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Background: To rapidly scale up HIV care, several sub-Saharan African countries have decentralised antiretroviral therapy (ART) and HIV care delivery. Decentralisation triages patients by intensity of care need, with clinically "stable" patients being down-referred to primary care clinics from secondary or tertiary hospital settings. Compared to other age groups, adolescents demonstrate both high rates of new HIV infections and the worst care outcomes once initiated on ART. However, the effects of decentralising HIV care remain poorly characterised for adolescents, despite its extensive and continuing rollout. Therefore, this thesis aims to characterise the current reality of HIV care delivery for adolescents in South Africa's decentralised HIV care system, in order to identify potential ways to tailor services for improving care outcomes in this vulnerable population. Objectives: (1) Summarise current evidence for effects of decentralising ART delivery for youth health outcomes; (2) Assess adolescent attainment of HIV care targets in South Africa's decentralised healthcare system; (3) Characterise adolescent experiences of transition out of paediatric HIV care in South Africa's decentralised healthcare system Methodology: This thesis consists of a systematic review of decentralising HIV care for youth in low- and middle-income countries (Paper 1), and an epidemiological study of HIV care outcomes and experiences for ART-initiated adolescents (n=1080) in South Africa's decentralised HIV care system (Papers 2-3). Primary data analyses for Papers 2-3 were based on a community-traced cohort (2014-2018) of all adolescents who had ever initiated ART in 52 public healthcare facilities of a health sub-district of the Eastern Cape. This candidate was a lead Co-Investigator of this longitudinal cohort study. At each of the three study waves, adolescents completed questionnaires about their health on digital tablets, administered by research assistants. In parallel, participants' clinical records were extracted in two waves (2014-2015 and 2016-2017) from electronic and paper-based patient files in healthcare facilities. At each facility, healthcare staff completed a semi- structured interview that provided a facility "profile" of available services. Results: Paper 1: A systematic review was conducted in accordance with PRISMA guidelines to critically appraise evidence on the effects of decentralising ART delivery on health outcomes for adolescents and young people (10-24 years old) in low- and middle-income countries. An extensive search was conducted through 12 electronic databases, contacting relevant experts, and hand-searching references. Implementation fidelity, study quality, and risk of bias were assessed using the TIDieR checklist, CASP checklists, and ROBINS-I tool, respectively. Of 5302 records identified, 11 studies were potentially eligible but required age disaggregation. Only 2 studies could provide age- disaggregated data, but meta-analysis was not possible due to limited data availability and heterogeneity in implementing decentralisation. Results from these 2 studies suggest the potential for at least equivalent attrition outcomes within decentralised care, but both studies faced significant selection and allocation bias. This review highlighted three key limitations in the current evidence base: (1) a general paucity of evidence on decentralisation for adolescents and youth in resource-limited settings, (2) a critical gap in recent evidence (post-2011) on decentralising HIV care, and (3) the focus of evidence on highly resourced models of HIV care delivery, rather than public care models. This paper is published in Global Health Action. Paper 2: Using clinical records through 2017, this study evaluated adolescent progression along an extended HIV care cascade in South Africa's decentralised public HIV care system, including operational and care-terminating outcomes. Mortality and loss to follow- up recorded in clinical records were adjusted for unreported deaths and "silent" care transfers. Sociodemographic and treatment-related predictors were tested through sequential multivariable logistic regressions. Predicted probabilities for the effects of predictors were estimated by sex and mode of infection. Rates of mortality and loss to follow-up in the total cohort were 3.3% and 16.9%, respectively. Although almost all participants with available clinical records had at least one recorded viral load, only 51.1% of these adolescents had viral loads from the past 12 months. Having a recent viral load was associated with experiencing decentralised care and longer time on ART. The protective effect of decentralised care was greater for female and sexually infected adolescents. At most recent available viral load, 58.4% of adolescents were fully virally suppressed. Among the total cohort, only 23.2% of adolescents were fully virally suppressed in the past 12 months. Younger age and longer time on ART were associated with full viral suppression. Thus, although overall rates of viral load coverage are high, adherence to routine testing guidelines and viral suppression remain low for adolescents living with HIV in South Africa. This paper is under review at BMC Infectious Diseases. Paper 3: This study identified adolescents' pathways in HIV care across facility care types and levels in South Africa's decentralised HIV care system, including transitions out of paediatric care. Associations between transition pathways and care outcomes were tested in sequential multivariable regressions. Thematic analysis of clinic-level questionnaires identified transition support available at facilities. In the total cohort, 57.8% had initiated ART in paediatric care, and 20.4% had transitioned out of paediatric care, with median age at first transition of 14 years. Among those who transitioned, two main pathways were identified: down-referral transition to generalised primary care clinics (56.7%) and classical transition to specialised adult HIV care (43.3%). Across pathways, 27.3% experienced cyclical transition, with repeated movement between paediatric and non-paediatric care. Experiencing down-referral transition was protective against viral failure, and median post-transition viral load change was not clinically significant. Healthcare providers at hospitals and community health centres described informal "protocols" used to mitigate risk of negative post-transition care outcomes for adolescents. This study suggests a new, contextually relevant model for adolescent transitions out of paediatric HIV care, beyond models found in high-income countries. This paper is published in the Journal of Acquired Immune Deficiency Syndromes. Conclusions: This thesis provides new and urgently required evidence on the reality of HIV care outcomes and experiences for ART-initiated adolescents in sub-Saharan Africa. This thesis highlights adolescents' high level of inter-facility mobility in South Africa's decentralised HIV care system, as well as low rates of recent viral load availability and viral suppression in clinical records. Further, this thesis identifies multiple pathways of transition out of paediatric HIV care in South Africa. Down-referral transition to generalised primary care clinics, a result of decentralising HIV care, was associated with viral suppression and facilitated by informal protocols developed by healthcare providers. Findings suggest that decentralising HIV care has substantially transformed HIV care experiences for adolescents, including greater agency in their care-seeking. This unique context requires a shift in understanding sub-Saharan adolescent HIV care beyond current models from high-resource settings. With increased mobility across facilities and care levels, it is crucial to ensure that health information systems accurately reflect adolescents' current clinical status. Thus, this thesis highlights both the need for structural interventions to improve clinical data monitoring and the potential for feasible protocols to mitigate risk of negative care outcomes for adolescents as they approach adulthood. Still, further studies with greater longitudinal coverage are required to confirm the dynamic and long-term effects of decentralising HIV care.

