovery pathways for their relatives living with mental illness. This thesis will explore how relatives describe their support roles, including their strengths and areas where they state they need additional support. Twenty semi-structured in-depth interviews were conducted with relative caregivers of adults living with psychotic disorders in Tanzania. These transcripts were coded and analyzed thematically using content analysis to distinguish their perspective surrounding the relative's role and sentiments as a caregiver. Themes of instrumental support, emotional support, informational support and appraisal for the individual living with psychosis, along with caregiver expectations from the patient, providers and greater community were identified. Analyses revealed that: 1) financial and basic needs are critical, 2) acceptance and desire for improvement in relatives’ well-being, 3) there are information/ knowledge gaps for how to promote recovery via social support, and 4) caregivers bear more responsibility than communities for care but caregivers also expect more from affected individuals, providers and the community. Despite the constant and necessary provision of social support administered by these caregivers, the support of the caregivers themselves should also be recognized and in order to fully aid those who are living with mental illnesses.
Open Access
Combining cross-sectional survey data with geographic activity space to examine the relationship between place and youth HIV risk behavior in Kenya
(2017-04-23) Schmidt, Christina
Adolescents (15-24) comprise 37% of the nearly 1 million new HIV infections in southern and eastern Africa each year (UNAIDS, 2016a), representing a particularly vulnerable and important at-risk population. Despite increasing recognition that HIV risk is driven by social and physical characteristics of an individual’s community, assessment of socio-ecological HIV risk factors has remained a challenge. This investigation proposes a novel method of evaluating environmental risks through the use of GIS generated “activity spaces,” and community identification of risk-areas. Through combining metrics of ecological risk with cross-sectional survey data on psychosocial correlates of HIV, this investigation reveals how participatory techniques can be use to identify ecological drivers of HIV risk.
Open Access
Determinants of Secondary School Attrition and Related Health Factors among Female Youth in Rural Kenya
(2016-04-28) Fowler, Zack
This paper investigates the determinants of secondary school attrition and related health factors among female students in rural Kenya. To explore the relationship between attrition determinants and negative health outcomes, a mixed-methods approach was taken to collect both qualitative and quantitative data. Semi-structured interviews were conducted with 35 female youth that had terminated their enrollment in a Muhuru Bay secondary school between 2011 and 2015. Using grounded theory and thematic analysis, dominant themes were identified pertaining to determinants of attrition and implications for attrition-related health outcomes. Participants reported three primary causes of attrition: adolescent pregnancy (65.7% n=23), poverty and school fees (45.7% n=16) and early marriage (5.7% n-2). Health-related themes emerged in three major themes: in-school factors, out-of-school factors, and new-situation factors. Emergent health-related subthemes vary per temporal category and include forming relationships for favors, pride from enrollment status, intimate partner violence in early marriage, familial violence in response to situation changes, and abortion in response to early pregnancy. Numerical attrition data collected for the graduating classes of 2014 and 2015 in Muhuru Bay revealed no significant difference between male and female rates of attrition in the community. This may suggest that the burden of poverty in Muhuru Bay is so elevated that confounding factors of attrition, such as gender, are masked. Further research is necessary to determine health factors of male attrition and potential points of intervention for both male and female students.
Open Access
Drug Development for Neglected Tropical Diseases: DNDi and the Product Development Partnership (PDP) Model
(2016-04-25) Tuttle, Julia
Abstract Neglected tropical diseases (NTDs), including leishmaniasis, Chagas disease, sleeping sickness, dengue fever, and schistosomiasis to name a few, are endemic in 149 countries and impact 1.4 billion people- often the most vulnerable groups in the poorest countries (WHO 2016). Unfortunately, many of these diseases have no vaccines to prevent them, nonexistent or incredibly problematic treatments, and limited resources dedicated to monitoring, controlling, and improving the situation of those who are infected. These diseases may impact millions of people, but the affected population is too poor to exert economic sway and attract investment under the current medical research and development system, and a long-standing market failure has left their needs unmet. However, since the turn of the century, the growing humanitarian concern for NTDs has prompted exploration into innovative partnership and financing mechanisms for developing health technologies for these diseases. Product development partnerships (PDPs), such as the Drugs for Neglected Disease Initiative (DNDi), have emerged to coordinate new collaborations between private industry, academia, and the public sector. Furthermore, the political landscape around NTDs is changing as exemplified by the fact that the World Health Organization (WHO) is endorsing demonstration projects to experiment with "delinkage" principles that aim to separate the innovation market from the price of products and increase affordability and access. These novel approaches to drug development are important case studies in understanding how to best address the market failure around diseases of poverty and offer insight as to what strategies effectively advance the development of innovative health technologies. The lessons learned from the activities of DNDi and other PDPs shed light on how to align the goals of global health with political and economic realities.
