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Recent Submissions
Postpartum mental health: using quantitative and qualitative methods to evaluate screening, treatment pathways, and policy in Massachusetts
(2026) Gallagher, Kerrin; Cole Brahim, Megan B.
Addressing postpartum depression is a national priority for health policy, as it affects 1 in 8 childbearing people in the United States (US) and has many health and social implications for both the parent and child. Although highly prevalent, research shows that postpartum depression is underdiagnosed and undertreated. Screening can aid practitioners in identifying postpartum depression symptoms, and national guidelines recommend screening at both maternal postpartum and well-child visits. While well-child visits in the first six months of life are typically focused on infant milestones, since 2010, the American Academy of Pediatrics (AAP) has recognized that well-child visits could provide multiple points of contact to screen parents for postpartum depression. With proper implementation, screening at well-child visits allows for detection and connection to treatment resources for parents experiencing postpartum depression. Despite AAP recommendations, approximately 50% of pediatricians nationwide report screening parents for postpartum depression at well-child visits. To encourage screening, in 2016, Massachusetts’s Medicaid program began reimbursing pediatric providers for postpartum depression screenings conducted during well-child visits for infants up to six months old. Leveraging the Massachusetts All Payer Claims Data and qualitative key informant interviews, the goal of this dissertation is to better understand postpartum mental health screening and utilization in Massachusetts through these specific aims: (1) To descriptively characterize 7-year longitudinal trends of postpartum mental health healthcare utilization and screening rates in Massachusetts; (2) To evaluate the impact of the 2016 Massachusetts Medicaid well-child visit screening reimbursement policy on documented postpartum depression screening rates at well-child visits and treatment utilization (e.g., psychotherapy, mood-related medication use); (3) To understand postpartum depression screening practices at well-child visits, identify barriers to and best practices for screening, and contextualize real-world referral to treatment pathways at community health centers through qualitative key informant interviews.
Environmental exposures and markers of early disease among young people at risk of chronic kidney disease of uncertain etiology
(2026) Hall, Samantha Marie; Leibler, Jessica H.
Prevalence of Chronic Kidney Disease (CKD), the ninth leading cause of death globally, is rising, and mortality rates from unexplained CKD epidemics are among the highest in the world. Chronic kidney disease of uncertain etiology (CKDu) is an ongoing epidemic concentrated in rural communities across tropical regions and is not caused by traditional CKD risk factors. Compared to the United States and Canada, male CKD mortality is 5–10 times higher in parts of Central America, where the disease is termed Mesoamerican Nephropathy (MeN). After disease emergence in the late 1990s–early 2000s among Salvadoran agricultural workers, epidemiological investigations have assessed MeN risk in relation to exposures to heat stress, agrichemicals, heavy metals and metalloids, silica, and a genetic susceptibility, though full disease causality remains uncertain. Repeated kidney injury from heat stress exposure in physically intense occupational settings is the leading hypothesized causal risk factor; however, communities across the globe with similar heat stress exposure profiles do not display CKDu, supporting a multifactorial disease etiology. Previous investigations of children and adolescents born in communities with high CKDu prevalence have demonstrated elevated kidney injury biomarkers, which suggests early life exposures may play a role in disease incidence in adulthood. Despite notable occupational research on working-age males, epidemiological investigation of kidney health among youth in Central America at risk of MeN remains scarce, and to date, there is limited research on females.
In this dissertation, I present novel analyses which contribute to the knowledge of environmental exposures and MeN-related kidney function among young people in Central America, including males and females of varying work status. All analyses use data sourced from an ongoing, NIH-funded prospective cohort study, Estudio Jovenes-Nica (EJN), composed of nearly 500 Nicaraguan individuals followed across childhood, adolescence, and young adulthood. In this dissertation, I apply complex and high-dimensional statistical and exposure assessment methods to evaluate urinary metabolomic markers, estimate heat stress, and quantify metal exposures in relation to kidney health.