What predicts the adoption of informed consent laws for pelvic exams within the United States? As of January 2023, 22 states have adopted informed consent laws for pelvic examinations on women, with eleven being under Democratic control, six being Republican control, and five with divided control between the legislature and gubernatorial level at the time of adoption. Little attention, however, has been given to women’s health mandates outside the issue of abortion and to variation among state partisan adoption regarding informed consent for pelvic exams. This paper examines the impact of partisanship, the percentage of women in the legislature, and the sponsorship of legislation by women. I present an original dataset of state-level informed consent laws for pelvic exams, followed by applying a Cox proportional hazard model to study informed consent implementation, as well as a descriptive analysis of the influence of women and partisan sponsorship. This study offers insight into the impact of women in passing women’s health mandates by examining the influence of women legislators and partisanship on women’s healthcare initiatives outside of abortion. Advisor: Alice Kang

Within the past decade, the US tobacco product market has transitioned from being dominated by cigarettes to now offering an expanding array of different products. Of these, electronic cigarettes (e-cigarettes) have gained in popularity and become widely used by youth and younger Americans. Given the sharp increase in high school and even middle school students vaping, there has been pressure across all levels of government to address the issue through enhanced tobacco control policies. This dissertation focuses on the ground-level implementation of recently passed policies to identify gaps in tobacco control across the US. Presented in three research papers, the overarching aim is to understand how new tobacco control policies, such as Tobacco 21 and flavor restrictions, are implemented within communities. Additionally, features of the US political system which impact implementation are explored as well as potential solutions to issues identified. In the first paper, observations from tobacco retail locations in two Michigan cities (Grand Rapids and Detroit) assessed the retail environment for presence and advertising of menthol tobacco products. These assessments were used to identify if disparities in mentholated product availability and marketing existed across racially and economically diverse neighborhoods. Contrary to previous studies, neighborhoods with a higher percentage of non-Hispanic Black residents were no more likely to have mentholated products and had higher, not lower, prices for Newport menthol cigarettes (a popular menthol brand). In this study, Hispanic communities, instead, were observed to have greater availability and advertising for mentholated products. Some retailers also had illegal self-service displays, indicating lack of effective enforcement. The focus of the second paper was testing Theda Skocpol’s theory of advocacy using Tobacco 21 as a case. The spread of policies raising the age of sale for tobacco products to 21 (Tobacco 21) has been used as a classic example of a grassroots movement in public health literature, but this does not align with Skocpol’s work which indicates politics are often driven by advocacy organizations rather than truly grassroots activists. Through interviews with public health advocates in Colorado and Virginia, I found evidence that Skocpol’s theory holds true: national advocacy organizations played a pivotal role in spreading Tobacco 21 across the US with minimal citizen involvement outside of professionals promoting the policy as a public health measure. The third and final paper studied enforcement of minimum legal sales age policies, identifying factors which differentially impact retailer compliance rates across the country. Those factors include: a network of two federal enforcement regimes along with varying state policies and a possibility for local regimes in some states; Tobacco 21 increasing the age of sale resulting in state law changes; and the COVID-19 pandemic limiting retailer inspections. Across the three studies, it is apparent that institutions within the US government and power structures which favor national advocacy organizations contribute to vastly different policies across states which are implemented to varying degrees. At the ground level, this results in some states and localities having excellent updated policies and enforcement while other regimes lack the funding and infrastructure to enforce federal mandates.

The dissertation is a compilation of three essays on Turkey's poverty alleviation programs. The first paper focuses on the welfare impact of the global financial Crisis on Turkish households. The second paper considers the protective impact of the Green Card non-contributory health insurance program in Turkey during the Crisis in 2008-2009. The third paper uses experimental data from the field in eastern Turkey, to look at patterns of agricultural technology diffusion in a rural development program implemented in a post-conflict setting.

Non-communicable diseases (NCDs) are a global public health problem, causing 74% of all deaths worldwide. High systolic blood pressure and an unhealthy diet are the first and second most important contributors to the burden of cardiovascular diseases.In this dissertation, I analyze policies implemented in micro-and macro-environments aiming to modify the food environment to address the burden of diet-related non-communicable diseases (DR-NCDs). I follow Hawke's framework that highlights the food environment as a mediator between preference learning and actual food consumption. Thus, policies that address the food environment are more likely to succeed because they address the main barriers to healthy eating.The first paper provides evidence of the food industry's tactics in weakening and preventing the national and international diffusion of the sugar-sweetened beverages (SSB) tax's policy effectiveness, implemented in Mexico in 2014. The food industry paid scientists to produce evidence aligned with their interests, showing that the tax was ineffective in improving health and harming the economy. The second paper examines how a workplace SSB sales ban at the University of California, San Francisco (UCSF) reduced SSB consumption at work and outside work. Heavy SSB drinkers reduced their consumption by half at work and outside workplaces. Finally, the third paper evaluates the impact of a Food Pharmacy Program (FPP) at clinics in the San Francisco Health Network. The FPP is associated with significant systolic and diastolic blood pressure reduction in low-income adults with hypertension, with greater effects among those with poor blood pressure control, and those that attended the FPP at least five times.I conclude that to reduce the burden of DR-NCDs, a package of interventions and policies at different levels that modify the food environment may be effective in reducing the access to health-harming products and increase the availability and access to healthy food. In addition, governments and policymakers should be free of conflict of interest and implement policies based on independent peer-reviewed evidence.

This dissertation investigates the dynamics of different market failures in global pharmaceutical markets. It explores how pharmaceutical markets are shaped by state intervention or the absence of state intervention. Governments have a range of policy tools, market mechanisms, and legal avenues available to improve access to medicines. However, efforts by policymakers to address drug shortages, as well as high and rising prices, are frustrated by deep cracks in the information ecology. Despite policy efforts to improve transparency, the most central questions to access policy – How much does it cost to manufacture a medicine? What prices are being charged in different markets? Is the medicine affordable? How much manufacturing capacity is there at present, where is distributed, and how much could be mobilized in an emergency? – cannot be readily answered, for most medicines and in most markets, with the data that are currently collected. Such information asymmetries engender not just inefficiency, but can also drive inequality, with those least able to pay high prices or compensate for supply shocks disproportionately affected by monopoly markets or exogenous shocks like COVID-19. This dissertation takes steps towards filling these data gaps and offers new methods that can be expanded to other therapeutic areas, geographic regions, and market interventions. The three chapters that follow investigate market dynamics that affect medicines through three stages of the supply chain: first, markets for the raw ingredients used to manufacture medicines; second, the economics of converting raw ingredients into finished products that can be delivered to patients; and third, the dynamics of price competition for marketed medicines. I analyze the effectiveness of state efforts to control prices, and consequences where markets are left to an “invisible hand that is often not there”. Chapter 2 applies recent advances in quasi-experimental methods (synthetic difference-in-differences) to a novel, large dataset of trade data to evaluate the effect of COVID-19 on markets for active pharmaceutical ingredients (API) in India and China. Separate analyses are undertaken for key essential medicines and medicines speculatively repurposed for COVID-19, as well as analysis of heterogeneous effects experienced by low- and middle-income country (LMIC) and high-income country (HIC) markets. I find that prices for pharmaceutical raw materials doubled following the WHO declaration of a pandemic on 11 March 2020 for key essential medicines, and increased by as much as 500% for speculatively repurposed medicines like hydroxychloroquine and ivermectin. The volume of pharmaceutical raw materials exported to LMICs decreased in the year following the pandemic, while the amount exported to HICs increased. The causes for this disparity are complex and beyond the scope of this chapter, but qualitative work undertaken adjacent to this dissertation suggests that there was higher price sensitivity among LMIC purchasers and manufacturers responded to a decreased production capacity by prioritizing supply agreements with clients in HICs. Chapter 3 focuses on the global insulin market, a market characterized by an established oligopoly: three firms are estimated to control over 90% of the global insulin market, while access to treatment remains a challenge, with an estimated quarter of patients rationing insulin. Using trade data and interviews with manufacturers, this paper models the manufacturing costs for different types of insulin, as well as two other key groups of novel diabetes treatments: glucagon-like peptide 1 receptor (GLP1) agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors. The analysis finds that newer insulins, SGLT2 inhibitors, and GLP1 agonists can be profitably manufactured for prices significantly below current market prices. This suggests that prices of these key diabetes medicines could fall with increased competition or changes in procurement and price negotiations. More generally, these findings demonstrate that modeling of pharmaceutical manufacturing costs is feasible even without access to confidential internal data. Chapter 4 uses a sharp change in competition (antitrust) jurisprudence in the UK as a natural experiment to investigate how competition investigations and fines impact pricing practices in the pharmaceutical sector. Controlled interrupted time series (CITS) and difference-in-differences analyses are applied to generic drug price data in the UK to evaluate whether a landmark competition case (Pfizer and Flynn Pharmaceuticals v. the UK Competition and Markets Authority) had spillover effects in deterring excessive pricing across the generics markets. The analysis finds that only medicines with price increases of more than tenfold since 2010 responded to the increased probability of prosecution signaled in Flynn by lowering prices, and even these price reductions were modest (a 5% reduction relative to changes observed for non-excessively priced generic medicines). This suggests that the fine issued by the UK competition authority has so far not been effective as a deterrent to ‘excessive pricing’.