Open Access
Ecological Modeling for Public Health: Predicting Hotspots of Human and Vector Contact in Rural Madagascar
(2019-04-12) Fitzgerald, Ryan
Vector-borne diseases account for almost one-fifth of all infectious disease cases globally, and are a particularly pressing public health issue in low and middle-income countries. In Madagascar, ticks and flea vectors are known to transmit a wide array of pathogens that impact the health of domestic animals and people, most notoriously in the cases of recent plague outbreaks. This study sought to investigate if ecological factors could be used to predict the abundance of disease vectors across landscapes and within the boundaries of a rural village in northeast Madagascar. Using high resolution ecological data from satellite imagery and human land use data collected by portable GPS devices, maps of overlap between ticks and humans were created, and subsequent exposure measurements were calculated for individuals. Within the village, ecological survey data were used to generate geospatial models of flea abundance. The identification of risk hotspots is a crucial public health interest in low-resource settings like rural Madagascar, as preventative resources can be targeted specifically to these areas, lowering the costs of such interventions. Ecological modeling that incorporates human land use data is an innovative approach that shows potential to shift vector-borne disease outbreak infrastructure away from reactionary control measures and instead towards efficient, proactive methods.
Open Access
Equity in Healthcare Access: Using Cultural Competency Training to Bridge the Gap between Providers and Latino Patients in Durham, NC
(2022-04) Green, Azana
Alongside Asians, Latinos are the fastest growing ethnic group in the United States with a projected population of 99.8 million by 2050 and 111.22 million by 2060. With this significant uptick comes an inevitable diversification of the social, linguistic and cultural landscapes of the country. One’s cultural background influences beliefs about causes of illness, expectations for care, preferred treatment methods, and much more. However, U.S. healthcare providers and the overall systems within which they work are not always equipped with the proper knowledge, tools, and resources to equitably treat all Latino patients seeking care. As a result, the Latino population faces significant inequities in acceptability and appropriateness access which asks, ‘”what happens to a Latino patient upon obtaining physical access to a health system?” “How do their sociocultural beliefs influence their interactions” and furthermore, “what is the quality of the relationship between the patient and the provider?” With this in mind, the aim for the study component was to assess the impact of a cultural competency educational intervention at a Duke Health Clinic via the implementation of an original survey instrument that gauges need satisfaction concordance amongst Latino patients and their providers. The results indicated that both patients and providers reported highest overall satisfaction with the demonstration of cultural comfort, however providers indicated that they felt the weakest about their demonstration of cultural humility and patients felt the weakest about the maximization of cultural opportunities during the clinical encounter. While there is still much room for improvement, significant progress has been made, especially over the past twenty years, in the incorporation of diversity frameworks within healthcare institutions. The next step is to standardize and equitably disseminate them throughout the country so that all providers are rightfully equipped and all patients are rightfully served.
Open Access
Evaluating the Patient Experience of Women Receiving Mobile Health App Facilitated HPV-Based Cervical Cancer Screening
(2020-04-17) Chalem, Andrea
Cervical cancer is a disease that disproportionately burdens countries with less developed healthcare infrastructures where the populations have less access to healthcare resources. Screening for cervical cancer is essential to disease prevention and to getting patients proper and effective treatment. HPV testing via self-collection as a form of cervical cancer screening has been shown to be an effective method of preventing the development of cervical cancer and amenable to use in resource-limited settings. In western Kenya, an mHealth strategy called mSaada has been piloted to support the HPV-based cervical cancer screening cascade. mSaada is placed in the hands of community health volunteers (CHVs) who lead the screening process and aims to address provider and patient barriers to screening delivery. This thesis study aimed to investigate how the use of mSaada by CHVs affects the patient experience of women screened by during the HPV-based cervical cancer screening process. This cross-sectional study assessed the experience of 120 patients through the Patient Experience Questionnaire. Participants were evaluated for their perception of CHV knowledge and ability, their own comfort level and understanding, their attitude towards the screening process, and how mSaada affected these perceptions. There were overall high endorsements towards almost every aspect of the screening experience, indicating acceptance of the screening process and comfort in interacting with the CHV. However, a small percentage of respondents were less comfortable with how mSaada affected their comfort level. This study emphasized the importance of taking into account the patient experience when implementing a new digital health strategy and suggests that future use of mSaada can reevaluate CHV training methods and place a greater emphasis on communication and how to best disseminate information.