Chapter One provides important contextual background on disease epidemiology of CKDu and MeN, disease history in the context of the Central American sugarcane industry, and key components of kidney physiology and measurement. Chapter Two details an untargeted urinary metabolomics analysis in which I evaluated metabolomic profiles in relation to CKDu risk factors. This work contributes to knowledge regarding early CKDu processes and subclinical monitoring efforts. In Chapter Three, I evaluate longitudinal kidney function against the leading hypothesized MeN risk factor, occupational heat stress, through detailed occupational history questionnaire data. Here, I integrate advanced epidemiological model building with local expertise from our community-based field team leaders. Last, in Chapter Four, I describe toenail metal concentrations and their association with cross-sectional kidney function in a subset of EJN participants. Traditional regression models and novel mixtures methods are used to evaluate single and co-metal exposures, as well as any joint effect, higher-order interactions, and nonlinearities.
In Chapter Five, I discuss strengths and limitations of the analyses and areas for continued investigation. I highlight the importance of implementing causal methods, refining disease definitions, and understanding the social and commercial determinants of health within MeN-endemic communities.
Evaluation of a Massachusetts Medicaid housing support program in a safety-net health system: implementation and health care utilization outcomes
(2026) McCann, Nicole Cristina; Shafer, Paul R.
Housing-related needs, including homelessness and housing instability, are prevalent and increasing. In 2024 in the United States, an estimated 771,480 people were homeless on a given night, an 18% rise from 2023. Additionally, in 2023, 17% of households spent more than half of their income on housing or lived in severely inadequate conditions. Housing-related needs are linked to mortality, poor health, and costly acute health care utilization and exacerbated among people with substance use disorders. To improve patient outcomes and reduce costs, health care entities, including state Medicaid programs and local health systems, have adopted initiatives to identify and address patients’ housing-related needs. Yet such initiatives vary widely in their design, including supports offered and eligibility criteria. More research is needed to understand how setting-specific contextual factors like population and health system characteristics influence program implementation and effectiveness. Housing support program evaluations have faced several limitations, including challenges with identifying individuals’ housing-related needs, constructing comparison groups, and linking implementation factors to outcomes. This dissertation used qualitative and quantitative methods to evaluate the implementation and health care utilization outcomes of a Massachusetts Medicaid housing support program, MassHealth Flexible Services Program for Housing (FSP-H), within the largest safety-net health system in New England. In Chapter One, I provided an overview of the literature on housing as a health-related social need, an in-depth description of the health system setting and FSP-H, and the conceptual framework supporting my analyses. In Chapter Two, I validated a pragmatic algorithm that combined six structured data elements from the electronic health record to identify patient housing-related needs compared against two reference standards. With all data elements combined, algorithm sensitivity ranged from 62%–81%, and specificity was 97%. Health-related social need screening yielded the highest single-element sensitivity but remained limited: 57%–62% of those with housing-related needs were detected via screening. Address information and diagnostic codes had low sensitivity. Findings demonstrate the value of integrated clinical and administrative data and highlight areas for improvement including changes to health-related social need screening and documentation. In Chapter Three, I conducted in-depth interviews with key informant stakeholders involved in the health system’s administration and delivery of FSP-H. I aimed to understand facilitators and barriers to FSP-H implementation over time within the health system, with considerations for patients with substance use disorders. Key informants strongly valued FSP-H, noting the importance of formal contracted partnerships with external housing organizations which shifted case management responsibilities from clinical staff to housing experts. However, they also described challenges, including tension in patient prioritization (i.e., trade-offs between offering services broadly to those with housing-related needs, or focusing on highest-acuity patients). Frequent changes to FSP-H, including evolving eligibility criteria, were sometimes perceived as top-down or misaligned with local realities. Results highlight the acceptability of Medicaid-based housing—health partnerships, as well as the need for evidence-informed program design and evaluation and transparent bidirectional communication about program decision-making between state Medicaid agencies, program administrators, and on-the-ground stakeholders. In Chapter Four, I linked FSP-H programmatic records, electronic health records, and administrative claims data to evaluate the association between FSP-H receipt and health care utilization and cost outcomes. I used a staggered difference-in-differences approach to compare monthly inpatient and emergency department utilization and total cost of care in FSP-H recipients versus a comparison group of individuals with housing-related needs who were ineligible for FSP-H due to their insurance plan (identified via the Chapter Two algorithm). FSP-H was not significantly associated with utilization but was associated with decreased monthly total cost of care, which approached statistical significance ($634 decrease, p=0.053). Significant declines in monthly inpatient utilization were observed among individuals with substance use disorders and those with frailty, and in monthly total cost of care among those with frailty. Results suggest FSP-H may be associated with reduced health care utilization and costs, particularly in high-risk clinical groups. Findings offer early evidence for state Medicaid plans implementing or iterating housing support programs. Findings from this dissertation can inform health system practice and Medicaid health-related need-focused waiver policy, with insights applicable to similar interventions in other settings and to future research.
