Sociologists have used boundary work theory to explore the strategies deployed by professionals to define and defend jurisdictional authority in the arenas of the public, the law and the workplace. My dissertation investigates how medical providers and public health professionals negotiate authority over abortion in Senegal. Although induced abortion is prohibited in Senegal, medical providers are permitted to treat complications of spontaneous and induced abortion, known as post-abortion care (PAC). Introduced to Senegal in the late 1990s, the national PAC program is primarily supported by American development aid. This study explores how medical providers manage complications of abortion and in particular, how they circumvent the involvement of criminal justice authorities when they encounter suspected cases of illegal abortion. I also study how boundary work is accomplished transnationally through the practice of PAC within the policy framework of American anti-abortion population assistance and the national prohibition on abortion. Findings are based on an institutional ethnography of Senegal's national PAC program conducted over a period of 19 months between 2009 and 2011. Data collection methods included in-depth interviews with 89 individuals, observation of PAC services, and review of PAC records at three hospitals. I also conducted an archival review of abortion and PAC in court records, the media, and public health literature. Findings show that medical providers and public health professionals perform discursive, technical and written boundary work strategies to maintain authority over PAC. Although these strategies have successfully integrated PAC into maternal health care, they have reinforced the stigma of abortion for women and health professionals. They have also reproduced gendered disparities in access to quality reproductive health care. PAC has been implemented in nearly 50 countries worldwide with varying legal restrictions on abortion. This study illustrates not only how medical professionals practice abortion care in such settings, but also how they navigate a precarious array of medical, legal and global health obligations.

A study to determine the effects of the new prospective reimbursement method on the role of discharge planners in the acute care hospitals and their impressions of its impact on elderly patients. A mail survey questionnaire examined the task responsibilities of personnel providing discharge planning services to the elderly. The components of successful discharge plans and the frequency of obstacles to optimal discharge plans were also assessed. Findings, based on a 75.3 percent response rate from hospitals (hospital N = 58, individual respondent N = 235), revealed that social work appeared to be the predominant discipline conducting discharge planning activities in New York City hospitals. The prospective payment system has changed discharge planning task frequency and the time allocation of tasks, perceptions of inpatient populations, the need for case management and readmission rates. Family support was the strongest predictor for successful discharge plans cited by discharge planners while lack of interdisciplinary communication was a prime reason why discharge plans go awry. Discharge planners do not generally view their role as responsible for advising patients of the appeals mechanism. Professional discipline and the prospective payment system were the single most important independent variables to explain the variance among the areas of inquiry. Hospital auspice and bed size, and respondent's years of experience and employment tenure at their hospital were not very useful to explain differences. The comparison of nurses and social workers on performing parallel discharge planning functions showed that nurses tend to be more collaborative than social workers. One-third of the nurse and social worker respondents reported that their professional preparation was inadequate for discharge planning responsibilities and have recommendations for the curriculum of their respective professional schools.