Open Access
Examining Interactions between Race and County Type on Substance Use Disorder in Minoritized Populations
(2024) Wright, Jacqueline
Open Access
Exploring Machista Gender Roles and Psychosocial Well-being: An Exploratory Analysis in Camasca, Honduras
(2019-04-20) Malo, Vincenzo
There is a severe lack of mental health research in rural regions of Latin America like Camasca, Honduras, where typically there exists a societal construct of hypermasculinity and patriarchal authority termed machismo. Much of the current literature on psychosocial factors of mental health in settings with machismo report gender disparities with women experiencing worse outcomes. This study sought to characterize indicators of machismo through division of labor and perceived parental roles, and to then use these data to explore their interactions with psychosocial aspects of mental health. This study recruited 53 participants (41 female) from Camasca, Honduras to participate in orally-administered interviews. Three scales for resilience, general stress, and parental stress were administered in addition to open-ended questions to gauge satisfaction with and comfort discussing parental responsibilities across gender. Overall, the majority of participants reported there are gender differences in parental responsibilities with most explanations mentioning men working as a family’s economic provider and women taking on childcare responsibilities. There were trends towards men experiencing worse levels of general stress and parental stress, although there were no gender differences in resilience. These measurements did not vary by differences in perceived parental responsibilities. Most women reported being more comfortable discussing parental responsibilities with other women, while men typically reported no preference. In light of these results, machista societal organization creates a unique context in which to study psychosocial well-being and provides a useful lens for understanding health disparities in similar gender-rigid contexts. These results suggest that perhaps there is an internalization of traditional gender norms, such that men and women report stressors according to what is deemed stressful in their society, and that furthermore gender-disparate workforces may contribute to gender-specific experiences. Gender-specific differences may also emerge from the importance of agricultural industry, suggesting a possible factor perpetuating machista norms.
Open Access
Exploring Predictive Effects of Epstein-Barr Virus DNA Levels on Nasopharyngeal Cancer Staging and Relapse
(2025-04-15) Shaw, Neha
Nasopharyngeal carcinoma (NPC) is an Epstein-Barr virus (EBV)-associated malignancy with a distinct geographic distribution, particularly affecting populations in Southeast Asia. Plasma EBV DNA has emerged as a key biomarker for NPC, offering potential applications in disease burden assessment, treatment monitoring, and relapse prediction. However, the transition from EBNA-1 to BamHI-W targeted polymerase chain reaction (PCR) assays in clinical practice raises questions about assay comparability and prognostic significance. This retrospective cohort study examines the correlation between EBV DNA levels and clinical tumor-node-metastasis (TNM) staging and evaluates the predictive value of EBV DNA for relapse in a synthetic dataset, meaning anonymized, artificially constructed data modeled after real patient distributions, of 100 stage II NPC patients from the National Cancer Centre Singapore (NCCS). Patients were stratified based on EBV DNA assay type, EBNA-1 (pre-2016) or BamHI-W (post-2016), and analyzed using statistical methods including Spearman’s correlation, linear regression, Kaplan-Meier survival analysis, and Cox proportional hazards modeling. Results indicated no statistically significant correlation between EBV DNA levels and TNM staging for either assay, suggesting that EBV DNA may not directly reflect tumor burden. Similarly, no significant differences in relapse-free survival were observed between the two assay groups. However, male gender emerged as a significant predictor of relapse (HR = 11.885, p = 0.0369), aligning with prior research on sex-based differences in NPC progression. These findings contribute to the ongoing discussion on EBV DNA as a prognostic biomarker in NPC. While EBV DNA remains clinically valuable, its integration into patient risk stratification should consider demographic and molecular factors beyond assay selection. Future research should explore prospective validation in larger, multi-institutional cohorts and investigate complementary biomarkers to enhance NPC prognostication.