“I can’t imagine you being a social worker without upholding social justice:” an exploration of how social justice is modeled in an MSW program
(2026) Vugić, Lea; Lombe, Margaret
Social work is a helping profession that centers social justice as one of its six core pillars. Social workers are tasked to uphold social justice by promoting social change and challenging injustices through their work with the most vulnerable and oppressed populations in our society. Hence, social work education has a unique responsibility to adequately prepare social workers for their work. Social justice is implicitly and explicitly present in social work education programs through standards, norms, and values. Despite its centrality to the social work profession and education, a unified definition of social justice does not exist and there is limited understanding of how concepts of social justice are modeled to students through the two main content delivery modes: (i) The classroom (ii) The placement (practicum). To address this limited understanding, a qualitative research design that is rooted in Institutional Theory was employed. Data were collected from 15 Master of Social Work (MSW) students, 10 MSW faculty, and five MSW placement supervisors from one school of social work in the Northeast region of the United States. Three themes were created utilizing Reflexive Thematic Analysis to explicate how social justice is modeled to students in one MSW program: I. Systems and Policies Signal Commitment to Social Justice; II. Experiencing and Witnessing Injustices Based on Identity; and III. Showing How to Do Social Justice in Action Develops Understanding and Skills. The themes highlight that systems and policies set the tone for commitment to social justice, but students, faculty, and supervisors experience and witness injustices. Nonetheless, showing social justice in action develops students’ understanding and skills of social justice. Institutional Theory supports the framework that standards, norms, and values inform the explicit and implicit curriculum which enforces systems and policies, experiences, and actions. Implications point to intervention on the program level to implement systems and policies that explicitly and implicitly center students, faculty, and supervisors in order to eliminate or minimize experiences with injustices, leaving opportunities to enact social justice in action, which develops understanding and skills.
Integrase inhibitors and cardiometabolic disease in people living with HIV: evidence from sequential target trial emulations
(2026) Kileel, Emma Margaret; Brennan, Alana T.
Over the last decade, substantial advancements in antiretroviral therapy (ART) have transformed the HIV disease landscape. HIV, once a life-threatening condition, is now considered a manageable chronic illness so long as the individual adheres to long-term ART regimens. However, despite having improved safety profiles and enhanced resistance barriers, the newest class of ART regimens, integrase-strand transfer inhibitors (INSTIs), have been linked to clinically significant weight gain compared to other ART strategies. Whether this weight gain subsequently increases an individual’s risk of cardiometabolic disease, including diabetes, hypertension and cardiovascular disease, remains unclear. Existing literature on the topic are conducted primarily in high-income settings among treatment naïve individuals and show conflicting results. Given the widespread adoption of INSTIs as the recommended first and second line regimens for HIV treatment, understanding their associated cardiometabolic disease risk is essential. In this dissertation, we leveraged data from the global Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) to address these critical evidence gaps. In the first study, we utilized a sequential target trial emulation approach to estimate the effect of switching to an INSTI-based treatment regimen, versus remaining on a non-INSTI based regimen, on the 5-year risk of incident obesity, diabetes, hypertension, and major adverse cardiovascular events (MACE). Data from emulated trials were pooled and hazard ratios (HRs) were estimated using counterfactual methods including inverse probability of treatment weighted Cox proportional hazard models accounting for competing risks. We found that participants who switched to an INSTI-based regimen, compared to participants who did not switch, had a higher average hazard of obesity (HR: 1.41, 95% confidence interval (CI): 