<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>

In my dissertation, I examine the impacts of the local urban environment on health in the developed and developing world. By 2008, more than half the global population resided in urban areas, yet many questions regarding the health impact of urban environmental factors remain unanswered. I use large, unique micro data sets on fetal health in New York City, where 8 million people reside, to observe the impacts of air pollution and extreme weather events on birth outcomes. Previous work has shown that fetal health can affect long-run outcomes, like educational attainment or income, so it is necessary to understand how exposure to various environmental factors might affect fetal health. In contrast to the U.S. where air quality regulations have been implemented since the 1960's, I also observe air pollution in Nairobi, the capital of Kenya and home to 3.1 million residents. Currently, there are no air quality regulations enforced in Kenya, nor any long-term consistent pollution monitoring, though by 2020, more than half of Kenya's population is expected to reside in urban areas. Additionally, few studies have examine urban air pollution in sub-Saharan Africa. So in another chapter, I measure occupational exposure levels of fine particulate matter (PM2.5) for individuals who work by roadways and inside informal settlements. These chapters incorporate elements from economics, public health, and atmospheric science to better understand these issues and the potential policies needed to reconcile problems of urban development and sustainability. In my first chapter, "Transit buses and fetal health: Evaluating the impacts of bus pollution policies in New York City," I provide the first estimates of the impacts of diesel vehicles on fetal health using quasi-experimental analysis. The U.S. Environmental Protection Agency (EPA) re- duced emission standards for transit buses by 98% between 1988 and 2010. I exploit the variation induced by these policy changes over time to evaluate the impacts of transit bus pollution policies on fetal health in New York City (NYC). I use bus vintage as a proxy for street-level bus emis- sions and construct a novel panel data set for the NYC Transit bus fleet that allows me to assign maternal exposure to bus pollution at the census block level. Results show a 10% reduction in emission standards for particulate matter and nitrogen oxides during pregnancy increased infant Apgar 5 scores by 0.003 points and birth weight by 6.2 grams. While the impacts on fetal health are modest, the sensitivity of later-life outcomes to prenatal conditions suggests improved emission standards between 1990 and 2009 increased total earnings for the 2009 birth cohort by at least $51 million. In my second chapter, "Occupational exposure to PM2.5 from roadways and inside informal settlements in sub-Saharan Africa: A pilot study in Nairobi, Kenya," I observe the impacts of exposure to PM2.5 for at-risk populations. Few studies examine urban air pollution in sub-Saharan Africa (SSA), yet urbanization rates there are among the highest in the world. In this study, we measure 8-hr average occupational exposure levels of fine particulate matter (PM2.5), black carbon, UV-PM, and trace elements (Al, Si, P, S, Cl, K, Ca, Ti, V, Mn, Fe, Co, Ni, Cu, Zn, Se, Br, and Pb) for individuals who work along roadways in Nairobi, specifically bus drivers, garage workers, and street vendors. As a comparison group we also measured exposure levels for women who reside and work inside informal settlements in Nairobi and who may also be exposed to high levels of urban air pollution. First, we find strong correlations among sources of roadside dust and vehicle exhaust across all groups. Second, we find bus drivers in Nairobi experienced 2 to 5 times the PM2.5 levels as bus or truck drivers in U.S. or European cities. Additionally, exposure levels for garage workers, street vendors, and women in Mathare were not statistically different from each other, suggesting residents in informal settlements in SSA also experience high exposure levels. These results suggest major health benefits from regulations targeting diesel exhaust emissions and roadside dust for the large portion of Nairobi residents who walk and work along roadways. We also find that improved cook stove programs could reduce PM2.5 exposure levels for informal settlement residents, particularly women. This is the first study to measure occupational exposure to urban air pollution in SSA and results from this suggest that roadway emissions are a serious concern. In my third chapter, "The relationship between temperature and fetal health in cities," I observe the impact of extreme weather events on fetal health in New York City. Climate change is projected to increase the duration, intensity and frequency of heat waves, but few studies have examined this relationship, which is of particular concern in cities where the urban heat island effect could exacerbate impacts. In this study, I combine average daily temperature from 1985-2010 with detailed birth certificate data in New York City and flexibly estimate the impact of an increase in maternal exposure to moderate and extreme temperatures. I find exposure to a day where temperature is greater than 85 degrees F is associated with a 0.37 to 1.14 g reduction in birth weight. However, I find no effect on gestational age. The effect on birth weight is modest, but using projections on how climate change might affect future heat waves, I find birth weight could reduce by 8.5 to 26.2 grams in the future, or about six times the current impact.

