<p> Since 2014, voters in four California cities approved ballot measures seeking to levy a penny-per-ounce tax on sugar-sweetened beverages (SSBs). Prior to these instances of success, over 128 local and state SSB tax proposals in the U.S. failed passage since 2009. The recent success of SSB tax passage in California presented an opportunity to explore factors associated with SSB tax passage, and to explore if John Kingdon&rsquo;s Multiple Streams Approach (MSA) applied in cases where the tax passed. The study also identified how Kingdon&rsquo;s theory may be modified in cases involving local governments. </p><p> I conducted a retrospective qualitative analysis using primary and secondary data collection to compare the outcome of SSB tax proposals across California cities. I interviewed 22 individuals using semi-structured telephone interviews to learn about each city&rsquo;s SSB tax proposal and process. Successful and unsuccessful SSB tax proposals were compared to learn from both passage and failure. </p><p> Five key themes or patterns were associated with cases of success including: (1) advanced planning, (2) building support, (3) voter engagement, (4) messaging, and (5) media. Cities that failed to pass the tax did not achieve consensus about the problem, or the proposed solution. A policy that is perceived as technically unfeasible has reduced chances of survival. The MSA provided a useful framework for analyzing factors associated with SSB tax success, however it remains unclear how much independence there is between the three streams at the local policymaking level. Based on the results from this study, I proposed a modification to the <i>problem stream</i> by adding a typology of events to further analyze factors associated with why a policy alternative may rise or fall on an agenda. </p><p> The results from this project have the potential to broaden the application of the MSA theory. The findings from this study will be useful to policymakers and advocates in cities that utilize direct or representative democracy, and may lead to other local level SSB tax adoption in the future. Policy entrepreneurs play an important role in shaping the course of how a problem is perceived. Problems and solutions that resonate with voters are more likely to rise on an agenda. This project also demonstrates the value of learning from policy failures. In some cases, iterating a strategy after a failure may be the only way to innovate towards a successful outcome over time.</p><p>

<p> The United States is experiencing an unprecedented crisis of prescription and illicit opioid misuse, addiction and overdose. Coincident with the increase in opioid misuse and addiction in the U.S. over the past decade are rising rates of prescription opioid injection and transmission of infectious diseases such as hepatitis C virus (HCV) and endocarditis. </p><p> Following the 2015 HIV outbreak in Scott County, Indiana associated with injection of the prescription opioid oxymorphone, and a decade-long increase in viral hepatitis infection rates, especially in areas of the U.S. with long-standing prescription opioid misuse and addiction, policymakers, public health practitioners, and other stakeholders have become increasingly concerned about prescription opioid injection misuse and related harms. </p><p> Syringe Services Programs (SSPs)&mdash;evidence-based programs that provide sterile injection equipment and comprehensive infectious disease, substance use, and overdose prevention and treatment services&mdash;have been identified as a potential key intervention in response to the opioid crisis and increasing opioid injection. However, there is limited recent research characterizing the population of people injecting prescription opioids and other drugs that can help guide how to best position SSPs to reach and impact this population. Further, the policy environment for SSPs is rapidly evolving, with multiple states enacting laws, regulations, and policies in recent years to enable the establishment of SSPs. Collectively, the research gaps around prescription opioid injection and the changing policy environment for SSPs has created a critical need to better define the characteristics of people who inject prescription opioids, to identify the services and resources needed by this population, and to understand how SSPs are navigating the evolving policy environment in order to maximize their role in response to the opioid crisis. </p><p> This dissertation research aims, through the use of mixed methods, to address these knowledge and policy gaps through: 1) systematically reviewing the literature to synthesize what is known about the population of individuals who inject prescription opioids in the U.S.; 2) estimating the magnitude of prescription opioid injection in the United States; 3) examining overall, sociodemographic, and substance use trends and correlates of prescription opioid injection among a nationally representative sample to identify populations at-risk for prescription opioid injection and related harms; and 4) using these quantitative findings to inform a qualitative exploration of SSPs&rsquo; responses to the rapidly changing policy environment in the midst of the evolving opioid epidemic and how they can be further leveraged to reduce the harms associated with opioid injection. This dissertation accomplishes these aims through three separate, but related studies. Taken together, the new knowledge produced from this dissertation can be used to inform the development, prioritization, and implementation of policies, programs, and practices that aim to reduce prescription opioid injection and its related harms and expand the role of SSPs in response to the U.S. opioid crisis.</p><p>

Thesis (M.S.P.H.)--University of Michigan, 1935.

Thesis (M. Arch.)--University of Hawaii. / Includes bibliographical references (leaves 157-161). Also issued in print.

Thesis--University of Florida. / Description based on print version record. Typescript. Vita. Includes bibliographical references (leaves 176-184).