1.22, 1.59), diabetes (HR: 1.50, 95% CI: 1.24, 1.81), and hypertension (HR: 1.45, 95% CI: 1.26, 1.67). However, we did not observe a meaningful effect of switching on MACE (HR: 1.17, 95% CI: 0.87, 1.57). In analyses stratified by sex, point estimates were higher among females compared to males. In the second study, we used the sequential target trial emulation approach to emulate a series of trials comparing the effect of switching to an INSTI-based treatment regimen, versus remaining on a non-INSTI based regimen, on changes in blood pressure and incident hypertension. We then applied causal mediation analysis methods to estimate the total intent-to-treat effect, the natural direct effect (NDE), and the natural indirect effect (NIE) of switching to an INSTI on changes in systolic and diastolic blood pressure, mediated by percent weight gain among males and females separately. Additionally, we applied causal mediation methods for survival analyses to estimate the proportion of incident hypertension risk mediated through percent weight gain. Among females, we observed a meaningful increase in systolic blood pressure (SBP) among switchers compared to non-switchers that increased over the duration of follow-up (change in SBP at Month 24 (M24): 0.3mmHg, 95% CI: -0.3, 0.9 mmHg; M36: 0.4, 95% CI: -0.3, 1; M48: 2 mmHg, 95% CI: 1, 3 mmHg; M60: 4 mmHg, 95% CI: 3, 5 mmHg). Notably, weight gain explained only 5% of the 4-mmHg increase at Month 60. We observed similar trends in diastolic blood pressure. In contrast, males showed minimal changes in both systolic and diastolic blood pressure, with weight gain explaining some but not all of this effect. In the overall population, the relative risk of hypertension was 42% higher among switchers compared to non-switchers (HR: 1.42, 95% CI: 1.22, 1.64), with little evidence of mediation through weight gain (6%), though this may reflect the limited number of events. In the third study, we sought to investigate the joint effects of pitavastatin and INSTI-based ART regimens on the risk of obesity, diabetes, hypertension, and MACE. We employed the target trial framework to describe the ideal trial that we would conduct to estimate joint effects of randomization of pitavastatin (versus placebo) and switching to an INSTI (or no switch). However, the data structure did not support a reasonable emulation of the target trial as statin randomization and regimen changes did not occur simultaneously, or in a temporally consistent manner. Consequently, we emulated a series of trials of switching versus not switching to an INSTI-based regimen and considered pitavastatin randomization an effect modifier. We used inverse probability of treatment weighted generalized linear models, stratified by levels of pitavastatin randomization, specifying binominal distribution and appropriate link functions to estimate risk differences (RDs) and risk ratios (RRs). Estimates showed modest increases in the relative risks of obesity, diabetes, and hypertension following a switch to an INSTI in both pitavastatin and placebo arms. For MACE, estimates indicated minimal association with INSTI switch in the pitavastatin arm (RR: 1.06, 95% CI: 0.60, 1.68) but a modest increased risk in the placebo arm (RR: 1.51, 95% CI: 1.05, 2.13), suggesting potential effect modification. In summary, we leveraged a global cohort of people with HIV at low-to-moderate cardiovascular disease risk and employed advanced epidemiologic and analytic methods to estimate causal effects of switching to INSTI-based treatment regimens on cardiometabolic outcomes. While absolute risks were small, our findings suggest a modest but concerning cardiometabolic risk profile emerging after INSTI initiation, warranting close clinical monitoring. We also clarify potential mechanistic pathways, identifying weight gain as one contributor to INSTI-associated blood pressure changes while also suggesting that additional biologic or sex-specific mechanisms may play a role. Finally, we found minimal evidence that statin therapy modified these associations, but observed that INSTI initiation may elevate long-term cardiovascular risk in the absence of statin therapy, highlighting the potential value of pitavastatin as a preventive strategy for people with HIV initiating INSTI-based ART. Together, this dissertation offers a comprehensive assessment of the cardiometabolic impact of INSTI-based ART.
Exogenous estrogen exposures and stroke risk in migraine with aura
(2026) Gibbs, Liza R.; Jick, Susan S.