This dissertation reports the findings of an evaluation of the Five Hospital Homebound Elderly Program in Chicago. The Program is a model long term home care demonstration project which is community-based and provides a unique combination of medical and social supportive services to chronically impaired homebound elderly. The Program differs from most Medicare certified and reimbursed programs and is a potential model for expanded benefit programs now being considered in Congress. The evaluation of the Program encompassed both impact and process issues, utilizing a pre/post test quasi-experimental design with a non-equivalent control group. Within this design, the comprehensive functional status of 122 consecutively admitted Five Hospital clients and of 123 controls was assessed at time of acceptance to service and nine months later, using the Duke/OARS Multidimensional Functional Assessment Questionnaire. The control group consisted of recipients of OAA Title III home-delivered meals who live in an area that is geographically contiguous to the Five Hospital Program's catchment area and who were similarly elderly and impaired. Rates of hospitalization, institutionalization and mortality were also obtained in addition to rates of home care services utilization for both groups. Analysis of pretest data, which was obtained on 75% of newly accepted FHHEP clients and 74% of control group clients, revealed that, overall, the two groups were remarkably similar on measured variables with the exception of. the fact that Five Hospital clients were significantly older (x̄ age 80.4) and more impaired in Instrumental Activities of Daily Living than controls but also enjoyed better social supports. These differences were of interest because advanced age, poor ADL and poor social supports are variables which have been reported to be associated with admission to long term care institutions in the literature. At post test, functional status data were obtained on 83% of experimentals and 81% of controls, with mortality being the major cause of attrition in both groups (12% and 11%, respectively). Major findings derived from the analysis of outcome measures revealed no difference between the two groups with respect to mortality rates. However, bivariate analysis revealed interesting differences between the two groups with respect to the characteristics of subjects who died. Variables which appeared to be similarly and differentially associated with increased incidence of mortality in the two groups were therefore identified and discussed. However, the number of subjects who experienced this outcome in both groups was too small to permit any conclusions to be drawn. The fact that mortality rates were almost identical for the two groups, given the greater age and ADL impairment of experimental subjects at pretest, is interpreted as suggestive of a possible beneficial effect of treatment which might warrant follow-up in a study with a larger sample size. Effects of treatment on functional status included a trend towards perception of improved social supports. mental health and physical health, as well as a significant decrease in unmet needs among experimental subjects (p < .05). Somewhat paradoxically, these beneficial changes were accompanied by a significant (p < .01) deterioration in Physical Activities of Daily Living. It is suggested that this change in PADL status may be confounded with the reception of the treatment which consisted of regular assistance with ADL tasks. Comparison of pre and post test hospitalization rates revealed no differences between the two groups, with the exception of the fact that fewer Five Hospital subjects were repeat users at pre and post test. A highly significant difference was observed in the rates of institutionalization for the two groups with experimental subjects experiencing this outcome less frequently than controls (p < .01). Multivariate analysis which attempted to control for selection differences and other explanatory variables failed to degrade this effect which remained significant. Furthermore. when the above outcome measures were analyzed according to level of treatment received, the same relationships described above were observed. The above findings were interpreted to indicate that, overall, the Program had beneficial effects on its clientele and that this model of long term care services has important implications for the development of national long term care policy.

There is broad agreement that medicine ought to be `evidence based' and `personalized' and that data should play a large role in achieving both these goals. But the path from data to improved medical decision making is not clear. This thesis presents three methods that hopefully help in small ways to clear the path. Personalized medicine depends almost entirely on understanding variation in treatment effect. Chapter 1 describes latent class mixture models for treatment effect heterogeneity that distinguish between continuous and discrete heterogeneity, use hierarchical shrinkage priors to mitigate overfitting and multiple comparisons concerns, and employ flexible error distributions to improve robustness. We apply different versions of these models to reanalyze a clinical trial comparing HIV treatments and a natural experiment on the effect of Medicaid on emergency department utilization. Medical decisions often depend on observational studies performed on large longitudinal health insurance claims databases. These studies usually claim to identify a causal effect, but empirical evaluations have demonstrated that standard methods for causal discovery perform poorly in this context, most likely in large part due to the presence of unobserved confounding. Chapter 2 proposes an algorithm called Ensembles of Granger Graphs (EGG) that does not rely on the assumption that unobserved confounding is absent. In a simulation and experiments on a real claims database, EGG is robust to confounding, has high positive predictive value, and has high power to detect strong causal effects. While decision making inherently involves causal inference, purely predictive models aid many medical decisions in practice. Predictions from health histories are challenging because the space of possible predictors is so vast. Not only are there thousands of health events to consider, but also their temporal interactions. In Chapter 3, we adapt a method originally developed for speech recognition that greedily constructs informative labeled graphs representing temporal relations between multiple health events at the nodes of randomized decision trees. We use this method to predict strokes in patients with atrial fibrillation using data from a Medicaid claims database. I hope the ideas illustrated in these three projects inspire work that someday genuinely improves healthcare. I also include a short `bonus' chapter on an improved estimate of effective sample size in importance sampling. This chapter is not directly related to medicine, but finds a home in this thesis nonetheless.