This dissertation consists of two empirical policy papers and one methods paper. All three papers examine the effect of changes to the Medicaid program. The first paper examines the impact of Medicaid expansion of jail-based recidivism. The second paper estimates the effect of retroactive eligibility waivers in Medicaid on enrollment. The third explores the implications of choosing a study design on the estimated effects of these changes by re-analyzing three published papers. In Chapter 1, co-authors and I estimate the impact of Medicaid expansion on recidivism. Previous research on the relationship between financial access to care and re-offense is mixed, and much of the published work is subject to selection bias, does not have a comparison group, or lacks a defined intervention. We use the variation introduced by the 2012 Supreme Court ruling in NFIB vs. Sebelius to derive causal estimates of this relationship using 48 months of booking and release data from six county jails. Three of the six counties are in Medicaid expansion states, and three are in non-expansion states. We conduct three case studies using a comparative interrupted time series analysis (CITS) to estimate the differential change in the probability of re-arrest and the number of arrests between the expansion and non-expansion counties. We find mixed results across these three case studies – in two case studies, we estimate declines in the probability of re-arrest of 5 and 13 percent. In the third, we estimate an increase of similar magnitude. We find a similar pattern of results with the number of arrests. To put these mixed results in context, we supplement our quantitative analysis with information from site visits and stakeholder interviews to identify mediators and moderators of the relationship between financial access to care and recidivism. In Chapter 2, I estimate what happens to Medicaid enrollment after the implementation of a retroactive eligibility waiver in a state’s Medicaid program. Retroactive eligibility provides 90 days of Medicaid coverage prior to a person’s date of application, given that the beneficiary was eligible in those 90 days. In the past five years, seven states have eliminated retroactive eligibility for some portion of the Medicaid population. However, we know of no study that examines what happens to enrollment, beneficiary financial status, or health outcomes after the removal of this provision. We use 24 months of Medicaid enrollment data in four of the seven retroactive eligibility waiver states to estimate the relationship between retroactive eligibility removal and changes in enrollment. Using a difference-in-differences (DID) and geographically similar comparison states, we find no impact of retroactive eligibility on Medicaid enrollment in any of the four states. However, the confidence intervals suggest that we may be under-powered. To address the power concerns, we combine the four retroactive eligibility states and their comparators in a pooled analysis. Here, we find a 10 percent decline in Medicaid enrollment at five and six months after waiver implementation, suggesting that removing retroactive eligibility may have a ‘chilling’ effect on Medicaid enrollment in the months after implementation. In Chapter 3, I explore the differences between two similar study designs – CITS and DID. Both of these designs use two time periods and a comparison group; they also use the change in the comparison group to estimate the counterfactual for the treated group without treatment. However, the use of these two study designs is disciplinary, and the respective disciplines prefer one design over the other. This is due, in part, to the lack of mathematical formalization for CITS. To understand the differences (if any), we first carefully write down the potential outcome model for two versions of each design – a general version of CITS, a linear version of CITS, DID with time fixed effects, and DID with time fixed effects and group-specific trends – and conduct a modeling exercise to estimate the counterfactuals for each. We, then, re-analyze three published studies to understand the situations where one of these designs might be preferable to the others. We find that general CITS and DID with time fixed effects and group-specific trends produce the same counterfactual and estimate the same treatment effects. The only difference between these two designs is the language used to describe them. We also find that when researchers lean into each design’s respective constraints – linearity for CITS and a zero difference for DID – counterfactual and treatment effect estimation differ. Empirical researchers should provide a clear explanation of the counterfactual assumptions being made and the model specification to allow for a more transparent evaluation of the plausibility of these assumptions.