Combined oral contraceptives are contraindicated in persons with migraine with aura due to stroke risk. Similarly, some guidelines for hormone therapies used for treatment of menopausal symptoms recommend caution in persons with migraine with aura. However, this guidance is informed by sparse or older evidence reflective of higher doses than typically prescribed today. This dissertation aims to, among female individuals with migraine with aura, describe the utilization of estrogen-containing oral contraceptives and hormone therapy for menopause and to evaluate the impact of use of these medications with respect to risk of stroke. The first study describes the utilization of oral contraceptives, including those with and without estrogen, as well as hormone therapy for menopause among individuals with migraine with aura at relevant age ranges corresponding with typical use. This study evaluates use before and after diagnosis with migraine with aura, overall and over calendar time. The second study compares the risk of ischemic and any stroke among individuals of reproductive age initiating use of combined oral contraceptives and progestogen-only pills. The third study evaluates the risk of ischemic, hemorrhagic, and any stroke among individuals with migraine with aura of plausible menopausal age initiating hormone therapy for menopause compared with non-users. Both comparative studies use inverse probability of treatment and censoring weighting to account for confounding and differential censoring and estimate absolute and relative risks to help contextualize findings for public health decision making. All three studies are conducted using the Clinical Practice Research Datalink (CPRD) Aurum, longitudinal primary care medical record data from the United Kingdom. Linked hospital data, available for most individuals, are also leveraged for outcome assessment in the comparative studies. This dissertation found that, despite contraindications, utilization of combined oral contraceptives decreased but did not fully cease after diagnosis with migraine with aura, with 15% of individuals of reproductive age prescribed combined oral contraceptives post-diagnosis. Initiation and continued use of combined oral contraceptives was associated with approximately one additional ischemic stroke per 10,000 people in the first year of use compared with progestogen-only pills. Utilization of hormone therapy for menopause was common among individuals of post-reproductive age with diagnosed migraine with aura, with nearly half having a prescription. Initiation and continued use of hormone therapy was associated with approximately 10 fewer ischemic strokes per 10,000 people in the first year of use compared with non-use, with this reduction predominantly driven by use of transdermal and vaginal formulations. While some findings were imprecisely measured, this work provides reassurance that the risk of stroke associated with these estrogen-containing medications is not greatly increased among individuals with migraine with aura relative to historical estimates in more general populations.
Pharmacoepidemiological studies of treatments for chronic inflammatory skin diseases
(2026) Jin, Yinzhu; Jick, Susan S.
The rapid expansion of new immunomodulatory therapies for inflammatory skin diseases has intensified the need for timely, rigorous real-world safety evidence. While administrative claims data are a valuable source for generating rapid post-marketing evidence, pharmacoepidemiologic studies relying on these data face persistent methodological challenges, including limited sample sizes for newly approved therapies, unmeasured confounding by disease severity, and complex treatment patterns that complicate causal inference. This dissertation addresses these challenges through three interconnected aims that span study design methodology, bias quantification, and applied comparative safety research in psoriasis and atopic dermatitis.In the first aim, we compared the risk of infections and malignancy among patients with psoriasis initiating interleukin-17 inhibitors (IL-17i) versus tumor necrosis factor inhibitors (TNFi) using three pharmacoepidemiologic study designs: an active-comparator new user design, a hierarchical prevalent new user design, and a switcher new user design. No significant differences in serious infection, outpatient infection, or malignancy were observed across the three designs. The hierarchical prevalent new user design provided improved precision during the early post-approval years while yielding point estimates similar to the traditional new user design, supporting its use as a complementary approach for early post-marketing surveillance when new user sample sizes are limited.
The second aim employed a simulation-based quantitative bias analysis calibrated to the three Aim 1 cohorts to quantify the expected residual bias from unmeasured disease severity and to evaluate the effectiveness of proxy adjustment of unmeasured disease severity, such as use of non-biologic immunomodulatory medications at baseline. The proxy-confounder correlation emerged as the primary determinant of bias reduction, achieving up to 48% reduction in bias due to unmeasured disease severity at a proxy-confounder correlation of 0.7 but negligible improvement at 0.2. Under the most clinically plausible scenario, residual bias of 13–25% on the odds ratio scale persisted after proxy adjustment, providing practical benchmarks for interpreting claims-based comparative safety estimates that lack clinical severity data. The simulations also revealed that standard propensity score adjustment can occasionally increase bias through bias unmasking when measured and unmeasured confounders exert opposing effects.
