Public Health Policy & Administration

Public Health Policy and Administration (PHPA) faculty include: Karla Bartholomew, D. Phuong (Phoenix) Do, Linnea Laestadius, and Jenna Loyd. Current PHPA research explores the role of policy in influencing population health, as well as the drivers for policy development. This multidisciplinary program includes research on food systems and environmental policy, immigration and detention policy, housing policy, neighborhood context, residential racial and economic segregation, tobacco control, public health law, maternal and child health, violence, the interconnections among race, gender, and class, and the social determinants of health inequities. Learn more about featured research projects by PHPA faculty:

Affordable Care Act and public health: The role of “community benefits” regulations
Karla S. Bartholomew
The Patient Protection and Affordable Care Act (ACA) was enacted in March 2010 to expand health insurance coaverage and improve the quality of health care. Though focused on the health care system, ACA has public health implications with its Prevention and Public Health Fund, mandated prevention services, and community-based activities. One such community activity is the “Community Benefits” requirements for tax-exempt hospitals. The IRS has explicated the community benefits provisions through a series of rules, the latest to take effect in October 2013. Ambiguity surrounding this requirement remains, however, as do risks of unintended adverse effects.

Barriers and opportunities to advocating for a domestic right to food in the U.S.
Linnea Laestadius, Jillian Parry Fry, Roni Neff
Food insecurity has remained a pressing public health problem in the US, particularly in light of the economic downturn. One approach to addressing this issue is to move toward recognition of access to healthy food as a human right. This study, conducted in partnership with the Johns Hopkins Center for a Livable Future, seeks to document how non-profit food-focused advocacy groups conceptualize the right to food and understand the barriers preventing campaigns advocating for a right to food. A pilot study is currently being developed, with plans for a larger study in 2014.

Developing an ethical framework for a newborn screening program in Morocco
Karla S. Bartholomew
Congenital disorders are a major source of pediatric morbidity in Morocco, due in part to high levels of consanguinity. Various levels of Newborn Screening (NBS) programs exist in Morocco for select conditions (e.g., congenital hypothyroidism, phenylketonuria) in limited numbers of urban hospitals. The Moroccan government, health care providers, geneticists, and researchers are currently exploring processes to establish a national NBS system in the face of competing health priorities, limited infrastructure, and unexplored social and ethical issues. Building upon best practices of the US and European NBS programs, ethical principles of public health genomics, and the societal context of Morocco, we are exploring the legal, social, and ethical issues associated with establishing a successful NBS program in Morocco.

Evaluating the effect of local smoke free regulations on birth outcomes and prenatal smoking
Karla S. Bartholomew, Rahi Abouk
Smokefree regulations have the potential to impact birth outcomes through changes in both smoking prevalence among pregnant women and exposure to secondhand smoke during pregnancy. Research exploring the role of smokefree regulations on birth outcomes is limited and does not yet provide a consensus statement. West Virginia (WV) is one of only eight states without a statewide smoking regulation, but has no state preemption law that would otherwise prohibit local jurisdictions from enacting smokefree regulations. As such, local Boards of Health have enacted county-level smokefree regulations across WV’s 55 counties. We exploit the variations in county regulation restrictiveness and timing by conducting a Difference-in-Difference estimation to assess the impact of variations in smokefree regulations on birthweight, gestational age, and prenatal smoking between 1995-2011.

Immigration in a carceral era: Consequences and political responses
Jenna Loyd, Andrew Burridge, Matt Mitchelson
Immigration policy and criminal justice policy are often thought of as discrete, yet the interaction between these fields remains little explored. Dr. Loyd is the coeditor with Dr. Matt Mitchelson and Dr. Andrew Burridge of a volume entitled Beyond Walls and Cages: Prisons, Borders, and Global Crisis (University of Georgia, 2012) that documents the intersections among criminal justice, immigration, and border security policy and responses to them.

The impact of WIC on preventative dental utilization among Medicaid children
D. Phuong Do, Christine Veschusio
While research into WIC’s impacts continues to be an active area, most studies have examined birth outcomes, infant and child growth, and feeding practices as endpoints. Investigations into other outcomes, including children’s oral health, have received little attention. In this study, we apply a longitudinal analysis to examine the effect of WIC participation on the utilization of preventive dental services by Medicaid enrolled children in South Carolina. We further test whether rural/urban residence and dental Health Professional Shortage Area (DHPSA) status modify the impact of WIC on dental utilization. We first estimate pooled logistic regression models as baseline estimates. We then account for possible unobserved confounding by estimating child fixed-effects models, which control for all time-invariant child (and family) characteristics. Results from both estimation strategies are compared.