I am devoted to health policy research, especially tackling the opioid crisis, and evaluating marijuana laws and newly emerging issues associated with legal recreational drugs. Opioid overdose in the United States continues to jeopardize public health. Meanwhile, the majority of states have legalized medical marijuana and one third of them further liberalized recreational marijuana. Marijuana liberalization, although originally independent of the growing opioid crisis, may be a harm reduction approach to the crisis because marijuana may be a substitute for opioids in pain management at a relatively lower risk. However, marijuana liberalization may also lead to marijuana-related harms, such as marijuana-related emergency department visits. Moreover, e-cigarette use has been rising among youth and young adults at an alarming rate and led to the current outbreak of lung diseases. My dissertation consists of three papers: “Paper 1: The Impact of Medical and Recreational Marijuana Laws on Opioid Prescribing in Employer-Sponsored Health Insurance,” “Paper 2: The Impact of Medical Marijuana Smoking Ban on Emergency Department Visits Related to Marijuana and Opioid Use,” and “Paper 3: Marijuana Use in E-Cigarettes among U.S. Youth.” Paper 1 Abstract: Marijuana may provide an alternative for pain management at a relatively lower risk of addiction and virtually no risk of overdose. Using data from Truven Health MarketScan Commercial Claims and Encounters Database between 2009 and 2015, I studied the effects of medical and recreational marijuana laws on opioid prescribing in employer-sponsored health insurance. I used a differences-in-differences (DD) approach and found that the implementation of medical marijuana laws (MML) and recreational marijuana laws (RML) reduced morphine milligram equivalents (MME) per enrollee by 7% and 13%, respectively. The reduction associated with medical marijuana laws was largely in people aged 55-64, while the reduction associated with recreational marijuana laws was mainly in people aged 45-54. My findings suggest that both medical and recreational marijuana laws have the potential to reduce opioid prescribing in the privately-insured population, especially for the middle-aged population and pain patients. Paper 2 Abstract: Medical marijuana liberalization has been spreading across U.S. states and empirical studies have found that medical marijuana and prescription opioids may be substitutes, yet no study has examined the impact of medical marijuana smoking bans on marijuana- and opioid-related emergency department visits, despite the fact that people historically prefer to smoke marijuana for medical purposes, and most marijuana-related emergency department visits were associated with Cannabinoid hyperemesis caused by smoking marijuana. The purpose of this study is to examine the impact of smoking bans by analyzing a nationally representative sample of the privately-insured population. Using data from Truven Health MarketScan Commercial Claims and Encounters Database between 2011 and 2016, I employed a differences-in-differences (DD) quasi-experimental design to examine the differences in marijuana- and opioid-related ED visits between states with medical marijuana smoking bans and states without such bans. I aggregated the data at the state/month level. I found that state medical marijuana laws with smoking bans were associated with a decrease in the number of marijuana-related ED visits by -3.289 per month (95% CI=-5.453, -1.125), which can be translated to a 16.3 percent decrease. State medical marijuana laws with smoking bans were associated with a decrease in the number of opioid-related ED visits by -3.808 per month (95% CI=-6.703, -0.913). The combination of medical marijuana laws with smoking bans and legal dispensaries was consistently associated with decreases in marijuana- and opioid-related ED visits among all ages. The findings suggest that medical marijuana laws with smoking bans coupled with legal dispensaries may improve the safety of marijuana use without compromising the accessibility of marijuana. Paper 3 Abstract: Non-nicotine substances, including marijuana and THC concentrates, can be used in e-cigarettes. By 2014, e-cigarettes had replaced traditional combusted tobacco products, such as cigarettes, and become the most prevalently used nicotine products among US youth. E-cigarette use among US youth continues to grow rapidly. State liberalization of medical and recreational marijuana makes marijuana more accessible and further reduces public perceived riskiness associated with marijuana use. Previous research has documented youth concurrent use of nicotine and other substances in e-cigarettes. I used data from the 2016, 2017 and 2018 National Youth Tobacco Survey (NYTS), a nationally representative sample of US 6 to 12 grade students to examine the trend of marijuana use in e-cigarettes as well as behavioral and environmental factors associated with marijuana use in e-cigarettes. I found that marijuana vaping increased among high school students but not among middle school students from 2016 to 2018. Being male was at greater odds of marijuana vaping. Compared to White non-Hispanic students, Hispanic students were at greater odds of marijuana vaping, while other non-Hispanic students were at lower odds of marijuana vaping. High school students were at greater odds of marijuana vaping than middle school students. The odds of marijuana vaping increased among high-school Hispanic females and among other non-Hispanic males from 2017 to 2018. The odds of marijuana vaping increased among high-school black females and among middle-school Hispanic females from 2016 to 2017. Both high-school Hispanic females and males were increasingly more likely to vape marijuana from 2016 to 2018 after controlling for behavioral and environmental factors. The odds of marijuana vaping continuously increased among those who did not report flavors as one of the reasons of using e-cigarettes from 2016 to 2018, among those who did not report less cost as one of the reasons of using e-cigarettes from 2016 to 2018, and among those who did not report less harmfulness as one of the reasons of using e-cigarettes from 2016 to 2018. My findings suggest that E-cigarette policy may need to focus on the increase in marijuana vaping among Black and Hispanic female students, and Hispanic students in general. Banning flavored e-cigarettes may not reduce marijuana vaping among youth. Lower cost and less perceived harmfulness associated with e-cigarette use may not be associated with the trend of marijuana vaping among youth.

This dissertation consists of three essays on the U.S. Health care policy. Each paragraph below refers to the three abstracts for the three chapters in this dissertation, respectively. I provide quantitative evidence on how much Prescription Drug Monitoring Programs (PDMPs) affects the retail opioid prescribing behaviors. Using the American Community Survey (ACS), I retrieve county-level high dimensional panel data set from 2010 to 2017. I employ three separate identification strategies: difference-in-difference, double selection post-LASSO, and spatial difference-in-difference. I compare how the retail opioid prescribing behaviors of counties, that are mandatory for prescribers to check the PDMP before prescribing controlled substances (must-access PDMPs), vary from the counties where such a PDMP check is voluntary. I find must-access PDMP reduces about seven retail opioid prescriptions dispensed per 100 persons per year in each county. But, when I compare must-access PDMPs counties with bordering counties without such law, I find a reduction of three retail opioid prescriptions dispensed per 100 persons per year suggesting the possibility of spillovers of retail opioid prescribing behaviors. As of 2019, all U.S. states, except Missouri, have enacted voluntary Prescription Drug Monitoring Programs (PDMPs). In response to the relatively low uptake of voluntary access, several states have strengthened their PDPMs by requiring providers to access information regarding prescription drug use under certain circumstances. These “must-access” PDPMs require states to view a patient's prescription history to facilitate the detection of suspicious prescription and utilization behaviors. This paper develops causal evidence of the effectiveness of “must-access PDPM laws in reducing prescription opioid overdose death rates relative to voluntary PDMP states. I find that PDMPs are ineffective in reducing prescription opioid overdose deaths overall, but the effects are heterogeneous across states with “must-access” PDMP states. I find that marijuana and naloxone access laws, poverty level, income, and education confound the impact of must-access PDMPs on prescription opioid overdose deaths. The optional provision of Medicaid expansion, through the Affordable Care Act (ACA), has triggered a national debate among diverse stakeholders regarding the impacts of Medicaid coverage on various dimensions of public health, costs, and benefits. Randomized experiments like the Rand Health Insurance Experiment and the Oregon Health Insurance Experiment have generated some credible estimates of the average treatment effects of insurance access. However, identical policy interventions can have heterogeneous effects on different subpopulations. This paper uses data from the Oregon Health Insurance Experiment to estimate the heterogeneous treatment effects of access to Medicaid on health care utilization, preventive care utilization, financial strain, and self-reported physical and mental health. I detect heterogeneous treatment effects using a cluster-robust generalized random forest, a causal machine learning approach. I find that the impact of Medicaid is more pronounced among relatively older non-elderly and poorer households, consistent with standard adverse selection theory. Furthermore, I implement the “efficient policy learning," another machine learning strategy, to identify policy changes that prioritize providing Medicaid coverage to the subgroups that are likely to benefit the most. On average, the proposed reforms would improve the average probability of outpatient visits, preventive care use, overall health outcomes, having a personal doctor and clinic, and happiness by a range of 2% to 9% over a random assignment baseline. These findings help design Medicaid Section 1115 waiver.

