Date of Award

January 2018

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Xiao Xu

Second Advisor

Kate Cooney


The overall objective of this thesis research was to elucidate the ecosystem of women's health social enterprises (WHSEs) based in the United States (U.S.). Aim I was to conduct a secondary data analysis of a random national sample of nonprofit WHSEs based in the U.S. regarding their characteristics and areas of intervention. Aim II was to conduct a qualitative assessment of a sample of women's health social entrepreneurs based in the U.S. regarding their perspectives on the ecosystem of WHSEs. Aim I utilized the GuideStar database and assessed enterprise size, geographic location, financial distress, health intervention area, and health activity category using descriptive statistics, statistical tests, and multivariable regression analysis via SPSS. Aim II utilized in-depth interviewing and grounded theory analysis via MAXQDA 2018 to identify novel themes and core categories while using an established framework for mapping social enterprise ecosystems as a scaffold.

Aim I findings suggest that WHSE activity is more predominant in the south region of the U.S. but not geographically concentrated around cities previously identified as social enterprise hubs. WHSEs take a comprehensive approach to women's health, often simultaneously focusing on multiple areas of health interventions. Although most WHSEs demonstrate a risk for financial distress, very few exhibited severe risk. Risk for financial distress was not significantly associated with any of the measured enterprise characteristics. Aim II generated four core categories of findings that describe the ecosystem of WHSE: 1) comprehensive, community-based, and culturally adaptive care, 2) interdependent innovation in systems, finances, and communication, 3) interdisciplinary, cross-enterprise collaboration, and 4) women's health as the foundation for family and population health. These findings are consistent with the three-failures theory for nonprofit organizations, particularly that WHSEs address government failure by focusing on the unmet women's health needs of the underserved populations (in contrast to the supply of services supported by the median voter) and address the market failure of overexclusion through strategies such as cross-subsidization and price discrimination. While WHSEs operate with levels of financial risk and are subject to the voluntary sector failure of philanthropic insufficiency, the data also show that they act to remediate other threats of voluntary failure.

Aim I findings highlight the importance of understanding financial performance of WHSEs. Also, lack of significant associations between our assessed enterprise characteristics and their financial risk suggests need for additional research to identify factors that influence financial performance of WHSE. Aim II findings show that WHSEs are currently engaged in complex care coordination and comprehensive biopsychosocial care for women and their families, suggesting that these enterprises may serve as a model for improving women's health and healthcare. The community-oriented and interdisciplinary nature of WHSE as highlighted by our study may also serve as a unique approach for research and education purposes. Additional research on the ecosystem of WHSE is needed in order to better inform generalizability of our findings and to elucidate how WHSE interventions may be integrated into policies and practices to improve women's health.


This is an Open Access Thesis.

Open Access

This Article is Open Access