Investigating the relationship between neighborhood poverty and mortality risk: A marginal structural modeling approach
D. Phuong Do, Lu Wang, Michael R. Elliott
Estimating the causal impact of neighborhood effects from observational data has proven to be a challenge. Omission of relevant factors may lead to overestimating the effects of neighborhoods on health while inclusion of time-varying confounders that may also be mediators (e.g., income, labor force status) may lead to underestimation. Because policy inferences and anticipated impacts of interventions rely on estimates of causal versus associational connections, addressing these sources of bias are important to make appropriate policy recommendations. Using longitudinal data from the 1990 to 2007 years of the Panel Study of Income Dynamics, this study investigates the link between neighborhood poverty and overall mortality risk. We address the issue of possible downward bias due to adjusting for mediating factors by employing a marginal structural modeling strategy, which appropriately adjusts for simultaneous mediating and confounding factors. We then compare conventional naïve estimates to those recovered from marginal structural modeling. To address the issue of possible upward bias due to omitted variables, we conduct a sensitivity analysis to assess the robustness of results against unobserved confounding.

Political geographies of health and violence
Jenna Loyd
The geographic unevenness of health and violence is well established, yet questions of the place of health and how social and economic forces interact remain vibrantly debated. This project examines how activists and advocates conceptualize and contest health and environmental inequities, primarily in United States cities. Her book Health Rights Are Civil Rights: Peace and Justice Activism in Los Angeles, 1963-1978 (University of Minnesota Press: 2014) explores how the how Black freedom, antiwar, welfare rights, and women’s movements formed alliances to organize for dignified health care and investment of resources in creating socially and environmentally just cities.

State and local agency responses to community health concerns associated with industrial farm animal production
Jillian Parry Fry, Linnea Laestadius, Clare Grehis, Keeve Nachman, Roni Neff
Large-scale industrial farm animal production (IFAP) operations have been associated with a number of health concerns for individuals residing near facilities. This study sought to examine the ways in which state and local agencies respond to and prevent community-driven health concerns associated with IFAP facilities. An initial manuscript focused on state and county health department responses was published in PLOS ONE in 2013. A follow up manuscript examining state departments of agriculture and facility permitting agencies is currently under review.

The Ties that Bind: Investigating the Interconnections between metropolitan segregation, neighborhood context, and racial/ethnic health disparities
D. Phuong Do, Reanne Frank, John Iceland, Lorraine Halinka Malcoe
Though neighborhood conditions, such as poverty and disorder, are thought to be the primary means through which segregation affects health, we know very little about how segregation and neighborhoods interact together to influence the health. Are the effects of metropolitan segregation conditioned on neighborhood factors or are the effects uniform across all neighborhood types? Do the effects of neighborhood-level (local) segregation on health differ from the effects of metropolitan- level (metro) segregation? Using data from the National Health Interview Survey, this study comprehensively examines the interconnections between metropolitan segregation, neighborhood context, and individual health. We utilize spatial measures of metro and local segregation, account for neighborhood conditions, and apply three-level hierarchal models to asses how contextual factors at different levels interact to affect the health of blacks, Hispanics, and whites in the U.S. This fundamental determinants perspective underscores the potentially immense impact of housing policies, urban design, and the spatial allocation of resources and risk exposures to combat the root cause of racial/ethnic health disparities in the U.S.

Welfare reform’s mandatory maternal employment and infant health
Karla S. Bartholomew, Rahi Abouk
Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) in August 1996. The hallmark of this “Welfare Reform” was the requirement that adult recipients, predominantly single mothers, work to receive benefits. While this mandatory employment has the potential to impact children’s health, its effect on infant health has not been well-studied. Under PRWORA, states have unprecedented discretion in defining their programs, leading to variations in state work requirements. We assess the impact on infant health of state work provisions (time exempted from work after infant’s birth, work hours required, and sanctions for work noncompliance). Initial analyses suggest that states with more stringent sanctions policies had statistically significant higher postneonatal mortality (PMR, days 28-364). We now follow up those initial findings.

Where is remote?: Development of immigration detention and deterrence policies in the United States
Jenna Loyd, Alison Mountz
The often remote locations of immigration detention facilities has long been a concern for legal and health advocates as well as concerned family and community members. Explanations for how the US immigration system works and has expanded are crucial to effective advocacy, yet remain contested. Jenna Loyd’s postdoctoral work with Dr. Alison Mountz examined the development of detention as a form of deterrence, and the consequences this policy has had for asylum seekers and ‘irregular’ migrants seeking entry to the United States. They are writing a book on the development of United States deterrence policies since the passage of the Refugee Act of 1980 and consequent expansion of the immigration detention system.