BACKGROUND: The growing prevalence of common mental health problems poses a serious hindrance to young adults, and the majority of those in need of mental health support do not seek professional psychological services. Digital mental health interventions (DMHIs) that allow for self-management of mental health symptoms could provide a useful adjunctiveto traditional one-on-one counseling or therapy and offer a useful prevention tool for students at risk for experiencing mental health crises. This dissertation explored the efficacy of self-guided DMHIs targeting college students, the factors associated with help-seeking in young adults, and the impact of implementing an evidence-based DMHI at a public 4-year university for first-year students. METHODS: The first analysis employed a systematic review guided by the PRISMA protocol to examine the effectiveness of technology-delivered interventions (e.g., mobile app) in reducing, improving, or preventing symptoms associated with depression, anxiety, psychological distress, or stress in college students from 2008 to 2021. The second analysis used the Healthy Minds Study (HMS) data from 2015-16 to 2020-21 to analyze help-seeking associations of college students through a binary logistic regression model. The final paper proposed a cost consequences model using HMS data from 2018-19 to 2020-21 to identify differences in cost-effectiveness of digital versus traditional mental health services. The RE-AIM model and Aday and Anderson’s Framework for the Study of Access guided the final analysis. FINDINGS: Certain evidence-based mindfulness, cognitive behavioral therapy (CBT), and acceptance commitment therapy (ACT) apps effectively improved symptoms associated with common mental health problems in college-aged students, though adherence was a common challenge faced by researchers. As young adults experience an increase in severity of their mental health symptoms, the odds that they seek professional help diminishes. This trend was more pronounced in students with depressive symptoms compared to those presenting anxiety symptoms. Non-Latinx Black students presented the greatest lack in help-seeking in the study sample. Non-Latinx White, Latinx, and multi/other race students demonstrated a steady increase in help-seeking behavior prior to the COVID-19 pandemic. However, by 2018, help-seeking began to plateau and decline in the years leading up to and during the pandemic. Headspace, an evidence-based mindfulness app, demonstrated promising outcomes as a cost-effective intervention that may serve to complement traditional campus mental health services and prevent the onset of common mental health problems when integrated early in the college experience. CONCLUSIONS: Leaders and mental health professionals in higher education continue to face serious challenges as they navigate the increasing severity and complexity of student mental health needs in the wake of the COVID-19 pandemic. Although utilization of mental health services has steadily increased in the last decade, colleges and universities are not able to keep up with demand. Most students in need of mental health services will never seek professional services. When integrated thoughtfully into different aspects of campus life, certain evidence-based, self-guided DMHIs offer a versatile and cost-effective approach to improving student access to a wider range of quality mental health services.

This thesis paper strives to identify the relationship between Medicaid expansion and Emergency Department use. I use a Monte Carlo simulation for demonstrating the endogeneity problem and a copula model using the Oregon Health Program (OHP) data to show the previous literature has exaggerated the causal relation between Medicaid expansion and Emergency Department use. This paper can be divided into two parts. First, it tries to focus on the under-identification of multiple endogenous variables problem in typical econometrics papers, where researchers correct for a single endogenous variable but intentionally or unintentionally ignore the endogeneity of one or more other independent regressors. So, the motivation for first part of this thesis comes from the fact that the previous literature does correct the multiple endogeneity issue. Second, I endeavored to solve this under-identification problem of multiple endogeneity by incorporating a copula regression, along with OLS and 2SLS. The new approach to solve the under-identification problem is a copula method where we have flexibility of using different distribution methods to choose the best one. Using a copula method, we have found that Medicaid does indeed increase the emergency department use, however, not at the rate as the previous literature showed. This is the major contribution of this thesis

Throughout the last decade or so, Opioid related fatalities are at all-time high in the United States. New Mexico’s problem with Opioids abuse in not a new phenomenon and a large number of New Mexicans are losing their lives almost on a daily basis. The paper highlights the alarming situation of overdose deaths caused specifically by the abuse of Prescription Opioids and Heroin which, in 2016 alone have taken 347 lives in New Mexico. Policy makers along with other stakeholders play a vital part in shaping the politics along with other interventions which can help tackle the epidemic. The paper provides analysis of state policies along with other initiatives taken to tackle the Opioids epidemic in New Mexico. After an in-depth analysis of the situation in the state, the paper will conduct strengths, weaknesses, opportunities and threats (SWOT) analysis of possible interventions and policies aimed at addressing rising overdose deaths caused by Prescription Opioids and Heroin. Recommended interventions include, Creation of Prescription Opioids and Heroin crisis Action Team, Implementation of Alternative to Opiates program within the healthcare setting, Heroin Assisted Treatments as well as considering Opioid Use Disorder as a qualifying condition for accessing Medical Cannabis. Rising unnatural deaths caused by this epidemic is severe and all the stakeholders in New Mexico must call for desperate measures to deal with such desperate times.

This dissertation applies tools from health services research to the college sports medicine context. The first two papers analyze a sample survey of college football players, asking questions about individual-level risk perceptions and injury reporting. The third paper evaluates a novel combined data set and evaluates institutional-level modifiers of athlete injury outcomes. Together these papers provide important evidence about individual, institutional, and ethical considerations of risk in college sport. Chapter one describes features of athletes’ concussion and injury reporting tendencies. Using original survey data from a cohort of college football players, we evaluate two assumptions of the current literature on concussion reporting. First, we assess whether athletes make reasoned deliberative decisions about whether to report their concussion or other injury. Second, we investigate whether the probability of reporting a concussion or injury is independent of where it occurs in the sequence of injuries experienced. Descriptively, we find that athletes are much less likely to report a concussion to a medical professional than they are to report another injury. We also find a much lower rate of concussion reporting in this study compared to the previous literature. There is no association between concussion or injury reporting behaviors and one measure of athletes’ ability to switch between fast reactive thinking to reasoned deliberative thinking. We do find significant variation in athletes’ injury and concussion reporting over the sequence of injuries. While the likelihood to report decreases for both injury and concussion, there is a notable decrease in the probability of reporting around four concussions, a cutoff that sports medicine clinicians may use as an occasion to discuss curtailing sports participation. Sports medicine clinicians may need to consider athlete injury history as a risk factor for concussion under-reporting. Chapter two compares athletes’ perceptions of the risks of sports participation to an estimate of their actual risk. Using primary survey data of a cohort of football players from the most competitive sub-division of college football, we model athletes’ single-season risk of injury and of concussion and compare these to their perceptions of these risks. Across many measures, we find a significant proportion of athletes underestimate their risk of concussion specifically and injury overall. In the context of the modern debate around the risks of football, this has significant implications for advocates of an informed-consent approach to participation. Chapter three describes the relationship between access to clinicians and injury outcomes in the context of college athletics. Using a novel combined dataset including injury and exposure data from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP), sports medicine staffing data from NCAA Research, and athletic department characteristics from the United States Department of Education Equity in Athletics data, we evaluate whether the average number of clinicians per athlete at a college, is associated with rates of injury, reinjury, time loss to injury, and concussion. We also evaluate whether schools that voluntarily contribute data to the NCAA ISP differ from non-contributing schools in observable ways. We find a significant inverse relationship between number of clinicians per athlete and rates of injury, rates of reinjury, and rates of concussion, with schools one standard deviation above average in their number of clinicians per athlete having 9.5%, 2.7%, and 6.7%, fewer injuries respectively. We find a significant positive correlation between clinicians per athlete and time loss to injury, with schools one standard deviation above average in their number of clinicians per athlete having 16% greater time loss on average. Although these reductions in injury rates are relatively modest, the large number of college athletes means that the absolute reduction in injury that could be achieved is meaningful. For example, a 9.5% reduction in injury extrapolated to the NCAA context more broadly would equate to 3,165 fewer athlete injuries occurring annually. Schools that contribute data to the NCAA ISP tend to have more athletes, more clinicians per athlete, greater athletic department revenues and are more skewed toward Division I than non-contributing schools, reducing generalizability of these and other NCAA ISP findings. This study supports the idea that improving staffing in college sports medicine departments would improve athlete health and wellbeing by reducing rates of injury.

