Undergraduate Honors Theses and Student papers

Permanent URI for this collectionhttps://hdl.handle.net/10161/6

Duke migrated to an electronic-only system for theses between 2006 and 2010. As such, theses completed between 2006 and 2010 may not be part of this system, and those completed before 2006 are not hosted here except for a small number that have been digitized.

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Open Access
Power Behind Bars: Exploring Social Hierarchies in Men's Prisons with Educational Progams
(2025-04) Araujo, Kelly
This study examines how educational and rehabilitative programs influence social hierarchies in men’s prisons. Existing research emphasizes masculinity and violence as core to prison power structures, and most studies on educational and rehabilitative programs center on post-release outcomes like recidivism. However, little is known about how these programs affect the internal social dynamics of prison life itself, specifically how they may reinforce or disrupt the informal hierarchies that shape everyday interactions and status. Addressing this gap, survey data from 30 formerly incarcerated men was collected, both program participants (n=14) and non-participants (n=16). Findings show that program participants were less likely to associate masculinity and physical strength with status and more likely to value conflict resolution compared to non-participants. Longer program participation was linked to more positive views on the program’s impact, especially on masculine norms. While no significant differences emerged in perceived personal status or beliefs about violence, participants interacted more frequently with higher-status individuals and strongly supported expanding prison programming compared to non-participants. These results suggest that although educational and rehabilitative programs may not dismantle existing hierarchies, they introduce alternative systems of value that challenge dominant norms and reshape how respect and influence are earned inside prison.
Open Access
Preliminary Heart Rate Variability Values in Minoritized Older Surgery Patients
(2025-04-18) Minaya, Stephanie
Background: This study aims to characterize heart rate variability (HRV) in older adults from different racial backgrounds awaiting major surgery, with a focus on how chronic stress affects autonomic regulation. We hypothesize that autonomic fractionation, a paradoxical combination of high HRV and elevated blood pressure (BP), will be more prevalent among older Black/African Americans (B/AA) compared to age-, sex-, and surgery-matched White/Caucasian Americans (W/CA), even after adjusting for key demographic and clinical variables. While high HRV typically indicates physiological resilience, its coexistence with high hemodynamic metrics may reflect maladaptive autonomic regulation, potentially. Methods: We assessed HRV using 24-hour recordings from eCardioWatch 287 wristbands in race- and procedure-matched geriatric surgical patients. Overnight segments were analyzed to reduce motion artifacts. Time-domain (SDRR, RMSSD) and frequency-domain (LF, HF, LF/HF ratio) HRV metrics were extracted using Kubios, MATLAB, and Python, alongside hemodynamic measures including pulse pressure (PP), systolic and diastolic blood pressure (SBP, DBP), and mean arterial pressure (MAP). Paired t-tests were used to compare autonomic and vascular indicators between B/AA and WCA patients. Results: B/AA patients exhibited paradoxically elevated but highly variable HRV measures. SDRR was nearly double in B/AA patients compared to WCA (40.29 ms ± 29.36% vs. 21.95 ms ± 9.53%, p = 0.124), with a similar trend in RMSSD (50.37 ms ± 42.63% vs. 22.29 ms ± 8.78%, p = 0.092). Despite statistical non-significance, these differences suggest autonomic instability. Hemodynamic profiles showed wider pulse pressures in B/AA patients (64.50 mmHg ± 18.52% vs. 54.50 mmHg ± 12.64%, p = 0.114) and significantly lower DBP (69.90 mmHg ± 10.28% vs. 78.50 mmHg ± 8.00%, p = 0.029), indicating vascular stiffening. Frequency domain analysis revealed a lower LF/HF ratio in B/AA patients (0.789 ± 0.383%) compared to CA controls (1.653 ± 1.387%, p = 0.081), contradicting expectations of sympathetic dominance. Discussion: This study reveals a paradoxical autonomic profile in older B/AA patients, characterized by significantly elevated but highly variable HRV measures, including SDRR and RMSSD, compared to matched WCA controls. While group differences did not always reach statistical significance, the large effect sizes and pronounced interindividual variability suggest autonomic instability rather than enhanced cardiovascular health. Hemodynamic analyses further demonstrated wider pulse pressures and significantly lower diastolic blood pressure in B/AA patients, consistent with increased arterial stiffness and reduced vascular compliance. Frequency domain analysis revealed a markedly lower LF/HF ratio in B/AA patients, challenging conventional assumptions of sympathetic predominance in high-risk populations and pointing to potential baroreflex impairment or race-specific autonomic regulation.