This study examines the effects of family leave policy on eight child health outcomes - five age specific child mortality rates (infant, perinatal, neonatal, post-neonatal, and child mortality rates), low birth weight, and immunization rates for measles and DPT (diphtheria, pertussis, and tetanus) across 19 Organisation for Economic Co-operation and Development (OECD) countries from 1969 to 2010. In addition, this dissertation investigates the extent to which the effects of leave policy vary by period and across welfare regimes. This research contributes to the existing literature (Ruhm, 2000; Tanaka, 2005) by including one additional country, South Korea, a highly developed but considerably understudied country, and by incorporating data from 2001 to 2010. I use data on family leave policy from Ruhm (2000) and Tanaka (2005) and extend it using data from the Max Planck Institute for Demographic Research (MPIDR), Organization for Economic Co-operation and Development (OECD), World Health Organization (WHO), International Labour Organization (ILO), and World Bank. Additional data sources include the United States Social Security Administration (SSA), International Social Security Association (ISSA), and various government sources. I estimate the effects of family leave policy (specially, number of weeks provided) - considering both job protected paid leave and other leave (unpaid or non-job protected leave) - on child health using ordinary least squares (OLS) models. I control for other relevant variables including gross domestic product (GDP) per capita, health expenditures, healthcare coverage, dialysis patients, and fertility and female employment rates. I also include: (1) country fixed effects; (2) year fixed effects; and (3) country-time trend interactions. Missing values are imputed 20 times using the predictive mean matching method. The results suggest job protected paid leave significantly reduces infant mortality (deaths less than 1 year of age) and post-neonatal mortality (deaths between 1 month and 1 year of age). In particular, the largest effects of job protected paid leave are found in reducing post-neonatal mortality; the effects are robust throughout all model specifications. Comparing the effects of other leave (unpaid or non-job protected) and job protected paid leave, other leave has no significant effects on any of the outcome indicators. This suggests that parents do not respond to leave provided without adequate payment benefits or job protection, and mothers may return to work early. As a result, other leave does not have any significant effects on infant health. When investigating the effects of family leave policy by period with models estimated separately by two time periods, somewhat larger effects of job protected paid leave on post-neonatal mortality are found in the earlier period (1969-1989) compared to the later period (1990-2010); however, the difference in the policy effects between the two periods is not statistically significant. This difference may be explained by the fact that it was during the earlier period when most OECD countries provided leave for the first critical weeks and months after birth. In addition, when examining the effects of leave policy by welfare regime type with models estimated separately by regime type, larger effects of job protected paid leave on post-neonatal mortality are found in the Social Democratic and Conservative regimes than in the other regime types; however, the difference in the policy effects across regime types is not statistically significant. This difference may be explained partly by the fact that overall Social Democratic and Conservative welfare state countries provide more generous payment benefits for parents on leave. The concluding section discusses how these findings compare to previous research and explores future research and policy implications.

