In this dissertation I analyze patterns of maternal-infant health in developing contexts. My first chapter uses child hemoglobin as a bio-marker for maternal malnutrition in Senegal during the 2008 food price crisis. In early 2008, world rice prices skyrocketed, causing people around the world to plunge into poverty. Senegal, in particular, depends heavily on imported foodstuffs. I find that the crisis had a large, negative impact on child anemia in urban Senegal, most likely reflecting a deterioration of maternal nutrition caused by rising food prices. In the second and third chapters, we introduce a novel indicator of maternal-infant health: childhood sex ratios. Because infant females have lower rates of mortality than infant males, the sex ratio of the surviving population reflects the level of infant mortality. Childhood sex ratios are widely available from census data, meaning we can use them to shed new light on historical populations who lack traditional sources of data on infant mortality, like birth and death records. We apply this new method to the 19th-century US, where the lack of vital statistics has left uncertainty over even approximate levels of infant mortality. We find that the level of infant mortality in the pre-industrial US was much lower than previously thought, but that racial health disparities were much greater.

Post-World War II public schools in Harlem, New York were segregated, under-resourced and educationally inequitable. Addressing disparities in education was of paramount importance for the socioeconomic mobility and future of the neighborhood. In an effort to understand how race, religion, community, and education intersected in this context, this dissertation answers the following research question: How did St. Philip’s, the first Black Episcopal church in the city and one of the most historic churches in Harlem, participate in education during the post-World War II period? Responding to and preventing inequities in the neighborhood, including the substandard state of the public schools, St. Philip’s served as an educational space and organizational base for the community. St. Philip’s participation accounts for the way a Black church emerged as a space for education when the public schools were foundering. The church’s ethos of education - community engagement - reframes traditional frameworks of teaching and learning beyond schoolhouse doors. During the postwar period, St. Philip’s expanded its in-house programming for Black children, youth and adults, constructing a new community youth center, where classes, tutoring, after-school activities, college counseling, career guidance, day-care, recreation and clubs were community staples. Understanding the importance of inclusivity, continuity and consistency, programming was accessible to the entire neighborhood, regardless of membership with year-round services such as summer camp and career counseling. As an organizational base, the church hosted education talks and committee meetings, facilitating a forum for the community to engage in critical conversations about the state of education. It was a safe space for transparency and troubleshooting. Concerns about education expanded beyond conversations in the church, however. St. Philip’s corresponded directly with city governance, petitioning school-makers with recommendations and demands. This dissertation broadens the traditional civil rights narrative of Black religious activism, which has the tendency to dichotomize who participated and how they participated. This polarization includes regions: North-South, religions: Christian-Muslim, figureheads: Martin Luther King, Jr.-Malcolm X, and strategies: peaceful-militant. Historians Charles Payne and Nikhil Pal Singh push back on this oversimplified interpretation as “King-centric.”* St. Philip’s educational activism foils this paradigm as a Black Episcopal institution in a northern city. St. Philip’s brings nuance to categorizations of Black churches as either being focused on the far-reaching goal of social transformation or compliant with conservative social philosophies based on respectability politics. Its participation was both radical (such as establishing educational programming at the Community youth center that was open to members and non-members alike, regardless of class, age, political or religious beliefs) and conservative (such as sitting out of the 1964 citywide school boycott, while the majority of the Black community participated). In this way, St. Philip’s educational activism in Harlem calls into question criticisms of the Black Episcopal Church that position it as elitist and accommodationist to white values and white power, hence, apathetic to the challenges facing the Black population in cities during the post-World War II period. *Nikhil Pal Singh, Black Is a Country: Race and the Unfinished Struggle for Democracy (Cambridge: Harvard University Press, 2004), 6; and Charles Payne, I’ve Got the Light of Freedom: The Organizing Tradition and the Mississippi Freedom Struggle (Berkeley: University of California Press, 1995), 419.