The third aim applied these methodological insights to a comparative safety study of Janus kinase (JAK) inhibitors versus Th2 cytokine inhibitors among adults with atopic dermatitis, in relation to the risk of skin and soft tissue infections. JAK inhibitor use was associated with a 78% increased hazard of skin and soft tissue infections (HR = 1.78; 95% CI: 1.43–2.23), compared to Th2 cytokine inhibitors, with the excess risk emerging after 60 days of treatment. Young adults, males, and patients with greater baseline treatment burden were at highest risk. Marginal structural models with time-varying inverse probability of treatment weighting yielded a modestly higher estimate (HR = 1.98), suggesting that time-varying confounders partially masked the association.
Collectively, this dissertation contributes to methodological considerations in the design, analysis, and interpretation of claims-based comparative safety studies of immunomodulatory therapies for chronic inflammatory skin diseases and provides real-world evidence on the infection risk profile of JAK inhibitors in atopic dermatitis that may inform clinical monitoring strategies.
Brighter Path Collective: an occupational therapy life skills series for recovery
(2026) Farr, Louisa; Ursillo, Angela; Jacobs, Karen
Rehabilitation programs for addiction recovery in the United States typically provide detox services, psychological treatment, and academic education. However, there is a significant gap in support for long-term holistic wellness, particularly life skills training for people in recovery from substance use disorder — especially those from rural areas, low socioeconomic backgrounds, and correctional settings. People in recovery have often lost or never learned basic skills related to stress management, time management, self-care, healthy relationships, and financial management. Incarcerated individuals experience occupational deprivation as a form of punishment, which leads to further atrophy of these skills. Without transitional support that addresses these deficits, the cycle of addiction, incarceration, and recidivism tends to repeat.This doctoral project addresses that gap through the development of Brighter Path Collective, a North Carolina-based 501(c)(3) nonprofit, and its flagship program, Life Skills for Recovery — an evidence-based, eight-part interactive workshop curriculum for adults in substance use recovery. Grounded in the Framework of Occupational Justice, Kolb's Experiential Learning Theory, and the Cognitive Theory of Multimedia Learning, the program delivers practical, occupation-based skill training through hands-on, multisensory activities including group discussion, role play, journaling, guided meditation, and educational games. Workshop topics include Healthy Relationships, Stress Management, Self-Care, Nutrition, Time Management, Adverse Childhood Experiences (ACEs), Parenting, and Finance. The program can be facilitated by any licensed mental health professional and is available in both correctional and community setting formats.
A mixed methods evaluation design was developed to assess program outcomes, employing a Likert-scale pre- and post-test survey with participants and an in-depth interview with the jail warden. Quantitative data will be analyzed using the Wilcoxon Signed Rank Test, and qualitative data will be analyzed using reflexive thematic analysis. Anticipated outcomes include increased life skills knowledge, improved coping and self-management, and decreased recidivism and relapse over time.
Brighter Path Collective and its digital workshop series are scheduled to launch nationally in mid-2026, providing facilitators across the country with a ready-to-use curriculum to deliver life skills training in their own communities. Occupational therapy is uniquely positioned to lead this work, and this project contributes to a growing — though currently limited — evidence base for occupation-based interventions in recovery and correctional settings.
Rediscover Reading: empowering people with visual impairments through smart technology
(2026) Bianchi, Michelle Jayne; Gafni-Lachter, Liat
Acquired visual impairment significantly disrupts participation in daily activities, with reading identified as one of the most functionally limiting consequences. Despite the widespread availability of mainstream smart technologies, particularly smartphones with built-in accessibility features, these tools remain underutilized in clinical vision rehabilitation. This gap is driven less by technological limitations and more by insufficient practitioner training and lack of clinical confidence in integrating digital accessibility into care. Rediscover Reading: Empowering People With Visual Impairments Using Smart Technology (Rediscover Reading), a structured, evidence-based continuing education program for occupational therapy practitioners and vision rehabilitation professionals, was developed as part of this doctoral project to address this translational gap. Grounded in the unified theory of acceptance and use of technology, the person–environment–occupation model, and adult learning theory, this 16-hr hybrid program targets key aspects of assistive technology adoption, including performance expectancy, effort expectancy, and facilitating conditions.
