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Effects of Medicaid expansion and state inclusionary policies on immigrant health and healthcare use in the United States
(2026) Mulugeta, Martha; Shafer, Paul
The United States is home to an estimated 51.9 million immigrants, a growing population that experiences substantial disparities in health insurance coverage and access to care. These disparities are shaped and perpetuated, in part, by a complex and often exclusionary policy environment, exemplified by recurrent changes to the public charge rule and the recent enactment of the One Big Beautiful Bill Act (OBBBA). Among the most consequential policies reinforcing these barriers is the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, which bars legal immigrants from accessing public benefits including Medicaid, Children’s Health Insurance Program (CHIP), Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Supplemental Security Income (SSI) during their first five years in the U.S., a restriction commonly known as the “five-year bar”. PRWORA also replaced the Aid to Families with Dependent Children (AFDC) entitlement program with the TANF block grant, and added complexity to the determination of benefit eligibility through the strict definition of “qualified alien”. The effects of PRWORA extend beyond immigrants themselves, impacting U.S.-born children in mixed-status households. Although the vast majority of children in mixed-status families are U.S. citizens (88%) and therefore eligible for public benefits, their access and experience is often undermined by the restrictive provisions of PRWORA and the chilling effects of related immigration policies. In response, there have been efforts to improve healthcare access for immigrants through the adoption of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA), as well as inclusionary state Medicaid policies providing coverage to otherwise ineligible immigrants by using state or local funds. Despite these efforts, the uptake of public benefits remains low among eligible immigrants and U.S.-born children in mixed-status households—often due to the fears of immigration-related consequences, especially in light of recent changes to the public charge rule and rising anti-immigrant sentiment. In 2023, an estimated 18 percent of lawfully present immigrant adults were uninsured compared to 8 percent of U.S.-born adults. Among U.S. citizen children, 4 percent were uninsured among those with U.S. citizen parents compared to 8 percent among those with noncitizen parents, demonstrating that disparities based on immigration status persist decades after PRWORA. Similarly, following changes to the public charge rule, participation in critical food and nutrition programs like SNAP and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) declined among households with immigrant parents as compared to those with U.S.-born parents. This dissertation evaluates the compounding impact of federal and state health insurance policies—specifically PRWORA, Medicaid expansion, and inclusionary state Medicaid policies—on healthcare utilization, total healthcare expenditures, health outcomes, and experiences of care among multigenerational immigrant families. Guided by the Social Determinants of Health Framework, this research leveraged multiple years of restricted-use data from the Agency for Healthcare Research and Quality (AHRQ), linking the Centers for Disease Control and Prevention’s National Health Interview Survey (NHIS) with AHRQ’s Medical Expenditure Panel Survey (MEPS), along with state policy data from the Urban Institute State Immigration Policy Resource (SIPR). The long-term goal of this research is to strengthen the evidence base on the impact of health and social policies on immigrants and their families in the United States. Chapter 1 provides a review of the literature motivating this work, including a historical overview of U.S. immigration policy with a particular focus on PRWORA and its implications for public benefit use across generations. Chapters 2 through 4 present the three specific aims of the dissertation. Chapter 2, To Quantify Differences in Immigrant Adult Healthcare Use and Expenditures Following Medicaid Expansion, examined changes in healthcare utilization and expenditures following Medicaid expansion among immigrant adults based on years of residence in the U.S. Chapter 3, To Identify the Effect of Inclusionary State Medicaid Policies on the Physical and Mental Health of Immigrant Adults, assessed changes in physical and mental health functioning associated with the adoption of inclusionary state Medicaid policies among immigrant adults based on years of residence in the U.S. Chapter 4, To Assess the Timely Receipt of and Experience of Care for Children of Immigrants Following Medicaid Expansion, evaluated differences in the quality of care for children following Medicaid expansion based on household immigration status. Chapter 5 provides concluding remarks on the findings of Chapters 2 through 4, as well as directions for future research.
Effectiveness of treatment strategies for multdrug resistant tuberculosis
(2026) Brumfield, Sarah Denise; Horsburgh, C. Robert, Jr.