In this dissertation I examine the Child Tax Credit (CTC), who gets it and who doesn't, paying particular attention to children under the age of three, its legislative and political history, and how it could be improved. At $56.4 billion per year, the Child Tax Credit (CTC) is nearly the largest U.S. federal expenditure on children and families, second only to the Earned Income Tax Credit (EITC), at $59.5 billion (JCT, 2011). Created in 1997, it has been expanded seven times in just the last decade. Yet in spite of America's federal commitment of dollars and legislative commitment of reform, little has been written about the CTC. I examine the literature first to see if cash and cash assistance matter, finding on balance that there is strong evidence that it does, particularly for young children; second to show that the U.S. underinvests in this domain in young children relative both to what is needed and to what other advanced industrialized countries do; and third to lay out the case that changes to the refundable CTC offer one opportunity to address this underinvestment. I examine the legislative history of the CTC, as I believe both the policy analysis and history need to be understood to inform the policy responses. Next, I examine whether the portion of the new safety net that was fashioned as tax policy is working as child policy - specifically, whether it is reaching our youngest children, with initial evidence that it may not be in the case of the CTC (Burman and Wheaton, 2007) yet may be in the case of the EITC (Dowd and Horowitz, 2011). Using the 2011 Current Population March Supplement, I examine empirical evidence of the age distribution of federal tax credits for children, finding that 29% of children under the age of three are in families with too little earnings to get the full CTC, as opposed to 20% of older children. Nearly 13% of children under the age of three are in families with no earnings and as such get no CTC or EITC, as opposed to 8% of older children. While the EITC may disproportionately benefit young children, poor young children are more likely to be left out eligibility of the EITC than their older counterparts. Since infants may or may not be eligible for any CTC or EITC, depending on their birth month, I suggest that as some have found a marriage penalty in parts of the tax code, that there may also be a "baby penalty." I use micro-simulation to examine the costs and benefits of alternative CTC policies. Here I find that while full refundability may be the optimum CTC policy, that there are other possibilities, including those that increase the phase-in of eligibility, that are less costly, and also substantially lower child poverty among young children, including doubling the CTC for young children, increasing the phase in, and using a look back provision to allow families to use their previous year's earnings to calculate their refundable CTC and EITC. Yet, only moving to full refundability would do anything for the 12.67% of young children in families with no earnings. Finally, I propose policy responses that are rooted both in the science of increased cash investments in young children, and in the politics of working legislatively to get there, suggesting that policy makers consider the question of age equity when examining the distributional effects of tax policies. Implications for research and policy are discussed.

This dissertation explores the political development of Medicaid financing, specifically its federal-state cost sharing formula. This dissertation traverses a half-century of congressional policymaking and an original 30-year dataset of state-level Medicaid expenditure and enrollment figures to provide a positivist account of how the federal and state governments' shared financial responsibilities for Medicaid affect overall Medicaid expenditures and state budget priorities. This dissertation also considers the direct and indirect financial burden that Medicaid's costs impose on taxpayers--both in their capacity as Americans and as residents of individual states. This dissertation argues that the growth in Medicaid costs is attributed to the resiliency of a funding formula that subsidizes the states' policies and redistributes liability for Medicaid expenditures between the states and federal governments. By subsidizing the costs of a state's Medicaid program, a state's Federal Medical Assistance Percentage (FMAP) reduces the effective fiscal burden of its Medicaid policies, thereby incentivizing policymakers to expand Medicaid beyond what is warranted by the policy preference of the state's residents. As a result, state budgets are likely to reflect an intentionally inefficient, yet politically rational, allocation of public resources. Compounded over decades, and exasperated by more recent adjustments that reduce the states' direct fiscal responsibilities for their Medicaid policies, the fiscal imperative imposed by Medicaid's financing institution has compelled states to maintain a rate of growth in Medicaid expenditures that now threatens to overwhelm the states' ability to adequately fund its other public commitments.

