Dissertation Title: "Essays on Politics, Public Health Law, and Health Outcomes in the United States and Sub-Saharan Africa"
This dissertation is comprised of three papers that examine the political dimensions of health policymaking and the relationship between laws and population health. Paper 1 explores the political dimensions of policy formation concerning the human papillomavirus (HPV) vaccine in six states: California, Indiana, New Hampshire, New York, Texas, and Virginia. Utilizing thematic content analysis of semi-structured key informant interviews with key stakeholders in policy debates, newspaper articles, and archival materials, I detail the trajectory of public health policy approaches to HPV immunization and identify critical moments and key influences during the debates and examine policy outcomes through the lens of the Multiple Streams (MS) framework. I find that Multiple Streams model captures the dynamics of policy-making for the HPV vaccine in the sampled states. Effective political entrepreneurship made the difference between successful passage of some form of HPV-related legislation and failure to enact a policy. Political entrepreneurs built consensus among elected officials and key stakeholders by presenting proposals that were technically feasible, acceptable to the immunization policy community, and responsive to the political environment in the state. Public health officials, medical professionals, and policymakers seeking to encourage uptake of new adolescent vaccines such as the HPV vaccine should engage conservative family values and anti-vaccine advocacy groups early in the policy process to foster consensus-building. Moreover, less coercive policy measures to promote HPV vaccine uptake are less likely to be opposed by well-organized advocacy groups.
Paper 2 examines how exposure to obesity prevention laws enacted in all 50 states and the District of Columbia between 2000 and 2007 is associated with an individual’s body mass index (BMI) and classification as overweight or obese. Drawing upon an ecological model of health-related behavior and recent work on the relationship between public health laws and population health, it presents a conceptual framework linking multiple legal mechanisms and personal, social, organizational, and community ecological levels of influence on health to individual BMI and weight-based classification. Multivariate regression analyses with fixed effects using data drawn from the Behavioral Risk Factor Surveillance System (BRFSS) and LexisNexis suggest that individuals who live in states with laws designed to increase access to healthier foods through farmers’ markets are significantly less likely to be overweight or obese. Greater state-level legislative activity around obesity prevention or reduction is also associated with lower self-reported BMI.
Paper 3 extends previous exploration of citizens’ views and experiences with health services in twenty sub-Saharan African countries. It presents a conceptual framework for the development of individual-level attitudes that draws on several existing theories of public opinion formation and examines the relative importance of access to basic health services and perceptions of the quality of national leadership as drivers of public perceptions. Unmet need for medical care in the previous year was a significant predictor of less favorable views of government performance with health services in thirteen countries. Individual satisfaction with personal living conditions was significant in ten countries and always predicted more favorable views of government efforts to improve basic health services. Close physical proximity to a health clinic always predicted more favorable views of government performance. Individual access to health care, personal living conditions, and perceptions of national leadership play a significant role in shaping public attitudes towards health services in the majority of countries and social identity indicators are also important, though in fewer countries and to a lesser extent.