Tuberculosis is one of the leading causes of infectious disease deaths worldwide, and multidrug resistant tuberculosis (MDR-TB) is a threat to its control. As it is resistant to the most effective first-line drugs, its treatment requires use of several second-line drugs that are less effective and can be highly toxic. In recent years, the WHO’s recommendations have been updated to prioritize regimens that use oral medications rather than injectables and ones that do not have to be taken for as long as in the past. The probability of successful treatment outcomes may be decreased by difficulty in adhering to regimens as well as emergence of resistance to second-line agents. In this dissertation, we aim to identify characteristics of participants and treatment regimens that promote successful outcomes. First, we attempt to identify participants that are adherent or non-adherent to regimens using a latent class analysis method. We analyzed data from the Predictors of resistance emergence evaluation in multidrug resistant-tuberculosis patients on treatment (PREEMPT) study, a prospective cohort study of people on treatment for MDR-TB and found that about 80% of the study population were expected to be fully adherent. Then, we assessed the effectiveness of different treatment regimens by examining whether treatment outcomes differ by WHO-recommended treatment regimens. Using the PREEMPT cohort, we found that the longer-term regimens appeared to prevent unsuccessful treatment outcomes but that newer generation drugs might improve outcomes. Finally, we attempted to identify predictors of emergence of resistance to second-line drugs while on treatment. We trained a prediction model using a least absolute shrinkage and selection operator (lasso) model on the Preserving effective tuberculosis treatment (PETTS) cohort study, a study of people on treatment for MDR-TB. We used the PREEMPT data as well as a clinical trial of delamanid vs. standard of care for MDR-TB to validate our prediction model. We found that creation of a well-validated prediction model for emergence of resistance is difficult to achieve because of the rarity of the outcome in our datasets. In summary, we identified a subpopulation of individuals who are less likely to fully adhere to MDR-TB treatment, effectiveness of longer-term WHO regimens, and difficulty of predicting emergence of resistance to second-line TB medications.
Assessing the impact of institutional and sociodemographic factors on treatment and outcomes in head and neck cancer
(2026) Qureshi, Muhammad Mustafa; Fox, Matthew
Disparities in head and neck cancer (HNC) outcomes reflect the complex interplay of social, institutional, and biological factors that influence access to care, treatment delivery, and survival. This dissertation examines structural and clinical determinants of inequities in cancer care through three population-based studies using data from the National Cancer Database (NCDB). Collectively, these studies evaluate the effects of healthcare system characteristics, global crises, and evolving treatment paradigms on outcomes among HNC patients. The first study assessed the association between hospital safety-net burden and survival among patients with head, neck, and thyroid cancers. Although crude analyses showed worse survival in hospitals with higher safety-net burden, the association was largely explained by patient and treatment characteristics. Using propensity score–based methods, safety-net burden was not independently associated with overall survival, indicating that differences in outcomes reflect patient mix and access-related disparities rather than hospital performance itself.
The second study evaluated the impact of the COVID-19 pandemic on diagnosis, treatment, and care delivery for HNC patients in the United States. The pandemic year (2020) showed a 17% relative decline in new cancer diagnoses. Among treated patients, there was a small increase in advanced-stage presentation and a shorter time from diagnosis to treatment initiation, while treatment utilization (surgery, radiation, chemotherapy) and radiation discontinuation were essentially unchanged compared with the pre-pandemic period. While baseline disparities by race, income, and hospital type persisted, the pandemic did not substantially exacerbate these inequities.
The third study assessed reduced-dose radiation (50–<66 Gy) versus standard dose (66–70 Gy) for HPV-positive oropharyngeal cancer. After inverse probability weighting and quantitative bias analysis for smoking, overall survival was comparable across dose groups. Survival patterns varied by treatment modality: reduced dose appeared beneficial in surgical/adjuvant settings and less favorable in definitive chemoradiation. No survival disparities were detected by race or income.
Together, these studies provide evidence that institutional context, systemic disruptions, and treatment innovations intersect to shape cancer care outcomes. The findings emphasize the need for equity-centered policies that strengthen safety-net infrastructure, ensure resilience during public health crises, and judicious implementation of emerging treatment innovations such as de-escalation therapies within an appropriate clinical context.
Exploring patient activation among dual-eligible Medicare beneficiaries: studies on the impact of enrollment in dual-eligible special needs plans and care coordination on activation and self-managed care
(2026) Davis, Amanda; Cole Brahim, Megan B.