Open Access
Impact Evaluation of a Diarrhea Treatment Uptake Scale-up Program in Nigeria - a Difference-in-Difference Analysis
(2025-04-18) Xiang, Catherine
Diarrheal disease is the second leading cause of death in children under 5 years in Nigeria with an estimated 151,700 annual child deaths. Clinton Health Access Initiative (CHAI) worked with the Nigerian government to reduce child mortality by increasing treatment and coverage of ORS and zinc treatment for diarrheal disease. It is important to evaluate the reported increase in zinc and ORS coverage after the intervention was applied to assess whether the increased availability of diarrhea treatment led to an increase in treatment-seeking behavior among children under 5 years with diarrheal disease. Through a difference-in-difference analysis (DiD) in STATA/SE 18.0, the paper will evaluate whether there was a causal impact of the zinc and oral-rehydration salt (ORS) scale-up program on increasing diarrheal treatment-seeking. A logistic regression with robust standard errors was conducted on four treatment seeking outcomes (zinc, ORS, zinc and ORS, and zinc or ORS) while controlling for individual, household, and community level variables. After controlling for individual, household, and community variables, there were no statistically significant changes in zinc or ORS treatment uptake for children under 5 years that could be attributed to the intervention (Odds of OR: 0.87 95% CI=0.48, 1.59), zinc and ORS treatment (Odds of OR: 0.73 95% CI=0.12, 4.30), zinc treatment (Odds of OR: 0.85 95% CI=0.16, 4.57), or ORS treatment (Odds of OR: 0.90 95% CI=0.48, 1.67). We therefore did not find evidence that the program had an impact on uptake of zinc and ORS treatment. There is a need for more research that adopts rigorous causal methods to demonstrate the impact of policies targeted at reducing the burden of diarrheal diseases.
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
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
The effects of mitochondrial damaging reagents on membrane potential and mitophagy induction, with implications in neurodegeneration
(2023-05-03) McBane, Jason
Mitochondria are double membrane-bound organelles with established roles in metabolism, biosynthesis, and energy production. Various mitochondrial quality control mechanisms have evolved to maintain the mitochondrial network. One such mechanism is mitophagy, where damaged mitochondria are removed from the cell via autophagosome engulfment and lysosome degradation. Mutations and deficiencies in mitophagy components are linked to Alzheimer’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis (ALS), suggesting mitochondrial regulation is vital for cellular homeostasis. As a result, research efforts have focused on understanding mitophagy by inducing the pathway using various mitochondrial damaging reagents. However, these studies have resulted in discrepancies in the literature, highlighting our gap in knowledge of the type and severity of mitochondrial damage that induces mitophagy and drives neurodegeneration. Here, I used quantitative live-cell imaging of HeLa cells to determine whether four mitochondrial damaging reagents are comparable in depolarizing the mitochondrial membrane potential and inducing mitophagy. These reagents include carbonyl cyanide m-chlorophenyl hydrazone (CCCP), valinomycin, rotenone, and deferiprone (DFP). I found that valinomycin is the most potent at uncoupling the membrane potential, and that only reagents that depolarize the membrane induce mitophagy. My results shed light on comparable and effective in vitro mitophagy-inducing damaging paradigms that could be used to further our understanding of the etiology of neurodegenerative diseases and potential therapies.
Unknown
Family Cost in the Modern American Carceral State: A Descriptive Study from a North Carolina Jail
(2024-04) Cao, Michael
The shadow of mass incarceration in the United States casts over the lives of the justice-involved, but also, at twilight, over the lives of their families. Drawing on family demography and carceral studies, I study the financial effects of incarceration on survivor (nonincarcerated) families in the ambit of a local North Carolina jail. Often born of necessity, a domain of costs threaten the family economy when a member is incarcerated, with the potential to worsen or create economic disadvantage. This vulnerability, I contend, is particularly manifest for families that must interact with jail systems, understudied locales that nevertheless contribute to the calculus of inequality as much as prisons. Here, previous work on the financial costs of imprisonment become emblematic of the issues at hand, but also inaugurate new analysis. Using a descriptive survey strategy, I examine the demographics, relationships, and expenditures of an exploratory sample of individuals supporting a jail-incarcerated family member in Durham, North Carolina. Study results magnified a narrative of incarceration as an engine for gender and racial stratification—specifically of Black mothers at odds with costs of keeping their incarcerated sons fed, safe, and dignified. Comparison of jail-related expenditure across a spectrum of income groups also revealed class disparity—whereby low-income families were furnishing the most to support the incarcerated. Subsequent consideration is then given to the apparatus of jail in a system of financial extraction, and how families find intelligibility in its imposed paradigm of costs and burdens.