<p> Existing research indicates that employee engagement is tied to positive organizational outcomes, like higher productivity and lower workforce attrition. Research also indicates the supervisors&rsquo; performance is a key element in improving the employees&rsquo; levels of engagement. Within the Federal government, there is a wide range of measured employee engagement. Given the importance of employee engagement, the key role of the supervisor, and the range of federal employee engagement, this mixed methods research was designed to identify promising practices from three agencies noted for their work in employee engagement between 2013&ndash;2016. There were three research questions. 1. Which large federal agencies&rsquo; survey responses in the Federal Employee Viewpoint Survey (FEVS) showed marked improvement in employee engagement and the performance of their first-level supervisors as measured between 2013 and 2016? 2. For those large federal agencies that were able to improve their employee engagement over the period 2013 to 2016, along with a large agency with consistently high engagement, what changes have they made in the areas of selection, development, guidance and support, and accountability for first-level supervisors? 3. Is there a correlation between the supervisors&rsquo; view of their agencies in those four areas, as reflected in the Merit System Protection Board&rsquo;s (MSPB) Merit Principles Survey Path L data, and the agencies&rsquo; employee engagement as evidenced by the established FEVS indices? </p><p> Through analysis of FEVS data, the Department of Labor, the National Aeronautics and Space Administration, and the Department of Housing and Urban Development, were identified as large agencies with unusually positive results in employee engagement. Qualitative interviews, and the examination of statements by senior agency representatives, provided data regarding agency initiatives related to the improvements in the Office of Personnel Management&rsquo;s Federal Employee Viewpoint Survey (FEVS) engagement indices. Additionally, the quantitative portion of this research identified specific areas of correlation between the views of supervisors at 20 large agencies using the Merit System Protection Board&rsquo;s 2016 Merit Principles Survey (MPS) Path L data, and employee engagement indices based on FEVS results from that same year. </p><p> Analysis of the quantitative data revealed numerous instances of statistically significant correlation between supervisors&rsquo; views expressed in the MPS data and the FEVS engagement indices. Composite variables were designed using the findings from the qualitative research and the identified correlations related to major initiatives. Linear regression of a model using three of these composite variables based on supervisors&rsquo; MPS responses, explained nearly 80 percent of the variation in FEVS employee engagement scores among the 20 large agencies in both the FEVS and MPS databases. Using both the rich understanding from the qualitative research, and the identified relationships from the quantitative results, recommendations for a process to address employee engagement in general, and numerous specific initiatives, focused on supervisors, are provided for consideration and further research.</p><p>

<p> This dissertation has both science and policy components. The research examines the presence or absence of two amphibian species in one Virginia County. Two amphibian species <i>Pseudacris crucifer</i> (Spring Peeper) and <i>Hyla versicolor</i> (Gray Tree Frog) are proposed to serve as a biotic indicator, or proxy, for water quality/watershed condition and ecosystem services. My dissertation hypothesized that amphibian presence of the target species would correlate with watershed integrity values, which was verified by statistical analysis. Greater amounts of amphibian presence correlated with higher watershed integrity scores. Detailed studies of amphibian occurrence, with continued monitoring, can document trends and behaviors of the target species. Facing concern for thresholds and factors that allow or limit amphibian presence, amphibian monitoring contributes to our understanding of anthropogenic impacts on biotic communities. </p><p> Both of the targeted amphibian species were distributed county-wide; occurrences were recorded in each of the major sub-watersheds. Areas surrounding the monitored road segments were calculated (using GIS technology) for the amount of areas assigned to one of four watershed integrity values. Amphibian occurrences correlated with watershed integrity scores using Spearman Rank Correlation. </p><p> What it means to possess watershed integrity sufficient to host amphibian populations brings science into the realm of public policy. Values, economics, demographics, education, politics and culture come into play. Watershed integrity, water quality and ecosystem condition, function and services directly impact human health and wellbeing, and can have profound influences on economic and cultural circumstances. </p><p> County-wide amphibian monitoring can establish an important baseline for ecological conditions, with the potential for citizen engagement. It is one more portal through which citizens may connect with the natural world. Connections to nature, along with environmental literacy and forward-looking public policies will be required to protect the ecosystem services upon which our communities depend. Monitoring for two or three amphibian species from public roads can become a citizen science effort that raises awareness of water resource issues. Aware and engaged citizens are needed to inspire governments and elected representatives to plan for 21^st century conditions and sustainability. If engaging citizens, of all ages, in the workings of their own watershed will deepen their understanding of this vital, complex and dynamic system, then we may realize higher levels of water stewardship and sustainability.</p><p>

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