Thesis (M.S.P.H.)--University of Michigan, 1935.

Thesis (M. Arch.)--University of Hawaii. / Includes bibliographical references (leaves 157-161).

<p> In response to the increased demand for primary care in the United States&mdash;a byproduct of a growing elderly population and insurance expansion under the Affordable Care Act (ACA)&mdash;the total number and capacities of community health centers (HCs) is expected to grow. While HCs have historically depended on physicians to deliver the majority of their care, more and more, they are shifting to non-physician clinicians, especially nurse practitioners (NPs); yet, little is known about the quality of care delivered by NPs in HCs or about the role state occupational restrictions have on these practitioners or their patients. </p><p> Using quasi-experimental methods and data from the community health center subsample of the National Ambulatory Medical Care Survey (NAMCS), this dissertation explores three distinct, but related, research questions regarding NP-delivered care in HCs&mdash;its effectiveness and comparability to physician care, the extent that tradeoffs in the quantity and quality of care are made, and the real-world risks and benefits of states easing their scope of practice restrictions. Findings, which suggest that NP care is comparable to physician care in most ways and that the quality of NP-delivered care does not significantly vary irrespective of states&rsquo; NP independence status, have important implications for policy and practice.</p>

<p> <b>Objectives:</b> Mothers of low socioeconomic status (SES) and of non-Hispanic black race deliver prematurely more often. The goal of my dissertation was to improve understanding of the mechanism of disproportionate premature birth in low SES women. I tested a psychological and physiological stress explanation of prematurity risk, estimated the effect of the Affordable Care Act (ACA) Medicaid expansion on gestational age (GA), and estimated how the ACA Medicaid expansion effect was influenced by race. <i><b>Data and Methods:</b></i> I developed a conceptual framework of how psychological and physiological stress increase premature birth risk utilizing Appraisal and pathophysiology theory. I generated hypotheses about how financial risk removal would impact GA and tested them utilizing variation in expansions in Medicaid eligibility for pregnant women in three matched state pairs and distribution of the Earned Income Tax Credit (EITC). I utilized data from the Pregnancy Risk Assessment Monitoring System and performed multivariate ordinal regressions. I also used national birth record data and exploited state variation in ACA Medicaid expansion status to estimate the impact on GA in non-Hispanic black and all other mothers using multivariate linear regressions and linear probability models. </p><p> <b>Results:</b> Hypothesis testing based on two of the three Medicaid expansion for pregnant women state pairs and the EITC analyses resulted in significant evidence (one-sided p-values &lt; 0.05) for a direct pathway between psychological stress concerning financial risk, physiological stress, and GA. The ACA Medicaid expansion was associated with an increase in GA for non-Hispanic black mothers (+34 hours), a decrease for all other mothers (&ndash;6 hours), and a 3% decrease (95% CI = &ndash;5% to &ndash;2%) in the incidence of early term or shorter gestation births for non-Hispanic black mothers. </p><p> <b>Conclusions:</b> Decreasing financial risk for low SES women with Medicaid or the EITC is associated with increased GA. The higher premature birth risk in this population is likely the result of a direct pathway involving psychological and physiological stress. Other financial risk removal strategies should be investigated. The ACA Medicaid expansion did not meaningfully influence GA on a weekly scale but did moderately decrease overall preterm birth risk in non-Hispanic black mothers.</p><p>

<p> The use of pharmaceutical products has steadily increased in the United States from 2 billion prescriptions in 1999 to 3.9 billion in 2009. Half of patients do not comply with the recommended prescription regimen and dispose of unused drugs in the environment. The U.S. Environmental Protection Agency and many researchers have highlighted the human-health risks associated with improperly disposing of pharmaceutical products. This quantitative cross-sectional study examined the potential correlations between people&rsquo;s actual disposal practices and their knowledge of the impact of disposal practices on the environment and human health, and availability of disposal options. The conceptual framework selected for this study comprised 2 models: the health belief model and the theory of planned behavior. Respondents to an online survey were 485 residents of the northeast United States, polled from the general population. Descriptive statistics and logistic regression were used to model responses from the dependent variable actual disposal practice (ADP) across the independent variables, and analysis of variance explored whether ADP differed across demographic variables. Statistically significant associations emerged among individuals&rsquo; knowledge of environment and human-health impact, recommended disposal practices, disposal options, and that person&rsquo;s likelihood to practice recommended disposal. Demographic variables did not impact disposal behavior. To promote positive social change, it is recommended that policymakers plan and implement the expansion of convenient drug disposal options, as well as information campaigns on proper disposal practices. In parallel, health care professionals should stress to their patients the importance of complying with prescribed regimens, thus minimizing the amount of unused or expired medications.</p><p>