Individuals enrolled in both Medicare and Medicaid, or dual-eligible beneficiaries, face complex health and social challenges, including poverty, disability, and unmet social needs. Compared to Medicare-only beneficiaries, they report poorer health, lower educational attainment, greater functional limitations, and higher post-acute care. Although they represent only 19% of the Medicare population, they account for 34.5% of Medicare spending. Dual-Eligible Special Needs Plans (D-SNPs) were created to align Medicare and Medicaid benefits, improve care coordination, and reduce fragmentation. Within this context, patient activation—the knowledge, skills, and confidence to manage one’s health—is critical for promoting self-management, improving outcomes, and reducing costs. Yet little is known about how activation differs by dual-eligibility or plan type, or how care coordination shapes activation for this population. This dissertation used a sequential, multiphase mixed-methods design to examine relationships among dual-eligibility, D-SNP enrollment, care coordination, and patient activation. Quantitative analyses using Medicare survey data employed Fairlie decomposition, propensity scores, and inverse probability weighting to compare activation between dual-eligible and Medicare-only beneficiaries and assess whether D-SNP enrollment was associated with higher activation. Qualitative interviews with care coordinators explored how coordination practices foster activation within these contexts. Quantitative findings showed dual-eligible beneficiaries had significantly lower activation, largely explained by social risk such as low education attainment. Explanatory factors differed by subgroup: for older dual-eligibles, limited English proficiency, living alone, poor perceived health, depression, anxiety, vision impairment, and limitations in activities of daily living (ADLs); for disabled dual-eligibles, intellectual disability and limitations in instrumental ADLs. D-SNP enrollment was associated with lower activation compared to Medicare Advantage, though similar to traditional Medicare. Notably, D-SNP enrollment was associated with lower activation among disabled and historically marginalized dual-eligibles, particularly, non-Hispanic Black enrollees. Qualitative analyses of care coordinators working with dual-eligible beneficiaries identified themes aligned with the Information-Motivation-Behavioral Skills model: (1) relational trust as a catalyst for engagement; (2) seeing the whole person, not the diagnosis; (3) personalization and adaptation in communication; (4) active confirmation of patient comprehension; and (5) collaborative problem-solving and momentum building. Practice and policy implications for dual-eligible beneficiaries include tailoring outreach strategies to specific subgroups, integrating patient activation into the D-SNP Model of Care, and ensuring comprehensive teach-back techniques are embedded within provider practices to reinforce comprehension of self-management behaviors. Systematically addressing modifiable risk factors may enhance activation, equity, and quality of life for high-need Medicare populations.
Effect of antiretroviral treatment strategies on retention in care, viral suppression, and non-communicable diseases in a large South African cohort: an emulated trial framework approach
(2026) Zheng, Amy Ye; Fox, Matthew
As HIV is now a chronic disease due to improved access to treatment and improved antiretroviral therapies (ART), there is a growing need for evidence regarding the long-term impact of ART use on the health of people living with HIV (PLWH) on treatment and how the risk of weight gain, changes in blood pressure, and other chronic non-communicable diseases (NCDs) like hypertension are impacted by the specific ART regimens are on. This is particularly important as HIV-NCD comorbidity reduces engagement in care and decreases quality of life. With almost eight million PLWH, South Africa has the world’s largest HIV burden and HIV treatment program. In 2019, South Africa’s treatment guidelines were updated to replace efavirenz with dolutegravir, due to clinical trials demonstrating dolutegravir’s efficacy. However, clinical trial populations are often healthier with better retention than real-world populations, in part due to a trial’s intensive follow-up procedures and their selective inclusion/exclusion criteria. As dolutegravir use has expanded, there is growing concern that dolutegravir increases the risk of NCDs. However, the magnitude and severity of this risk remain unclear. While observational studies can offer important insights, they are often limited by bias. Robust causal inference methods can help reduce the risk of bias. In this dissertation, we aim to evaluate the impact of different HIV treatment strategies on long-term retention in care and viral suppression, as well as to assess the association between dolutegravir use and adverse health outcomes—including weight gain, elevated blood pressure, and the development of hypertension.In aim one, using the Target Trial Emulation Framework we estimated, among treatment-naïve PLWH initiating treatment from 2019–2022 in South Africa, the effect of initiating a dolutegravir-based regimen compared to an efavirenz-based regimen on 12- and 24-month retention and viral suppression using data from the Themba Lethu HIV Clinical Cohort (TLC), a prospective cohort of PLWH receiving care at a clinic in Johannesburg, South Africa. Linear regression was conducted to estimate the causal risk difference on 12- and 24-month retention and viral suppression. Baseline characteristics were balanced via inverse probability of treatment weighting. Initiation of dolutegravir was associated with a 5-percentage point increase (95% Confidence Interval (CI): -0.02, 0.11) in retention and 4-percentage point increase (95% CI: -0.06, 0.16) in viral suppression among those with a viral load at 12-months. At 24-months, dolutegravir was associated with a 10-percentage point (95% CI: 0.03, 0.16) increase in retention and a 14-percentage point (95% CI: -0.02, 0.30) increase in viral suppression. Initiation of dolutegravir led to an appreciable increase in retention over 24 months when compared to efavirenz. A moderate but imprecise increase in viral suppression was found among those who initiated dolutegravir compared to efavirenz over the 24-month period.