Open Access
Spanking Isn’t Necessary: Key Influences on Parental Decision Making about Corporal Punishment
(2020-05-04) Lee, Olivia
Fifty years of research has revealed significant harms from the use of corporal punishment. Despite this, corporal punishment remains a cultural norm in the United States. Previous research has revealed the importance of parental attitudes and sources of advice, but little research asks parents directly about their discipline decisions. This study finds that parents use corporal punishment when they believe that 1) Spanking is sometimes necessary and 2) It is okay to slap an arm or a face instead of spanking and when they do not believe that using an object to spank is okay. Parents are less likely to use corporal punishment when a doctor has spoken with them about the harms of corporal punishment and if they were not spanked as children. Finally, an open-ended questioning format elucidated a connection between corporal punishment use and fear and anger on the parents’ part. Removing corporal punishment from cultural norm status will require harnessing the power of healthcare professionals and targeting the emotional responses and harmful attitudes that lead to violent punishment of children.
Open Access
EXAMINING THE IMPACT OF AUTHORITARIAN REGIME REPRESSION ON THE OPERATIONS OF HUMAN RIGHTS CIVIL SOCIETY ORGANIZATIONS IN EGYPT
(2024-04-22) Sreeram, Samyuktha
This thesis investigates the repressive actions of the Egyptian government under President Abdel Fattah el-Sisi towards civil society organizations (CSOs) from 2013 to 2023, with a focus on understanding why some organizations face heightened repression or closure while others do not. Using a comparative case study approach, the research examines three CSOs: the Arabic Network for Human Rights Information (ANHRI), the Al-Nadeem Centre for the Rehabilitation of Victims of Torture, and the Egyptian Initiative for Personal Rights (EIPR). While all three engage in similar human rights advocacy, the study finds that ANHRI, due to its high level of internationalization and success in publicizing government abuses, faced the most severe repression and eventual closure. In contrast, the Al-Nadeem Centre, despite initially being targeted, continued operating after its physical clinic was closed due to its reduced international profile and publicizing capacity. The EIPR, despite ongoing international relevance, has been rendered less effective at raising awareness following the exile and travel ban of its founding director. The study argues that regimes prioritize repression of organizations that are both internationally connected and capable of publicizing abuses, as these organizations pose a greater threat to the regime’s image. This research fills a gap in the literature by offering a framework to explain why certain CSOs are seen as greater threats and face more intense repression. Through qualitative analysis of human rights reports and interviews with subject matter experts, the thesis concludes that international attention and the ability to publicize state repression are critical factors determining the level of government retaliation. The study advocates for stronger international pressure to protect the shrinking civic space in authoritarian regimes, ensuring the continued work of human rights organizations.
Open Access
Navigating the Social Media Landscape
(2024-05-01) Blanding, Erin
How does the TikTok algorithm know what you are thinking before you even search it up? How do influencers rise to popularity? What does it take to capture a digital audience's attention in a saturated online atmosphere? Given the trajectory of artificial intelligence and its proliferation online, will there be any way to distinguish what is “real” and what is “fake”? Navigating the current social media landscape for creators and brands alike is a constantly evolving game of attempting to work with the algorithm instead of against it. TikTok’s “for you” feed revolutionized social media by prioritizing predictions of what users would want to see, rather than curating content they have already expressed an interest in. This has changed the way many popular social media platforms have organized their content. In combination with recommendations backed by unthinkable amounts of data, users are inundated with a never ending stream of addicting media that can have consequences socially and financially. This thesis delves into the relationship between content, data and data privacy concerns, artificial intelligence, and digital strategy as it relates to both individuals and companies in an ever changing, deeply interconnected digital environment.