This dissertation examines two common sources of increased health care costs – readmissions and the co-occurrence of depression among patients with diabetes. The first paper examines hospital performance in the Hospital Readmissions Reduction Program to determine whether sources of incentive heterogeneity are associated with differences in improvements over multiple years. I find that hospitals seem to be responding to the main incentive in the program, as those that performed poorly in previous years improve significantly more than hospitals that have avoided penalties. Hospitals also are making improvements in conditions that have the highest marginal benefit from better performance. Payer mix does not seem to be correlated with hospital performance over time even though the financial incentives of the program only apply to future Medicare reimbursements. In the second paper I develop a model to predict the onset of depression among individuals with diabetes. Using data from the Health and Retirement Study and the National Health and Nutrition Examination Survey, I find that gender, body-mass index, hypertension, history of stroke, history of heart disease, and duration of diabetes are significant predictors of annual depression status. I then build this depression prediction algorithm into the Michigan Model for Diabetes, an existing microsimulation model that allows users to evaluate the progression of diabetes. In the final paper, I use the modified diabetes simulation model to evaluate the cost-effectiveness of the collaborative care intervention to treat depression among patients with diabetes. Trials suggest that the collaborative care intervention, a multidisciplinary approach to address the depressive symptoms of patients, can be cost-effective in the short-term when used to treat patients with diabetes and comorbid depression. Using simulation models allows us to evaluate the long-term cost-effectiveness as well as the influence of a variety of inputs on the value of the program. Only when the utility loss associated with depression is small or the intervention effectiveness is substantially decreased does the intervention require a higher willingness-to-pay to be considered cost-effective. Otherwise, our base-case analysis and other one-way sensitivity analyses support the conclusion that this intervention is cost-effective.

Paper 1 discusses the question of whether health policy should treat drugs for rare diseases (“orphan drugs”) differently from drugs for common diseases. Due to the small number of potential patients, orphan drugs are less likely to be developed and tend to be expensive when they come to market. To promote development of and access to these treatments, many countries have instituted policies that give special consideration to orphan drugs in a variety of ways. This paper asks whether disease prevalence is a morally relevant characteristic that warrants such special treatment. After examining reasons given in the literature for distinguishing between rare and common diseases, I argue that it is not. It is the severity of orphan diseases that drives our judgments that important claims are being overlooked when orphan treatments are unavailable, not their prevalence. Unlike prevalence, severity is an appropriate consideration for priority setting. Therefore, policies aiming to treat all claims equally should make prevalence irrelevant rather than making it the basis of differential treatment. Paper 2 is a qualitative study of public values on the question of how the severity of a condition and its prevalence should affect priority setting. As part of two citizens’ juries in Alberta, Canada, participants engaged in a deliberative exercise designed to elicit trade-offs between helping small groups with severe conditions and larger groups with less severe conditions. A thematic analysis of transcripts of the deliberations indicates that the public would support funding high-cost drugs to meet the needs of a few when the interventions for rare conditions are life-saving; extend life enough to give hope of future improvement; and relieve otherwise intractable symptoms, especially pain. Considerations of whether a treatment manages symptoms or alters the underlying condition take low priority. These findings can inform Canada’s current drive to establish a national orphan drug policy. Paper 3 examines the use of cost-effectiveness thresholds in the British National Health System (NHS). A recent report states that the NHS’ cost-effectiveness threshold should be lowered from £30,000 to £12,936, to reflect the opportunity cost of a quality-adjusted life-year (QALY) rather than a measure of societal willingness to pay for a QALY. This paper argues that if the threshold is to be determined by opportunity costs, then the understanding of opportunity cost needs to be broadened to include not only QALYs foregone, but also effects on equity, financial protection, and other social values. Even if a broader notion of opportunity cost is considered, deriving the threshold from these costs raises a question of justification: opportunity costs are determined by political factors and facts about the health care system that are unrelated to patients’ claims on the NHS, and may seem arbitrary from their point of view.

This research aimed to explore how newly forming Clinical Commissioning Groups (CCGs) were tackling health inequalities (HIs) (if at all) in the UK. In 2010 the current coalition government was formed between the Conservatives and Liberal Democrats. Shortly after this, the White Paper Equity and Excellence: Liberating the NHS (Department of Health, 2010a) was published. This was the starting point for a large variety of policy documents being published outlining the healthcare changes that were to happen within the UK. Following the ‘pause’ a number of amendments to the initial policy proposals were outlined (Department of Health 2011). These included the newly named GPCCs being restructured and renamed as CCGs. Additionally, the Government took on board the recommendations of the Future Forum (June 2011) to make tackling HIs a duty for CCGs. The concept of HIs itself is very complex with a wide variety of definitions that have been discussed within the literature. It was acknowledged early on within this project that because of the complexities and variations in people’s understandings and interpretations of HIs that a fundamental element of understanding how CCGs are tackling health inequalities would be underpinned by individual’s own and organisational conceptualisations of HIs. Three CCGs in the North of England were recruited and qualitative methods, including interviews, observations and document analysis were used to collect data, over a period of 12 months from January 2012-December 2012. The timing of the project meant that data collection was conducted when the NHS was in a state of flux; CCGs were in shadow form, preparing themselves for the authorisation process. Interviews and observations ascertained that HIs were being conceptualised and tackled differently across the three CCGs. There were several common themes that were evidentially important to CCG members when describing the wider influences on their HI understandings and strategies to tackle HIs. These included history, relationships and the role of Public Health. The history of both organisations and relationships were acknowledged by all CCGs in shaping how they had developed under the current policy agenda and how they planned to tackle HIs (if at all). The role of Public Health was a key finding from this research, three different roles were identified, defined and explored in practice, examining how the roles influenced the HIs agenda differently. The Public Health roles of ‘service provider’, ‘co-owner’ and ‘critical friend’ have the potential to shape working relationships between Public Health and the CCG and shape the HIs agenda. Weick’s (1995) concept of sensemaking was used to examine how these main findings helped define the HIs agenda. Overall, HIs conceptualisation, strategies to tackle HIs and wider organisational relationships with PH and the LA are not consciously developed by these organisations. History and local contexts help generate schemata that underpin action.

Guatemala has an unacceptably high maternal mortality ratio (MMR) of 140, andimprovements in this area have been slow. Furthermore, gross inequalities in healthoutcomes exist within its population, with over 70% of maternal deaths in Guatemalaoccurring among indigenous Mayan women. Mayan communities have been historicallymarginalized, and most Mayan women prefer the services of traditional birth attendants(TBA). As such, a disconnect exists between the formal and traditional health sectors inGuatemala, contributing to poor maternal health outcomes. It is widely agreed thatprofessional midwifery is an important component of safe motherhood strategies that canreduce maternal morbidity and mortality. Today the Guatemalan Ministry of Health isreintroducing midwifery for the first time since 1960. Given the potential professionalmidwifery has to address the obstetric care needs of Mayan women and bridge the gapbetween the health sectors in Guatemala, formative research is needed at the outset toinform the design and implementation of this program.This dissertation aims to inform future directions for professional midwifery in Guatemalaby assessing and analyzing historical policies and current perspectives and presentingcontext-specific recommendations for the future. The first paper looks to the past toconsider how international and society-centered forces influenced the creation of policies inGuatemala regarding birth attendance since the signing of the Peace Accords in 1996 up tothe reintroduction of midwifery. Next, the second paper elucidates the misperceptions,attitudes and expectations about the addition of midwifery to the healthcare system byGuatemalan physicians, nurses, midwives and TBAs today, identifying potential threats andfacilitators to this strategy’s success in Guatemala. Finally, the third paper proposesrecommendations for the future, considering identified impediments to midwifery’s capacityfor sustainability. This dissertation provides findings that can improve the design,implementation, monitoring and evaluation of the professional midwifery strategy inGuatemala, and can inform program and policy decisions to implement this strategy inGuatemala, Latin America and beyond.