Open Access
Exploring the Link Between Mental Health of Caregivers and the Orphaned and Abandoned Children They Care for: An Investigation in Delhi, India
(2020-04) Vashisth, Shagun
Alternative care models for orphaned and abandoned children (OACs) have recently become a priority, especially in nations like India, with high populations of OACs. Despite the shift from institutional care towards a family-based model of alternative care in which caregivers are a central part of the residential care ecosystem, there is still a great lack of research exploring the mental health of OAC caregivers and the impact that caregiver mental health has on OAC wellbeing. This study involved interviewing 123 children and 34 caregivers within a residential care program that comprised 14 individual homes. Participants were administered psychometric questionnaires to gauge anxiety, depression, trauma, and caregiver attachment. The results identified the high trauma and negative psychological sequelae facing this program’s caregivers. Additionally, caregiver mental health outcomes were not found to be associated with child mental health outcomes. While this work did not statistically link caregiver mental health with child mental health, it is inevitable that a shared living environment intimately exposes each group to the other. To this end, more research is needed to understand the nuances of how traumatic life histories affect a caregiver’s mental health, parenting ability, and the mental health of the children they care for.
Open Access
From Bench to Bedside: Investigating the molecular mechanisms of sudden cardiac death while exploring stakeholder perspectives on risk predictive genetic testing
(2025-04-14) Sala, Angelina
Pediatric sudden cardiac death (SCD) is often linked to genetic conditions such as arrhythmogenic cardiomyopathy (ACM) and congenital heart disease (CHD). This thesis takes a multidisciplinary approach to investigate the molecular basis of SCD and the implications of predictive genetic testing in at-risk populations. A biology-focused approach identified a novel genetic mechanism for autosomal recessive ACM associated with loss-of-function variants in TAX1BP3. Using induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs), pharmacological inhibition of TRPV4 mitigated calcium leak and spark frequency–highlighting a potential therapeutic target for ACM. Additionally, this thesis investigated several genetic mechanisms of hypoplastic left heart syndrome (HLHS), a severe form of CHD, by evaluating levels of apoptosis and cell proliferation in iPSC-CMs. Preliminary findings suggest increased apoptosis and reduced cell proliferation may lead to the underdeveloped left ventricle seen in patients, however, overall findings warrant further investigation into other mechanisms. A global health approach was additionally incorporated by establishing a Community Advisory Board (CAB) to explore the ethical and clinical challenges of genetic risk prediction in CHD. Thematic analysis from the pilot CAB discussion highlighted concerns around clinical decision-making, resource allocation, and psychosocial impacts–emphasizing the need for standardized guidelines to ensure equitable and responsible use of genetic information. Altogether, this research advances precision medicine in pediatric cardiology by bridging molecular mechanisms with ethical considerations in genetic risk disclosure.
Open Access
Global Equity Challenges in COVID-19 Vaccine Purchasing
(2021-04-21) Raj, Aneesha
A rush to preemptively secure COVID-19 vaccines resulted in high income countries hoarding an excess supply while low- and middle-income countries are prevented from equitable access. Previous work on equity in vaccine purchasing has compared cases per million of COVID-19 to vaccination coverage but does not reflect urgent pressures placed on healthcare systems. This analysis investigates vaccination coverage against three measures of COVID-19 burden: deaths per 100,000 population, general hospital capacity reached, and ICU capacity reached, in order to identify the countries overburdened and underrepresented in vaccine purchasing. Publicly available data from the Duke Launch & Scale Speedometer, IHME COVID-19 projections, and Johns Hopkins COVID-19 mortality reports are used for this analysis. While non-high-income countries comprised 64% of this dataset, they represented 93% of countries in ICU crisis, 87% in general hospital capacity crisis, and 85% in a mortality crisis. This data provides evidence for the creation of a priority list for equitable global allocation of vaccines to low- and middle-income countries. High income countries can be incentivized to redistribute their excess vaccine supplies by reframing measures of pandemic progress away from nationalistic targets.