Open Access
Mixing and Enhanced Dissipation in Measure Preserving Dynamical Systems
(2023-04-29) Cheng, Jeffrey
The movement of particles and energy in a fluid is governed by the advection-diffusion equation. Given an underlying velocity field, a common question in fluid mechanics is to understand the motion described by the advection-diffusion equation. An interesting notion in fluid systems is the concept of mixing, the irreversible thermodynamic process seen by the mixing paint, mixing water of different temperatures, or the behavior of smoke in a smoke-filled rooms. In order to mathematically quantify mixing, we can view fluid systems as a measure preserving dynamical system. This paper will introduce the notion of measure preserving dynamical systems, quantify mixing and enhanced dissipation, and the study long term behavior of solutions to the advection diffusion equation. In particular, we provide an explicit instance of a smooth velocity field that exhibits enhanced dissipation at a rate of $\nu^{\frac13}$
Open Access
The Press and Peace
(2024-05-10) Bussey, Jakobe
This study utilizes state-of-the-art BERT (Bidirectional Encoder Representations from Transformers) models to perform sentiment analysis on Wall Street Journal and New York Times articles about the Iraq War published between 2002 and 2012 and further categorize them using advanced unsupervised machine learning techniques. By utilizing statistical analysis and quartic regression models, this paper concludes that the two newspapers report on the Iraq War differently, with both exhibiting a predominantly negative-neutral tone overall. Additionally, the analysis reveals significant fluctuations in negativity from both outlets over time as the war progresses. Furthermore, this study examines the objectivity of reporting between editorial and non-editorial articles, finding that non-editorials tend to report more objectively, and the neutrality of editorials remains relatively constant while the objectivity of non-editorials fluctuates in response to war events. Finally, the paper investigates variations in sentiment across different topics, uncovering substantial variations in positive, neutral, and negative sentiments across topics and their evolution over time.
Open Access
Long-Time Behavior of Some ODEs with Partial Damping
(2024-04-23) Huber, Owen
This thesis examines some partially damped ODEs with a conservative bilinear term, a damping matrix term with a nontrivial kernel, and a deterministic forcing term. We prove that, when forcing is absent, the condition that the bilinear term has no invariant sets in the kernel of the damping term is sufficient to show convergence of all solutions to the origin. We then consider the case that invariant sets exist in the kernel of the damping term and include forcing to escape the invariant sets. We show that solutions diverge under certain symmetries and give a partial proof of boundedness with hyperbolic equilibria in the kernel of the damping term.
Open Access
Towards a Characterization of the Complete Rotationally Symmetric Minimal Surfaces with Plateau-Like Singularities
(2024-04) Goldstein, Benjamin
The problem of finding and characterizing the surfaces in R3 which locally minimize area is known as Plateau's problem. Although the catenoid and the plane were proven in the 1700s to minimize area, there has been little further study of rotationally symmetric minimal surfaces. In this study, we investigate the complete rotationally symmetric solutions to Plateau's problem, revealing surprising depth due to singularities that may appear in a broad class of minimal surfaces. Our analysis is structured around the topology of the surface's generating graph, and we first consider surfaces of a simple topological type. For these surfaces, we prove new statements about complexity and shape, relating the number of singularities to the Hausdorff distance from a canonical example. We then consider more complicated structures, producing a novel surface with a handle (in particular, whose generating graph contains a 4-cycle). We finally provide direction for future study.
Open Access
Perceiving Blood Sugar: Kaleidoscopic Re-framing of CGM-Driven Diabetic Datafication
(2024-04-03) Sebastian-San Miguel, Sabrina
The means to enact the oversight of blood sugar levels have evolved throughout the history of type 1 diabetes. Using (auto)ethnographic methods of interviews, participant observation, and arts-based research creation, this thesis interrogates what new phenomena-in-practice accompanies the rise of continuous glucose monitoring (CGM) technology. The author argues that CGMs render glucose metabolism perceptible through the addition of new sensory modalities: visuality, audibility, and wearable materiality. In imparting these new perceptibilities, CGMs become more akin to medical visualization tools; dissolving the body-environment divide, CGMs project the metabolism into the environment through a variety of mediums. In turn, this more comprehensive association with the sensorium renders CGMs as more than a measuring technology. Presenting contributions across science and technology studies, disability studies, medical and visual anthropologies, this thesis explores the lived re-imaginations of the technological mediation of diabetic embodiments.