This research builds upon a body of work on the development and introduction of information systems in the UK National Health Service following the implementation of the White Paper 'Working for Patients'. None of the earlier studies examined the use of the information from those systems for costing health care services, the methodologies used by hospitals for costing their products or the comparability of the output from the costing methodologies used, thereby making this study different from prior work. Costing methodologies cited in the literature are described from the perspective of single organisations. This research analyses the development of an aggregated costing approach, focusing on the issues laced when trying to develop a costing methodology that will be applied to a group of autonomous organisations. The research provides a comparison of health care costing methodologies in both the United Kiiigdom and Ontario, Canada. Collected through interviews and a postal survey tool, data from NHS hospital care providers are analysed to identify both the conformity of the approach and the results of the costing methodologies eniployed. Information from an extended field study is used to review the development of a micro-costing framework in Ontario for radiation therapy services. These findings are then synthesised into a generic framework applicable within other health care organisations seeking to implement a comparative costing methodology. This lramcwork is used to identify possible causes of variance in health care costing approaches. Elements of the framework requiring modification to account for local conditions, such as salary rates or provider availability, are identified and suggestions are made for further work resulting from this research to increase understanding about variability in health care costing methodologies and test the implementation of the generic costing methodology.

This dissertation consists of two empirical papers and one methods paper. The first two papers use quasi-experimental methods to evaluate the impact of universal health insurance reform in Massachusetts (MA) and Thailand and the third paper evaluates the validity of a quasi-experimental method used in comparative effectiveness research (CER).

The objective of this dissertation is to evaluate whether two different types of policy interventions in the United States are associated with health service utilization and economic outcomes. Paper 1: The number of government lawsuits accusing pharmaceutical companies of off-label marketing has risen in recent years. We use Medicare and Medicaid claims data to evaluate how an off-label marketing lawsuit and its accompanying media coverage affected utilization and spending on gabapentin as well as other anticonvulsant medications. In this interrupted time series analysis of dual eligible patients with bipolar disorder, we found that the lawsuit and accompanying media coverage corresponded with a decrease in market share of gabapentin, a substitution of newer and expensive anticonvulsants, and a substantial increase in overall spending on anticonvulsants. Paper 2: Medicare Part D was a major expansion of Medicare benefits to cover pharmaceuticals. There were initial concerns about how the dually eligible population who previously had drug coverage through Medicaid would fare after transitioning to Part D plans. Using a nationally representative longitudinal panel survey of Medicare Beneficiaries that are dually eligible for Medicaid, we investigated whether differences in generosity of Medicaid drug benefits were associated with differential changes in drug utilization and out-of-pocket spending for duals after they transitioned to Part D. Our finding suggest that those who previously encountered a monthly drug cap prior to Part D implementation experienced a differentially higher increase in annual prescription drug fills compared with those who did not face a cap.

Accounting for 24 per cent of total disability in Australia, mental health disorders result in significant social and economic costs. Health care costs alone amounted to $4.1 billion in 2004-05. Mental health sufferers are more likely to be in low income groups and they often lack the financial, educational and social resources required to seek appropriate treatment. To date, no economic studies in Australia have investigated income and price issues related to the demand for mental health care, nor have any previous studies considered the importance of concession prices associated with the Australian health card for accessing mental health medication. My first paper establishes the trend in the use of mental health medication in Australia from 1989 to 2004-05, which has previously not been documented. Using decomposition analysis to investigate the contributing factors to the three-fold increase in the use of mental health medication over this period, I show that socio-demographic characteristics account for only a small amount of the growth. An examination of trends in the association of income with mental health risk and with mental health medication use shows a negative income gradient for both. My second paper examines in greater depth the effect of income on mental health medication use in 2004-05. Selection methods are used to separate the effect of income on medication use from the effect of income on mental health risk. By estimating mental health medication use separately for those with and without the health card, I determine that having the health card improves access to mental health medication use and that a positive income gradient for mental health medication use exists for those without the health card. My third paper uses a natural experiment approach to determine the price responsiveness of mid-high income seniors for mental health medication following income eligibility increases in 1999 for the Commonwealth Seniors Health Card. The results indicate that after controlling for health status no significant change in mental health medication use occurred following the policy for this group of mid-high income seniors, confirming the greater importance of the health card for mental health sufferers with low income.

This dissertation contains three empirical papers on important health policy issues. The first paper looks at the effect of changes in levels of Medicare home health care services on the informal care use of disabled, older adults. I estimate two-part models of informal care use, where the key independent variable is a measure of Medicare home health payment restrictiveness. Individuals who lived in states with less Medicare home health care services increased their use of informal care, although this effect is only observed among low-income individuals. The second paper assesses the effects of changes in employment incentives on the supply of informal support from adult children to their disabled, older parents. This study focuses on one specific form of informal support, co-residence with a disabled parent. I compare changes in co-residence patterns between 1990 and 2000 across groups of middle aged women whose co-residence patterns were arguably comparable, and who experienced very different changes in employment incentives. Results from difference-in-difference models provide support to the hypothesis that increasing employment incentives reduces the supply of informal support to disabled parents. The third paper looks at the effect of education on health status. This paper builds on the extensive research literature on this topic by measuring health in terms of the number of Quality-Adjusted Life Years experienced by individuals over an extended period of time. This measure captures overall health status over time, which is arguably a more important measure than point-in-time measures of specific health conditions or longevity alone. I use changes in compulsory schooling laws to identify the causal effect of education on health. Instrumental variables models provide evidence that the health returns to education are both statistically significant and substantial.

The topic that is addressed here is the embodying of the female patient through the political-medical discourse that accompanied the Women’s Health Equity Act and breast cancer politics between 1990 and 1993. Through an examination of women’s health policy during these formative years together with Foucault’s theory of the gaze and embodiment, this paper will formulate the manner in which the female patient comes to personify certain characteristics and medical concerns as an effect of the relationship between politics and medicine. In addition to the central thesis supplementary themes materialize throughout the paper. One motif is the cyclical relationship between politics and the media. When one party brings a subject to the forefront, the other reacts and strengthens national attention concerning the matter. Women’s health as a disciplinary field also raises questions regarding theories of the body by constricting patients to binary categories of male/man and female/woman, a concept that draw parallels to the codification of race/ethnicity in society. As a policy issue women’s health illustrates the contradictions that exist between the body, disease, the goals of medical care, and our self-image in relation to policy makers. Reviewing this period of research and the formation of women’s health policy exposes the multifaceted relationship between politics and medicine. Simultaneously, policy crafted between 1990 and 1993 highlights the deep roots of cultural bias concerning the social value of female bodies and their feminine body parts.