In aim two, utilizing the Target Trial Emulation Framework we evaluated, among ART-naïve individuals initiating treatment from 2019–2022, the impact of initiating a dolutegravir-based regimen versus initiating an efavirenz-based regimen on 12- and 24-month weight, body mass index (BMI), blood pressure, and incident hypertension, also using TLC data. Generalized linear models were used to estimate the mean difference in weight, BMI, blood pressure at 12- and 24-months and a log-binomial model was used to estimate the causal risk difference of 12- and 24-month incident hypertension were used. At 12-months, mean difference comparing dolutegravir to efavirenz in weight was 2.9 kilograms (95% Confidence Interval (CI): -0.3, 5.5), BMI was 0.8 kg/m2 (95% CI: -0.3, 1.9), diastolic BP was 1.6 mmHg (95% CI: -0.7, 3.9) and systolic BP was 3.9 mmHg (95% CI: 1.2, 6.6). Individuals who initiated a dolutegravir-based regimen had 1.35 times the risk (95% CI: 0.04, 0.5) of incident hypertension at 12 months compared individuals who initiated an efavirenz-based regimen. At 24-months, mean weight difference was 1.9 kilograms (95% CI: -1.3, 5.1), BMI was 0.6 kg/m2 (95% CI: -0.6, 1.9), diastolic BP was -0.4 mmHg (95% CI: -1.8, 5.1) and systolic BP was 1.7 mmHg (95% CI: -1.8, 5.1). Risk of incident hypertension was 22% higher among dolutegravir initiators compared to efavirenz initiators (95% CI: -0.1, 0.4). Dolutegravir was associated with greater increases in weight and systolic blood pressure over 24 months compared to efavirenz, with the greatest increase in the first 12 months. A moderate increase in incident hypertension was also observed.
In aim three, using data from TLC we emulated nine sequential target trials, among treatment-experienced PLWH, to estimate the effect of switching to a dolutegravir-based regimen versus remaining on an efavirenz-based regimen on 12- and 24-month retention and viral suppression from 2019–2022. At 12-months, switching to a dolutegravir-based regimen was associated with a 14-percentage point (95% CI: 0.10, 0.19) increase in retention and a 2-percentage point (95% CI: -0.04, 0.08) increase in viral suppression. By 24-months, we observed a 1-percentage point (95% CI: -0.05, 0.07) increase in retention and an 8-percentage point (95% CI: 0.02, 0.14) increase in viral suppression. Switching to dolutegravir led to an appreciable increase in retention at 12-months and a moderate but imprecise increase in viral suppression at 24-months. Findings suggest that switching to dolutegravir does not harm and might improve retention and viral suppression over a 24-month period.
Overall, we observed that initiating dolutegravir compared to initiating efavirenz led to improvements in retention and viral suppression at 12 and 24 months among PLWH who were treatment-naïve. However, initiating dolutegravir may also be associated with increased weight and systolic blood pressure, and subsequent increased risk of hypertension over the first 24 months of treatment initiation. Among treatment-experienced individuals while we found no appreciable difference in retention for those who switched to dolutegravir compared to not switching, our results suggest that it may potentially lead to improvements in viral suppression. Findings from this dissertation provide further evidence of the benefits of initiating treatment-naïve individuals onto dolutegravir but also highlights the importance of continuing to screen individuals for NCDs after ART initiation as dolutegravir may be associated with increased risk of weight gain and hypertension. Furthermore, our findings suggest switching individuals to dolutegravir does not adversely impact retention and may lead to improvements in viral suppression.
Health disparities in severe maternal morbidity: selection bias, intersectionality, and hypertensive disorders of pregnancy
(2026) Smith-Webb, Rashida Shavine; Ncube, Collette N.