Studies across low- and middle-income countries document quality shortfalls in both public and private sector health care. They notably highlight a “know-do” gap in primary care delivery: doctors possess requisite medical knowledge but do not expend adequate effort to treat patients. In explaining low quality, researchers have largely emphasized transactional aspects of health care, viewing doctors’ actions as shaped by their skills and incentives to perform and arguing that the micro-institutions that drive doctors’ clinical behavior are faulty. In contrast, in this project I analyze the social and political conditions in which public sector doctors deliver primary care in urban India. Viewing the doctors as both medical practitioners and state agents, I argue that health service outcomes depend on how doctors interpret policy mandates and relate to the communities they serve. I conceptualize their actions not just as medical transactions but also as social acts, shaped by the meanings they attach to their experiences and informed by the institutional history and social imaginary of state-provided care. During a year of ethnographic fieldwork (2013-2014), I observed clinical and non-clinical encounters of doctors employed in municipal government clinics and hospitals in a midsize Indian city; interviewed doctors, other health workers, elected officials, administrators, and staff of non-governmental organizations; and examined policies and administrative arrangements for urban health care since India’s independence. I demonstrate that municipal doctors confront a trifecta of challenges: a legal obligation to deliver urban primary care from within an outdated urban governance structure; a largely unregulated private sector that residents widely prefer; and rising commercialization in medical practice, under which specialized medicine has crowded out primary care in popular ideas about “good” medical care. Unable to remedy the low legitimacy of their services, doctors circumscribe their actions, seeking, as one doctor put it, only to ensure the ordinary. My findings suggest that transaction-specific interventions to improve quality, such as focused on skills and incentives alone, may do little to circumvent these local effects of the policy neglect of urban health care.

This dissertation studies the impact of institutional interventions on labor markets in the United States, Norway and India. The labor markets studied are diverse, and include the criminal sector in the United States, the healthcare sector in Norway and the market for workfare employment in rural India. Chapter 1 studies whether juvenile offenders are deterred by the threat of criminal sanctions. Existing research, which studies adolescent crime as a series of on-the-spot decisions, finds that deterrence estimates are negligible at best. This paper first presents a model that allows the return from crime to increase with previous criminal involvement. The predictions of the model are tested using policy variation in the United States over the period 2006-15. The results show that when criminal capital accumulates, juveniles may respond in anticipation of increases in criminal sanctions. Accounting for these anticipatory responses can overturn the conclusion that harsh sanctions do not deter juvenile crime. Chapter 2 studies the impact of a graduate's first job on her career trajectory, and how job-seeking graduates’ respond to the persistence of these "first job effects". For identification, we exploit a natural experiment in Norway, where doctors' first jobs were allocated through a random serial dictatorship mechanism until 2013. We use administrative data on individual outcomes to confirm empirically that the residency allocation mechanism effectively randomized choice sets of hospitals across medical graduates. We then use the resulting variation in individual doctors’ choice sets to show that first jobs affect doctors' earnings, place of residence, and specialization in the long run. Chapter 3 evaluates the effects of encouraging the selection of local politicians in India via community-based consensus, as opposed to a secret ballot election. I find that financial incentives aimed at encouraging consensus-based elections and discouraging political competition crowd in younger, more educated political representatives. However, these incentives also lead to worse governance as measured by a fall in local expenditure and regressive targeting of workfare employment. These results can be explained by the fact that community-based processes are prone to capture by the local elite, and need not improve the quality of elected politicians or governance.

This dissertation analyzes the effects of community violence on health care service utilization and access in Mexico. Given the widespread effects of violence, there is good reason to believe that health service delivery might be affected, but it is largely unknown. This study looks at potential channels through which violence may impact the supply and demand of health care services in Mexico, through qualitative and quantitative methods. It posits that violence can have heterogeneous effects on service utilization and provides a deeper exploration of factors that may have negative and positive effects on service utilization. Supply-side effects point towards deterring effects of violence in service utilization out of fear of travel and fear among medical staff to go to their workplaces or shortening the hours of operation out of fear of exposure. Mixed effects logistic regression models reveal demand-side effects through a significant increase in health care service utilization as violence increases possibly related to worsening health (e.g. through stress or other mechanisms), which may drive individuals to seek more services. In sensitivity analysis, increased primary care service utilization as a result of an increase in the homicide rate remains significant when predictors of service use such as having a chronic condition, insurance status and urban areas are included in the models. Qualitative findings also reveal an increased demand for mental health services at the primary care level as a result of increased community violence. Findings underscore the importance of access to outpatient services and mental health services at the primary care level in contexts of high violence. The significant increase in the use of outpatient service utilization point towards potentially protective behaviors driving the increase of use of services as violence increases. This analysis highlights the responsibility and need for providing safe access to medical services in contexts of violence that may translate to natural disasters or other man-made conflicts.

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Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 1980. / MICROFICHE COPY AVAILABLE IN ARCHIVES AND ROTCH. / Vita. / Bibliography: leaves 134-138. / by Naomi A. Pless. / M.C.P.