Background Primary care practices in the United States (US) are currently constrained in their ability to deliver high quality care due to population aging, insurance expansion, and an increasing prevalence of chronically ill patients. The nurse practitioner (NP) workforce plays a critical role in meeting the growing demands for primary care, particularly in rural and underserved areas. NPs are also more likely to deliver care to clinically and socially complex populations such as high-need high-cost (HNHC) patients. HNHC patients are adults who suffer from multiple chronic conditions and experience additional functional, behavioral, or socioeconomic needs. Despite comprising only 5% of the US population, HNHC patients account for nearly half of total health care expenditures and over 90% of Medicare expenditures. HNHC patients with behavioral health diagnoses such as depression or substance abuse face heightened challenges managing their conditions and consequentially have higher preventable spending and emergency department (ED) utilization compared to the overall HNHC population. Significant policy attention has been placed on enhancing primary care practices as a strategy to improve outcomes and reduce costs in HNHC patients. Structural capabilities are features of primary care practices (e.g., after-hours care or care coordination) which are needed to deliver high quality primary care and chronic disease management. Yet, to date little research has been done on structural capabilities in primary care practices where NPs deliver care to HNHC patients. The overall purpose of this dissertation is to understand how to enhance primary care delivery and structural capabilities to improve outcomes for HNHC patients. We have achieved the following specific aims: (1) Establish a clear definition of HNHC patients, (2) Identify existing primary care and payment models used among HNHC patients and evaluate their impact on ED utilization and costs, (3) Evaluate structural capabilities in NP primary care practices located in Health Professional Shortage Areas (HPSAs), and (4) Analyze the association between NP practice structural capabilities and ED utilization among HNHC patients with behavioral health conditions. Dissertation Chapters and Key Findings Chapter One includes an introduction to the landscape of current primary care delivery, the role of the NP workforce in expanding access, and the unique challenges of delivering care to HNHC patients. This chapter also discusses the conceptual framework guiding the dissertation, the specific aims of each study, and how each study will fill a gap in the literature. Chapter Two (Aim 1) consists of a concept analysis of HNHC patients using the Walker and Avant framework. Three subgroups of HNHC patients were identified: adults over the age of 65 who suffer from multiple chronic conditions with functional or behavioral health needs, the frail elderly, and patients under 65 years old with a serious mental health condition or disability. Antecedents that predispose an individual to becoming a HNHC patient include challenges accessing timely care, low socioeconomic status, or unmet needs. Persistent high spending occurs as a result of poorly managed chronic diseases leading to acute exacerbations, preventable health service utilization, and fragmented care between the acute and primary care settings. Chapter Three (Aim 2) is a systematic review of studies conducted from 2000-2020 on primary care and payment models used with HNHC patients. About half of the primary care models evaluated in the systematic review (11 out of 21 studies) showed no significant difference in ED utilization among HNHC patients. Care coordination and care management (15 out of 21 studies) demonstrated both positive and negative associations with ED utilization and costs. Primary care models that demonstrated significant reductions in ED utilization had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Chapter Four (Aim 3) includes a cross-sectional study of NP survey data from 2018-2019 on practice structural capabilities linked with data on primary care shortages (i.e., HPSA designation). Bivariate analyses and multivariable regression models were used to compare NP characteristics and structural capabilities in HSPA practices compared to non-HPSA practices. The majority of NPs in our sample (61%) delivered care in HPSA practices. NP practices located in HPSAs were significantly more likely to deliver care coordination compared to non-HPSA practices. We found no significant difference in prevalence of registries, after-hours care, or shared communication systems. Chapter Five (Aim 4) is a study of cross-sectional NP survey data from 2018-2019 on practice structural capabilities linked with Medicare Part A and Part B claims to identify HNHC patients and ED utilization. Multivariable Poisson models were used to estimate the association between ED utilization and structural capabilities in practices serving HNHC patients with behavioral health conditions including depression, alcohol use, and substance use disorder. Care coordination was associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders. Shared communication systems were associated with decreased rates of all-cause and preventable ED utilization among HNHC patients with alcohol use and substance use disorders. Chapter 6 is a summary of findings across studies in this dissertation and will present the strengths, limitations, and contributions to science. This chapter will also discuss implications for policy, practice, and directions for future research. Conclusion HNHC patients face complex and wide-ranging medical, social, and behavioral health needs resulting in poor clinical outcomes and high costs. Enhancing primary care is an urgent goal for policymakers to improve disease management while reducing overall costs of care. Findings from these studies demonstrate that NPs practice in underserved areas and are significantly more likely to deliver care coordination in HPSA practices and to HNHC patients with behavioral health conditions. Care coordination has the potential to increase effectiveness of primary care delivery by tailoring models to target specific HNHC patients. Shared communication systems also show promise for improving primary care delivery and reducing ED utilization among HNHC patients with alcohol use and substance use disorders. Future research should continue to explore how structural capabilities may enable NPs to deliver timely, high quality, cost-effective primary care for HNHC patients.

There is growing demand for reforms to the U.S. criminal justice system. Nevertheless, there are significant questions and relatively few answers. This dissertation studies multiple U.S. criminal justice system issues using detailed administrative data from Cook County, Illinois: Does policing the police increase crime? Does the composition of a police officer's academy cohort influence their future outcomes? Is pretrial electronic monitoring an attractive alternative to pretrial release and detention? To answer these questions, I use administrative data from Chicago and Cook County, Illinois, on the Chicago Police Department, Cook County Jail, and Circuit Court of Cook County, and a range of econometric methods. In Chapter 1, I study the effect of pretrial electronic monitoring (EM) as an alternative to pretrial release and pretrial detention (jail) in Cook County, Illinois. EM often involves a defendant wearing an electronic ankle bracelet that tracks their movement and aims to deter pretrial misconduct. Using the quasi-random assignment of bond court judges, I estimate the effect of EM versus release and EM versus detention on pretrial misconduct, case outcomes, and future recidivism. I develop a novel method for the semiparametric estimation of marginal treatment effects in ordered choice environments, with which I construct relevant treatment effects. Relative to release, EM increases new cases pretrial due to bond violations while reducing new cases for low-level crimes and failures to appear in court. Relative to detention, EM increases low-level pretrial misconduct but improves defendant case outcomes and reduces cost-weighted future recidivism. Finally, I bound EM's pretrial crime reduction effect. I find that EM is likely an adequate substitute for pretrial detention. However, it is unclear that EM prevents enough high-cost crime to justify its use relative to release, particularly for defendants who are more likely to be released. Chapter 3, joint with Bocar Ba, studies and differentiates between the effects of oversight and outrage on policing. Previous studies estimating the impact of police oversight on crime rely on major policing scandals as shocks to examine the impact of oversight on crime. We argue that the simultaneous effect of public outrage on officer behavior and crime contaminates these results, and we provide a conceptual framework that distinguishes between oversight and outrage. We identify two events relating to unexpected court rulings in Chicago that increased oversight and caused a decline in reported misconduct but had virtually no public reaction. Despite the decrease in reported misconduct, crime and officer activity were unaffected. We contrast this with a major policing scandal, after which we find both a rise in crime rates without an equivalent increase in arrests and a decline in officer stops and use of force. Our results suggest that police oversight can reduce misconduct without increasing crime.