Severe maternal morbidity (SMM), defined as unexpected outcomes of labor and delivery, affects more than 50,000 birthing individuals annually in the United States, and is characterized by persistent health disparities across various social factors, such as race/ethnicity and socioeconomic status. These patterns have continued over time despite evidence that many SMM events are preventable. Therefore, a deeper understanding of both social and clinical drivers, along with careful consideration of potential sources of systematic error, is critical to inform effective interventions. Using data from the Pregnancy to Early Life Longitudinal Data System, which links live birth and fetal death certificates to hospital delivery discharge records in Massachusetts, we analyzed deliveries from 1998 to 2021 to address key methodological, social, and clinical gaps in research on health disparities in SMM. In the first study, we estimated the effect of SMM, compared with no SMM at the first hospital delivery, on the risk of SMM at the second hospital delivery and applied inverse probability of continuation weighting to quantify the magnitude and direction of bias introduced by selective attrition. A history of SMM was associated with an excess of more than 500 SMM events per 10,000 in-hospital deliveries at the second delivery, underscoring the importance of tailored care in future pregnancies. We also found that Black birthing people were disproportionately affected, with rate differences (RD) exceeding 800 per 10,000 in-hospital deliveries. Selection bias was minimal and generally resulted in a slight downward bias of <1%. In the second study, guided by intersectionality, we used interaction analyses to examine the association between occupying one or more marginalized identities compared with only privileged social identities and the risk of SMM. Multiply marginalized groups (i.e., racially and ethnically minoritized individuals with socioeconomic disadvantage), as well as Black individuals with socioeconomic advantage, experienced excess SMM events (RD 27–150 per 10,000 in-hospital deliveries) compared with White birthing people with socioeconomic advantage. These findings highlight the importance of addressing multiple intersecting social positions in efforts to reduce disparities in SMM. In the third study, we used mediation analysis to estimate the proportion of the Black–White racial disparity in SMM that would be eliminated through the prevention of hypertensive disorders of pregnancy (HDP). HDP accounted for 38.5% of the Black–White racial disparity in SMM, indicating that prevention of HDP may represent a potential pathway for reducing part of the racial disparities in SMM. Together, these three studies advance our understanding of various methodological, social, and clinical factors underlying health disparities in SMM.
The impact of urbanization on the tree-associated microbiome
(2026) Atherton, Kathryn F.; Bhatnagar, Jennifer M.
Urbanization profoundly reshapes ecosystems, altering both abiotic conditions and the interactions between organisms, yet its effects on tree-associated microbial communities and their implications for urban forest health remain poorly understood. This dissertation examines how urbanization influences soil- and tree-associated microbiomes and microbial functional potential across urban-to-rural gradients, with the goal of linking microbial ecology to tree growth and mortality outcomes. I first demonstrate that urbanization increases overall soil microbial connectivity while simultaneously disrupting key ecological interactions, notably reducing connectivity among ectomycorrhizal fungi that form mutualistic relationships with tree roots. Urbanization also shifts the structure and composition of oak tree microbiomes, decreasing mutualistic symbionts and increasing decomposers and pathogens, with consequences for biogeochemical cycling, including higher nitrogen loss potential and reduced methane consumption. These microbiome shifts correlate with urban stressors such as heat, drought, and inorganic nutrient deposition. Integrating microbial and environmental data, I show that urban tree growth and survival are shaped by microbial composition: growth is positively associated with microbial functional groups such as saprotrophs and C-fixing bacteria, while mortality is linked to pathogenic and wood-decomposing taxa. These findings highlight the central role of the tree holobiont (i.e., the tree and its associated microbes) in determining urban tree performance. To better predict functional outcomes from microbial surveys, I developed Fun2FITS, a computational pipeline that links fungal ITS amplicon data to predicted gene content, enabling scalable inference of fungal functional potential across ecosystems. Validation demonstrates that Fun2FITS captures ecologically meaningful patterns, particularly for ectomycorrhizal fungi. Finally, I translate these insights into applied urban forestry strategies through GIS-based analyses that identify optimal front-yard planting locations in Boston to maximize ecological and social benefits. Collectively, this work provides a mechanistic understanding of how urbanization reshapes tree-microbe interactions, microbial functional potential, and urban forest health, offering tools for evidence-based management of resilient, sustainable urban tree populations.
