DIGITAL ACCESS TO

The El Paso, Texas-Ciudad Juárez, Chihuahua border region, colloquially known as the Borderplex, is one of the largest binational regions in the western hemisphere. Despite the two aforementioned sister cities having immediate adjacency to one another, complex geopolitics, historic treaties, and infrastructures have created systemic inequities for individuals who live adjacent to the border and cross it for opportunity on a daily basis. The geopolitical division bifurcates a singular region into a patchwork of lives, occupations, and families.

The Chamizal Dispute concerns hundreds of acres of land in this border region that have shifted ownership throughout its history. Due to the wording of the Treaty of Guadalupe Hidalgo, which established the border as the midpoint in the Rio Grande, flooding that would eventually shift the river’s course subsequently shifted the border. A 1964 resolution between the United States and Mexico redrew the border and encouraged the implementation of infrastructure as a proxy for the boundary. In the process, approximately 5,600 people living in El Paso at the Chamizal were uprooted, with land ceded to Mexico. Since the agreement, layers of infrastructure have been compounded, reinforcing and solidifying the border’s presence, ranging from highways to metal walls capped with barbed wire.

Furthermore, this thesis aims to analyze and critique the infrastructures that have created such a stark dichotomy between the two cities in this border community through the medium of housing. Formally comprehending the different definitions of family in a region with a high percentage of multi-generational households, the thesis further defines housing through design as a means of creating equity through access and of formally contrasting porosities with the symbol and solidity of the infrastructural border.

Infertility carries substantial psychological burden, yet psychosocial support remains limited, particularly outside active treatment. Meta-analytic effect sizes for expressive writing on quality of life in infertile populations remain negligible to small (g = 0.00 to 0.05). No study has evaluated structured expressive writing among women experiencing infertility outside treatment settings. INSPIRE is a single-blinded randomized controlled trial among women trying to conceive for over two years, not undergoing stimulated or medicated fertility treatment, with moderate to high infertility-related distress. Exclusions included active suicidal ideation, current psychotherapy, and recent pregnancy loss. Participants were randomized 1:1 via blocked randomization to structured expressive writing or matched neutral journaling delivered over four consecutive days via hybrid Zoom and REDCap. Recruitment used paid social media. The primary outcome is change in FertiQoL. Secondary outcomes include a five-item distress composite assessed at baseline, post-intervention, and four-week follow-up. Models adjusted for baseline FertiQoL. Twenty-nine participants (15 control, 14 intervention; mean age 39.7 years, 72.4% US-based, trying to conceive over two years) were analyzed from a target of 220. Baseline FertiQoL was comparable between groups. Adjusted between-group difference in FertiQoL Overall was 5.55 points (95% CI: -1.56, 12.67) at follow-up. The Emotional subscale showed an 11.30-point improvement at follow-up (95% CI: 0.89, 21.71; d = 0.59), a clinically meaningful effect exceeding prior benchmarks. The distress composite difference was -1.86 (95% CI: -3.75, 0.03) at follow-up. Emotional intensity was consistently higher in the intervention group at baseline and across all writing sessions, with greater Day 4 relief. These preliminary findings require confirmation in the fully powered sample. Preliminary findings suggest structured expressive writing may improve fertility-related quality of life, with clinically meaningful effect sizes. If confirmed, this intervention may offer scalable psychosocial support for individuals experiencing infertility outside active treatment.

Introduction: Prediabetes (intermediate hyperglycemia) is a high-risk state that is defined by glycemic variables that are higher than normal, but lower than the diagnostic threshold for Type 2 Diabetes Mellitus (T2DM). Nutu, a mobile application developed by Willow Laboratories, provides daily nudges to help users monitor their lifestyle and adopt healthier behaviors to reduce their risk for prediabetes. Willow Laboratories plans to expand into the Saudi market and is interested in understanding the current regulatory and policy infrastructure to support the launch of Nutu.

Objectives: To identify the key factors under which a digital prediabetes prevention platform can achieve successful adoption, scaling, and sustainability within the Saudi healthcare system, thereby addressing the disparity between policy ambition and implementation.

Methods: This study used a qualitative, exploratory research design with semi-structured interviews conducted with 35 senior leaders across the health care system, including policymakers, industry leaders, clinicians, and academics. The data were analyzed using a two-stage approach: Framework Analysis and NASSS (Nonadoption, Abandonment, Scale-up, Spread, and Sustainability)- structured synthesis.

Results: Prediabetes is a condition of public health importance that is not currently prioritized in National Clinical Guidelines and Care Pathways. From a policy perspective, the regulatory environment for new products or services aimed at the prevention and management of obesity and diabetes is considered positive, with strong political commitment to meeting Vision 2030 targets. However, several issues need to be addressed, including over-regulation, limited capacity to conduct clinical trials, poor health information systems, a price-oriented procurement system of health products, and the general lack of dialogue and coordination among stakeholders.

Conclusion: Even though Vision 2030 has made a huge difference in how the Saudi Healthcare system and innovation are changing, my assessment of the Saudi Ecosystem found that the majority of the NASSS domains will need significant work to deliver an effective prediabetes intervention. However, with the right engagement with regulators, a culturally relevant value proposition for the Saudi market, and the right partnership, I believe that Nutu can be successfully adopted, validated, and scaled for the Saudi market and for sustainable impact.

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

Background: Cervical cancer is a main cause of female cancer death worldwide; however,cervical squamous cell carcinoma (CSCC) is vaccine-preventable and curable if detected early. The fact that 348,000 women died from the disease, with 94% of deaths occurring in low- and middle-income countries (LMICs) in 2022, reflects the urgent need to integrate the multi-step continuum of care required for secondary prevention to increase coverage. Screening coverage across LMICs remains low, despite widespread national policies making cervical cancer screening a priority.

Methods: This study used an explanatory mixed-methods design combining a quantitative survey phase (Phase 1) with a qualitative, multi-country interview phase (Phase 2) to explore how cervical cancer screening and treatment services are integrated into health systems in GFF partner countries.

Results: Phase 1 demonstrated that screening coverage varies from 1% to 26% across GFF countries, with over 75% below 15%. A structural imbalance emerged: countries with the
highest HPV vaccination rates had the lowest screening coverage. A tiered country classification was designed to group partner countries into three tiers based on policy commitment, funding availability, and disease burden to guide tailored program support. Phase 2 qualitative analysis explained the mechanisms underlying the quantitative results, focusing on participants’ experiences during the implementation of HPV DNA testing. Participants described that HPV DNA testing requires women to interact with the health system multiple times, increasing the risk of an incomplete healthcare cascade. A causal loop diagram synthesized from both phases makes this structural logic clear and highlights where governance and financing investments are needed to break the cycle.

Conclusion: These findings reveal a gap between national commitments and operational realities, indicating that health systems are not yet structured to support the multi-step care pathway required by HPV DNA testing. Scaling up screening is not a technical challenge but requires a system level intervention. For those countries, this means tailoring support to each health system's readiness level, prioritizing government ownership and domestic co-financing, and viewing cervical cancer secondary prevention as an opportunity to strengthen the health system.