The curriculum is delivered across four modules: foundational knowledge of visual impairment and smartphone accessibility features; structured assessment for matching technology to client needs; hands-on experiential learning using low-vision simulators; and applied implementation through case-based analysis and role-play. The program emphasizes experiential and clinically relevant learning strategies to enhance practitioner competence in selecting, customizing, and training clients in the use of mainstream smartphone accessibility features to support reading.
A mixed-methods evaluation plan assesses feasibility and effectiveness, with primary outcomes focused on changes in practitioner knowledge, confidence, and self-efficacy in integrating technology into intervention. Pre- and postintervention measures include knowledge assessments and Likert-scale ratings of clinical confidence.
Dissemination efforts target clinical and academic audiences, promoting the integration of smartphone-based accessibility as a standard component of vision rehabilitation. The funding plan supports sustainable delivery and includes fee-for-service and potential grant funding.
By reframing commonly available devices as equitable assistive technology, this initiative advances occupational therapy’s role in promoting functional independence, accessibility, and occupational justice. The Rediscover Reading program offers a scalable, cost-effective model for enhancing technology integration in practice, ultimately improving participation outcomes for individuals with visual impairment.
Technology commercialization, competition, and the direction of innovation
(2026) McKeon, John L.; Simcoe, Timothy S.
The technology commercialization process—translating ideas into products—depends on access to critical resources and complementary assets, which in many markets are concentrated among a small number of firms. This structure may enable an efficient division of labor, with smaller actors specializing in upstream innovation and larger firms in downstream commercialization. Yet the need to ultimately transact over ideas may also shape upstream innovation, influencing which projects are pursued and which innovations reach the market. This dissertation examines questions motivated by this phenomenon, detailed in Chapter 1. Chapter 2 studies how startup acquisitions impact the positioning of rival startups. On one hand, the acquisition of a startup may put rivals at a competitive disadvantage, incentivizing positioning away from the acquired firm. On the other hand, a startup acquisition may send positive signals of future demand on the acquisition or product market, incentivizing rivals to position closer to the acquired firm. I compile a novel dataset of historical snapshots of startup websites over time and construct a measure of distance between startups' positions on the product market. Applying a matched difference-in-differences framework, I find that following the acquisition of a rival, startups move away from the acquired rival (differentiate themselves), on average. The effect is stronger among startups that have not raised venture capital, consistent with such firms possessing larger resource buffers to compete with an acquired rival, and in older markets, indicating that acquisitions in nascent markets convey stronger demand signals that mitigate competitive forces. These findings highlight the role of the M&A market in shaping the direction of entrepreneurial innovation, with implications for entrepreneurial strategy and antitrust policy. Chapter 3 investigates whether U.S. national security restrictions, which reduce acquisition market “thickness” in certain sectors but not others, alter the upstream R&D investments of potential targets. The analysis leverages a shift in U.S. national security policies through the Foreign Investment and National Security Act of 2007 (FINSA). We find a significant and deleterious effect of FINSA on the R&D intensity of potential targets, particularly in sectors with a higher reliance on foreign acquirers pre-FINSA. The results are robust to multiple acquisition-likelihood cutoffs and not explained by the late-2000s finance crisis. The study provides new evidence that fluidity in the market to acquire technology companies is consequential for upstream R&D investment incentives and reveals a possible unintended link between national security policies and innovative activity. Chapter 4 studies how the direction of innovative output changes as resource constraints are relaxed in the context of high-performance computing (HPC), a critical input to modern scientific research that is increasingly concentrated among a small number of technology firms. Using data from XSEDE, an NSF-funded program that allocates supercomputing resources to researchers, we leverage system-wide capacity constraints to identify the causal impact of variation in resource constraints on scientific output. We find that relaxing constraints increases the number of publications and shifts the direction of research. Scientists pursue less popular and newer topics, explore areas beyond their prior expertise, and broaden the scope of their work. However, these directional shifts are associated with fewer citations, suggesting a trade-off between frontier-expanding innovation and impact. Our findings show that allocation strategies shape not just the volume but the trajectory of innovation, with direct implications for R&D managers and policymakers supporting innovation under resource constraints.