There is little data available on the complex cause and effect of delayed hospital discharge; however, some evidence suggests that long-stay patients tend to be complex, older, and sicker. In Maine, a 2014 Maine Health Association report found complex hospital patients were waiting weeks, months and sometimes over a year in Maine Hospitals before accessing long-term services and supports. In response to these concerns around delayed discharge from hospitals, the First Regular Session of the 127th Maine Legislature created the Commission to study Difficult to Place Patients. The Commission ultimately passed Legislation that gave the Maine Long- Term Care Ombudsman Program the ability to assist with delayed discharges to decrease these delays and free up hospital beds. This paper will share and analyze preliminary data from this innovative program (approx. 1.5 fiscal years).

Few studies have examined soldier and commander views of the barriers and facilitators towards stricter tobacco control policy in the military. Commanders (n=10) from an army installation were individually interviewed and two focus groups (n=5 and n=9) of soldiers informed the development of a paper survey, which was administered to 328 of the 357 randomly selected soldiers. Facilitators identified were: uniformity; national level policy; informed by smokers, non-smokers and medical personnel; and provision of alternatives for stress relief. Barriers identified were: enforcement, low morale with tobacco cessation, perceived personal rights violation, and lack of belief that tobacco negatively impacts readiness.

Exposure to chronic childhood trauma increases the risk for the development of behavioral and mental health disorders and poor academic achievement. Nearly 70% of children have experienced some form of trauma, in the form of either a victimizing or non-victimizing event. Estimates suggest that 20% of children and adolescents have a mental health disorder, yet 70% do not receive mental health services. Children and adolescents of minority racial/ethnic groups and those living in poverty are at greater risk of exposure to trauma and less likely to have access to and utilization of mental health services. This increases the risk for poor academic achievement and school dropout. School success is a major determinant of a person’s opportunities for employment and social mobility advancement. Structural interventions are needed to provide resources to help prevent or mitigate the harm from exposure to chronic childhood trauma. One strategy to increase access and utilization of mental health services is the school-based health center (SBHC) model of care. This dissertation begins with a literature review to explore the association between trauma, mental health, academic success, mental health care disparities, and SBHC mental health services. This paper then employs a cross-sectional design to examine the School-based Health Alliance 2010-11 Census to describe and assess the characteristics of SBHCs with mental health providers. This study also examines the 2010 California Healthy Kids Core Module Survey to assess the need for mental health services in school-aged children in California. The findings demonstrate that exposure to chronic childhood trauma negatively impacts school achievement when mediated by mental health disorders. There are multiple characteristics associated with SBHCs having a mental health provider on-site at the school. There is a need for mental health services for 6th-12th graders. These students are being exposed to victimizing events on school campuses and are thus at higher risk for use of substances, symptoms of depression and eating disorders, and poor academic achievement. These findings have implications for policy makers and school health stakeholders in addressing the need for mental health services in children and adolescents exposed to chronic childhood trauma.

Public policies have different effects on different populations groups and can perpetuate health disparities among some populations. My research utilizes community-based participatory approach to research in the examination of one unique population: the Marshallese. This dissertation research presents three papers that are part of a cohesive research agenda predicated on community-based participatory research (CBPR) to facilitate policy-oriented learning. My research can be used to inform health policy, health care services, and health education. Chapter Two presents the article titled: Health Beliefs of US Marshallese Regarding Type 2 Diabetes. This article explores the research question: what health beliefs related to diabetes influence diabetes self-management behaviors? Chapter Three presents the article titled: Interpretive Policy Analysis: Marshallese COFA Migrants and the Affordable Care Act. This article explores the research questions: for Marshallese living in the United States, 1) what is their understanding of and experience with the ACA and related health policies; 2) what effect do the ACA and related health policies have on participants’ and the community’s health? Chapter Four presents the article titled: Family Model of Diabetes Education with a Pacific Islander Community, and this article explores the feasibility of a family model of diabetes education was conducted in participants’ homes with extended family members. This research, and my broader research agenda, seeks to improve health equality and decrease health disparities for the Marshallese community. The Marshallese community experiences many health disparities and constraints because to actions and policies of the US federal government, many of which must be addressed through changes in public policy. This dissertation research converges into a cohesive research agenda that is built on the principals of CBPR and is designed to fuel policy and programmatic action.

The first essay in my dissertation investigates the impact of a state policy designed to reduce substance abuse. Prescription drug monitoring programs (PDMPs) are state-run electronic databases that track the prescribing and dispensing of controlled substances. I examine the impact of PDMP implementation on various measures of opioid pain reliever abuse. I estimate difference-in-differences models, and address possible policy endogeneity by controlling for pre-implementation trends and related state laws. The preferred estimates suggest that PDMPs reduced opioid abuse treatment admissions by 13.1%. However I cannot reject the null hypothesis that PDMPs had no effect on self-reported nonmedical use and overdose deaths. The second essay investigates the relationship between parental job loss and child health outcomes. I use data on parental job displacement and child health outcomes from the Panel Study of Income Dynamics (PSID). Parental displacement results in a drop in family income and employer-provided health insurance, which is only partially offset by an increase in public and privately-purchased insurance. I find that parental job displacement is associated with a significantly lower likelihood of mental illness diagnosis, and a higher likelihood of ever drinking and using marijuana. I do not find significant effects of displacement on depressive symptoms, health status, and smoking. The third essay is joint work with John Cawley and Joseph Price. This paper investigates one possible determinant of physical activity: the success of local sports teams. We hypothesize that individuals living in an area with a successful local sports team will be more likely to engage in that sport as a result of role model or bandwagon effects. We merge individual U.S. data from the Simmons National Consumer Survey with data on sports team performance for a variety of sports at the professional and college level. We estimate ordered probit models of participation in a particular sport as a function of local sports team success, with controls for demographics as well as fixed effects of time and geographic area. We find some evidence that children are more likely to participate in sport when local teams perform well, and find weaker evidence of such a relationship for teens.

This purpose of this paper is to identify the effects an increase in active transportation to and from school would have on both commuters and communities, and to examine how to create a successful environment for active transportation models in Maine.

In the undertaking a recent history of such a fundamental law as one that deals with food, drugs and cosmetics in its relationship to the human race, we should realize that such a field has a history possibly as old as man himself. There have always been individuals in the good and welfare of others, and there have always been individuals interested in taking advantage of their fellow man for personal gain, frequently in an exceedingly unscrupulous manner. The Solicitor General of the United States, in a recent paper read at the commemoration the the fortieth anniversary of the original Federal Food and Drugs Act of 1906 pointed out that "the attempts of organized society to prevent the adulteration of food and drugs date back to ancient times. The racket implicit in the purveying of adulterated and misbranded commodities is now a new one by any means -- it has been practiced from the commencement of recorded times." The officials goes on and recites specific instances, telling how Pliny the Elder complained of "white earth" in his bread, the pepperers and spicers of London in the year 1316 began to regulate the quality of their produce, brewers were subject to fines for adulterating beer in the days of William the Conqueror, food control statutes were passed in France and Germany in the thirteenth century. The first pharmacopoeia was published in England by the College of physicians in 1613. In the fourteenth century the Provost of Paris forade the artificial coloring of butter. In the United States, Congress enacted a law to prevent the importation of adulterated and spurious drugs and medicine as far back as 1846.The Department of Agriculture through its Division (later Bureau) of Chemistry from 1863 to 1906 in its reports kept calling to the attention of the various Secretaries of Agriculture, and in a measure to the attention of Congress and the people of the United States, the need for remedying conditions of food and drug frauds perpetrated upon the consumer.