Dissertation Title: An Integrated Methodology for Prosthetic and Orthotic System Strengthening in Weak and Destroyed Health Systems: Development and Application in Sierra Leone

Abstract: 

Prosthetic and orthotic (P&O) care remains inaccessible to approximately 90% of the estimated 35 to 40 million people globally who require it, with the greatest treatment gaps concentrated in post-conflict and resource-limited settings. Despite sustained international engagement in these settings for decades, a persistent pattern of provision without the foundational conditions required to sustain it has produced repeated cycles of real short-term benefit and limited lasting capacity. This dissertation argues that this pattern reflects a methodological gap: the field has lacked the analytical and translational tools for converting barrier knowledge into context-specific, sequenced implementation strategy. It addresses that gap through three integrated frameworks developed and tested over five years of embedded partnership with Sierra Leone's Ministry of Health.

SABI (Systems Assessment for Barrier Interactions) provides a replicable multi-level framework for characterizing P&O system barriers and analyzing how they interact across individual, service delivery, and health system levels. Applied in Sierra Leone, SABI identified four barrier interaction types: vicious cycles, multiplicative effects, downward cascades, and upward masking, which together explain why single-domain interventions have not produced lasting outcomes. MAPS (Multi-level Architecture for P&O Strengthening) translates SABI findings into evidence-based intervention design through barrier-domain mapping, prior support model analysis, international framework alignment, and participatory co-design, producing the Sierra Leone-specific SITE strategy. ROOTS (Readiness assessment, Ordering by dependency, Ongoing vetting, Threshold recognition, Sustainable trajectory) provides the implementation sequencing framework, empirically grounded through a longitudinal realist evaluation of SITE (2023 to 2026), which demonstrated that infrastructure, supply chain, workforce development, and technology vetting must be established in that order, each creating the conditions the next requires.

Together these frameworks constitute a complete, integrated methodology for P&O system strengthening: from barrier characterization through strategy design to implementation sequencing, oriented toward local ownership and transferable across comparable settings globally.

Committee Members:

Prof. Hugh Herr, Ph.D.
Professor of Media Arts and Sciences
Massachusetts Institute of Technology 

Prof. Victoria Austin, Ph.D.
Associate Professor for Social Justice and Innovation
University College London

Prof. Rima A. Afifi, Ph.D.
Professor, Director, Prevention Research Center for Rural Health
University of Iowa