京都大学 / 新制・課程博士 / 博士(経済学) / 甲第23447号 / 経博第645号 / 新制||経||299(附属図書館) / 京都大学大学院経済学研究科経済学専攻 / (主査)教授 諸富 徹, 教授 岡 敏弘, 准教授 長谷川 誠, 特定准教授 Rudolph Sven / 学位規則第4条第1項該当 / Doctor of Economics / Kyoto University / DGAM

Preventing healthcare-associated infections (HAI) is a national priority. The Centers for Disease Control and Prevention estimates that one of every 25 hospitalized patients contract a HAI while receiving care. In 2009, the annual cost for HAIs in United States’ hospitals was estimated to be $40 billion, and there were 99,000 HAI-associated deaths. In nursing homes (NH), the situation is more dire; among the 4 million NH residents each year, there are 1-2.6 million serious infections and 1 out of every 3 NH residents is colonized with a multi-drug resistant organism. In addition to the frequent infections, over prescription of antibiotics in NH is significant, and frequently inappropriate. NH residents with HAIs are subjected to burdensome treatments and diagnostic procedures, leading to more complications in an already vulnerable population in which quality of life not life prolongation is often the treatment goal. Policy levers are actions designed to realize health objectives that can be taken by either public or private entities, and by individuals or groups. Health policy levers are deployed at all levels including federal, state, regional, and local levels. Vaccinations, such as polio, are one of the great success stories of how policy levers can prevent infections. However, undermined and eroded policy levers can have negative public health consequences, such as seen with the 2018-2019 rash of measles outbreaks. There is much work left to be done improving quality related to infections across all care settings. For this dissertation, I utilized the three-paper format and conducted studies examining the effectiveness of health policy levers used to improve healthcare quality and prevent infections across care settings. These studies were: 1) a systematic review of the published evidence on state mandatory reporting of HAI in hospitals; 2) an environmental scan cataloging state supported initiatives in NH infection prevention, and; 3) a quantitative analysis on the effect of new federal NH regulations on NH quality and patient outcomes. In the systematic review, I found that mandatory reporting was associated with reduced central line associate bloodstream infection rates. The environmental scan demonstrated that wide variation existed between states’ initiatives to support infection prevention in NH. In the quantitative analysis, I found that new federal regulations were significantly associated in improved NH quality in UTI rates and vaccination rates for influenza and pneumonia infections. Based on these results, clinical providers, administrators, policy makers and researchers can use health policy levers to reduce infections and improve quality.

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The elicitation and processing of relevant information is the core of any policy decision-making process. Modelling is about making sense of the available information. Models are able to incorporate the contextual influences on policy making (e.g. political and economic environments, community sentiment…etc). Systems analysis allows quantitative, empirical testing of models that exist in the study of public policy. Simulation and visualisation techniques can help policy makers to reduce uncertainties on the possible impacts of policies. In an effort to enable adoption of the systems thinking approach to address the central problem of empirical political study, this thesis presents a framework for prescriptive policy analysis that provides decision support to: the problem definition, ex-ante impact assessment and evaluation activities carried out at the policy formulation stage of the policymaking process. We contribute a new tool for systemic modelling and simulation of public policy decision situations. It aims to facilitate the cognitive activity of representing complex mental models using system dynamics simulation modelling. Using the ’labelled causal mapping’ method, a policy-oriented problem structuring method introduced in this research, the tool bridges the gap between the user’s mental model and the explicit graphical representation in order to enable knowledge representation and system analysis. The method provides a basis for further computational decision analysis using a common policy appraisal format, a multi-criteria model with main evaluation criteria (effectiveness, efficiency, relevance, coherence and added value), linked to a set of measurable, context dependent attributes (targeted impact variables from the policy model). A web-based tool prototype has been implemented in a Node.js environment and is accessible both from a web-based graphical user interface as well as a hosted API.  Multiple demonstration and test cases, from various policy areas and different EU policymaking levels, were used in several iterations of the build-evaluate cycle. This approach lead to the different studies that make up this research. / Sense4us - Data insights for policymakers and Citizens

京都大学 / 0048 / 新制・論文博士 / 博士(社会健康医学) / 乙第13005号 / 論社医博第9号 / 新制||社医||9(附属図書館) / 32933 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 玉木 敬二, 教授 小西 靖彦 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM

The focus of this research is in the area of online learning policy. Online learning is rapidly gaining popularity and is becoming more and more an integral part of the K–12 education landscape. Such a study is important because there are very few policies that have been created to govern online learning differently than traditional brick-and-mortar classrooms. Utah’s Statewide Online Education Program (SOEP) has been largely marketed as policy that does transcend these barriers. This research uses a multidimensional mixed-method case study to evaluate the program. The findings from this research provide evidence that the SOEP falls short of providing policy that can guarantee implementation of the program’s goals and purposes and fails to ensure quality online learning for students. The main conclusions drawn from this study are that principals are hesitant to implement the SOEP because they are concerned about the potential loss of funding and a lack of confidence in the quality of online courses. This dissertation recommends the following: The creation of technology funding that guarantees full access to the Internet for all students, the creation of a performance-based assessment system for all students, and online learning in-service and professional development for both principals and teachers.