The occupational therapy vision screen-OTVS: a vision screen tool for school-based and pediatric occupational therapists
(2026) Stewart, Carey; Patel, Neeha; Jacobs, Karen
Visual delays impact children across the nation and are often left undiagnosed and untreated. These visual delays impact a student's academic performance, achievement, and occupational performance. Many children in the United States are not receiving adequate visual care. Occupational therapists evaluate and screen children with visual delays with a variety of standardized tests and tools. Currently, there is no vision assessment, specific for occupational therapists to use with elementary age children. Occupational therapists are left to create their own screening procedures to fill this gap. The Occupational Therapy Vision Screen-OTVS is a vision screen tool designed for school-based and pediatric occupational therapists. The mission of The OTVS is to provide occupational therapists with a vision screening tool and resources that allows for comprehensive testing during occupational therapy evaluations, screens, and progress monitoring. To allow students to reach their full potential occupational therapists must understand the importance of vision and vision screens, have access to a screening tool that is affordable and easy-to-use, and have an avenue for follow-up care. The OTVS will allow for early detection of visual issues, will improve the frequency and quality of screens, provide an evidence-based approach, provide clear guidelines for occupational therapists, allow for more visual skills to be tested, improve occupational therapy evaluations, and allow therapists to impact functional vision early, when it is most crucial and beneficial for young children. Occupational therapists will be able to impact student’s functional vision skills, promote full student participation in academics, occupational performance, and improve a child’s independence, sense of self, and quality of life, so children may thrive within the classroom and beyond.
Eye-hand coordination: factors influencing gaze patterns during fingerspelling perception in American Sign Language
(2026) Gappmayr, Paris; Lieberman, Amy M.
Sign languages such as American Sign Language (ASL) unfold dynamically over time, requiring perceivers to make real-time decisions about where to direct their gaze to capture linguistic information as it occurs and before it disappears. While skilled deaf signers look mostly at the face during sign perception, gaze is sometimes directed to the hands when fingerspelling occurs. I conducted three experiments to explore how different features of the input (familiarity, predictability) and cues from the sign producer (mouthing and indexing to the fingerspelling hand) impact looks to the hands during fingerspelling perception. In Study 1, I compare the role of sign type (lexical signs vs. fingerspelled words) and familiarity (novel vs. familiar) on deaf signers’ gaze patterns while perceiving single sign video clips, finding that sign perceivers look more at the hands when viewing fingerspelled words and novel items. In Study 2, I explore how cues from the sign producer (mouthing and indexing, when the sign producer looks at and points to their own hand during fingerspelling) impact gaze patterns, finding that, while mouthing results in more looks to the face, indexing does not increase looks to the hands. In Study 3, I explore the role of prediction on gaze patterns within a sentence context, finding that signers make anticipatory looks when they expect fingerspelling to occur but are unable to predict the specific word that will be produced, such as during the introduction of a name. This dissertation provides evidence that sign perceivers flexibly adapt their gaze based on both the perceptual and linguistic demands of the input. Pairing eye-tracking methodology with the visual modality of ASL offers insight into language processing and prediction, showcasing how language users dynamically attend to certain features of the linguistic input in real-time.
Acceptance of wearable assistive technologies in an occupational therapy intervention to prevent and detect falls in older adults living in remote Nigerian villages
(2026) Uzokwe, Amaka Anthonia; Niemeyer, Linda; Jacobs, Karen
Falls are a leading cause of injury, disability, and loss of independence among older adults worldwide, with particularly severe consequences in underserved rural Nigerian villages where healthcare access, infrastructure, and emergency response systems are limited. This doctoral project, Acceptance of Wearable Assistive Technologies in an Occupational Therapy Intervention to Prevent and Detect Falls in Older Adults Living Alone in Remote Nigerian Villages, introduces a unique creative approach to addressing an urgent public health challenge. The author’s purpose was to design, implement, and evaluate a culturally responsive, occupational therapy led intervention that integrates traditional fall prevention applications⸺ environmental modifications, strength and balance exercises, and caregiver engagement⸺ with introduction of wearable fall detection devices that will optimize response time to a fall occurrence. The latter aspect of the project will be guided by established technology acceptance and health belief theories. Evaluation research for the anticipated 6-month pilot launch of the project will explore pre- and post-program numerical self-ratings of understanding, acceptance, and willingness to adopt both fall prevention and fall detection aspects of the program, as well as current anxiety, fear of falling, and quality of life. Focus groups and semi-structured interviews will gather information on participants’ qualitative experiences and reflections on program content and delivery. Key program goals for this culturally grounded community initiative are development of multilingual training materials, provision of free solar powered chargers, and establishment of community champions. The author’s vision is to offer a replicable model for elder empowerment and healthy aging in underserved populations and to expand the occupational therapy role in fall prevention and detection in low resource settings, thereby positioning this project as a step toward sustainable, community‑driven solutions for elder safety in Nigeria and Africa in general.