Open Access
Voting Early and On Campus: How North Carolina Universities Collaborate with County Governments to Increase Student Voter Access and Turnout
(2023-12) Thomas, Kathryn
College-aged voters face magnified costs of voting and turnout in low numbers. North Carolina college students have voted early and on-campus at specific schools for over a decade. How have on-campus early voting locations impacted the voting behavior of college students in North Carolina between 2012 and 2020? To analyze this question through a multi-faceted lens, I employed an explanatory sequential mixed-methods approach that integrates qualitative and quantitative methods. First, I selected six North Carolina universities and analyzed post-election data from the National Study of Learning, Voting, and Engagement to evaluate the impact of early voting on voting rates. Second, I interviewed county election directors and university officials to understand the administrative decisions behind site placement. Finally, I surveyed college students about their beliefs and experiences with early voting. The findings illuminate a model of voter engagement that increases voter access and turnout in North Carolina. Early voting is associated with higher turnout rates. County election directors indicate that early voting sites on campus are an effective way to reach voters. University officials understand the value of on-campus early voting as an opportunity to support student voting rights. Students value the convenience and report high satisfaction with the voting method. These findings suggest that placing early voting sites on college campuses is a cost-effective method of expanding voting access. University employees, in partnership with county election officials, can use on-campus early voting to promote political participation and help young citizens overcome the costs of voting.
Open Access
Navigating National Tragedy: A Comparative Analysis of Responses to Mass Shootings in Norway and the United States
(2024-04-22) Biddle, Clementine
The shooting at the Workers’ Youth League Summer Camp in Utøya, Norway on July 22nd, 2011, targeted teenagers, and lead to the deaths of 69 people. The shooting at Sandy Hook Elementary School in Newtown, Connecticut on December 14th, 2012, targeted children, killing 26 people. Gun violence, particularly extra-legal gun violence perpetrated by civilians, is a pervasive issue globally; however, the United States is an outlier in gun violence with repeated offenses particularly in educational environments. A mass shooting can be defined as one or more individuals killing or attempting to kill multiple people with a firearm in a populated area (Ray & Chmielewski, 2024). Norway has had three mass shootings resulting in death in recent history. There were more than 650 mass shootings in the United States in 2023 (Gun Violence Archive, 2024). What is the difference between the two nations? For my research, I explore the political and public responses of the nations by analyzing politicians' speeches and published opinion pieces in newspapers and magazines written by the public in both countries in relation to these instances of gun violence. I am interested in the historical, cultural, and political structures and institutions of the two countries that help to shape and form their responses to these national tragedies and how this in turn effects gun policy. In my analysis of Norwegian speeches and opinion pieces, I found themes of identity formation and community building as a nation, secular language, shock, and a strong correlation between political and public desires for the country. In my analysis of American speeches and opinion pieces, I found themes of passivity, division, polarization, and religious language. Understanding the differences in response and approach to issues of gun violence between Norway and the United States may begin to give context as to why the United States is plagued with repeated gun violence.
Open Access
That Sounds About White: Parental Racial Socialization and White Youth Identity Development
(2024-04-15) Culp, Mackenzie
Though parental racial socialization in the United States has been investigated since the 1970s, the literature almost exclusively focuses on its execution within minority families. The study at hand addresses this gap and ascertains how parental racial socialization works in White families. It unravels this question qualitatively, via semi-structured interviews with twenty students at a private university in the Southeast. The intention behind approaching college students was to gain a better sense of the kinds of racial behaviors and attitudes that White children internalize. In addition, it was hoped that interviewing college students about their parental racial socialization would provide insight into the impact that their parents have on their offsprings’ racial identities into adulthood. The findings of this paper were noteworthy, as they shed light onto how members of the dominant racial group in the twenty-first century learn to conceive of themselves and, by extension, racial others. Consistent with prior work on this topic, the main finding was that the parents of those surveyed neglected to converse with their kids about race and, for the most part, attempted to raise them “color-blind.” However, as I show, parents still passed on ideas about race, but through implicit means. A novel insight that this study provides is that White children in the twenty-first century may socialize their own parents about race once they mature and develop their own political opinions.
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
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.