[pt] A presente tese de doutorado é dividida em três capítulos. No primeiro capítulo, exploramos descontinuidades em elegibilidade à auxílio financeiro para matrícula em instituições de Ensino Superior privado no Brasil para investigar: (i) se estudantes alteram suas decisões em resposta a uma política pública desenhada para subsidiar acesso ao Ensino Superior privado, e (ii) como estudantes reagem quando podem optar entre obter subsídios para matrícula no ensino privado ou se matricular em instituições públicas gratuitas. Nossos resultados mostram que elegibilidade à subsídios aumenta a probabilidade de que estudantes se matriculem e permaneçam matriculados no Ensino Superior. Também concluímos que elegibilidade reduz probabilidade de matrícula em instituições públicas e que não há impacto em investimento em qualidade ao nível do curso. No segundo capítulo, desenvolvemos um modelo estrutural de demanda com escolha discreta para investigar quais fatores influenciam a escolha de estudantes entre diferentes cursos. Utilizamos esse modelo e a expansão de um programa federal de crédito estudantil no Brasil para avaliar como disponibilidade de crédito influencia escolha de curso quando os custos associados variam ao nível do curso. Nossos resultados mostram que os dois fatores com maior influência na escolha de estudantes entre diferentes cursos são mensalidade e o retorno esperado no mercado de trabalho. Nossos resultados também mostram que, quando há disponibilidade de crédito, estudantes —especialmente estudantes de menor renda—são menos sensíveis à variações de mensalidade. No capítulo final, investigamos se restrições no acesso à água encanada causadas por um evento climático extremo afetam desempenho escolar. Respondemos a essa pergunta avaliando as consequências de uma política de racionamento de água imposta pelo governo do Distrito Federal. Ao comparar o desempenho acadêmico de estudantes matriculados em escolas localizada em vizinhanças atingidas pelo racionamento contra o desempenho de estudantes matriculados em vizinhanças não afetadas, concluímos que o racionamento de água teve um impacto negativo e significante em desempenho acadêmico. Em especial, nossos resultados mostram que esse impacto é significativamente maior para estudantes matriculados em escolas de pior infraestrutura. / [en] This doctoral thesis, is comprised of three chapters. In the first chapter, we explore a discontinuity in eligibility for financial aid for private higher education in Brazil to investigate: (i) if students in the lower end of the ability distribution change their behavior in response to a policy designed to subsidize access to private higher education, and (ii) how students react when they are given the chance to choose between public tuition-free institutions and subsidized access to private higher education. We show that eligibility for financial aid increases students likelihood of enrolling and persisting in higher education. We also find that eligible students are less likely to enroll in public tuition-free institutions, with no clear impact on the choice of quality at the program level. In the second chapter, we develop a structural discrete choice model of demand to investigate the determinants of major choice. We use this model and the expansion of a government-funded student credit program in Brazil to evaluate how the availability of credit impacts major choice when—as in Brazil—tuition varies at the major level. We find that tuition and expected labor market returns are the main factors determining students choice between different majors.We also find that, when student credit is available, students— especially lower income—are less sensitive to price variations at the major level. In the final chapter, we investigate whether water shortages caused by an extreme climate event impact educational performance. We answer this question exploring the consequences of a water rationing policy that affected some neighborhoods in Brazil s Distrito Federal. Comparing the academic performance of students enrolled in schools located in neighborhoods affected by the rationing against the performance of students enrolled in non-affected neighborhoods, we find that water rationing has a negative and significant impact on students performance. In particular, we show that the impact is significantly stronger for students enrolled in schools with poor infrastructure.

This is a concurrent, mixed methods study of the impacts of Austin, Texas’s cultural plan, CreateAustin. In the study, trend analysis and a t-test were used to examine variables before and after the cultural plan was in place. At the same time, interviews with cultural planners were used to uncover other effects. My research addresses a gap in the literature between understanding the desired and actual outcomes of a cultural plan. Cultural plans are being developed by many communities in an effort to attract creative workers but they are rarely evaluated. Evaluation using a mixed methods approach is necessary to capture all the outcomes of a cultural plan, rather than the limited scope of impacts that are captured by qualitative or quantitative analyses alone. My analysis of the quantitative variables showed some significant differences between when the plan was in place and the years prior to its creation. Interviews with key stakeholders revealed the formation of new networks as a powerful outcome of the planning process. The results allowed me to gauge the overall impact of CreateAustin and make some observations about the cultural planning process in general, as well as uncover new directions for future research.

The policy to reduce teenage pregnancy in England has been used as a case study to explore health policy sustainability. Between 2010 and 2015 many areas across England sustained and improved their conception rate reductions following implementation of the 2000-2010 national Teenage Pregnancy Strategy. Little is known of the factors underpinning these successes in the policy context beyond 2010. This thesis investigates sustained and improved reductions in teenage pregnancy in local authority areas post 2010. The broader political and economic context in which policy is shaped is examined, and the influence of New Public Managerialism considered. The findings suggest three overarching themes which impact on policy sustainability: leadership; understanding the issue; and resources. The thesis develops a seven elements framework, identifying factors to be analysed for policy sustainability. The thesis makes a unique contribution to the understanding of teenage pregnancy policy, providing a detailed review of local actions post 2010. It further adds to the body of knowledge regarding policy sustainability with the development of the seven elements framework. In addition, the thesis is presented at a notable point in history, as the global Covid-19 pandemic takes hold across the world. This situation is considered in the light of insights from the thesis and implications for the policy context into the future are contemplated.

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