State-level Efforts Research Articles

Recommendations for Better Collaborative Groundwater Monitoring for the US High Plains Aquifer

Groundwater is a critical resource for the Great Plains region of the United States, providing drinking water for over 2 million people. However, the High Plains Aquifer (HPA) is under significant threat from over-extraction—defined as the excessive withdrawal of groundwater beyond its natural replenishment rate. This overuse jeopardizes not only water availability but also equitable access and allocation. Effective groundwater monitoring is essential to track trends in water availability, assess the impacts of extraction, and develop strategies to ensure long-term sustainability. Without comprehensive monitoring, it is difficult to address key issues like contamination, depletion, and groundwater quality degradation. While several state-level frameworks exist to enhance groundwater monitoring, they operate independently, leading to gaps in data sharing and collaboration, especially for a transboundary resource like the HPA. The Environmental Protection Agency (EPA) and U.S. Geological Survey (USGS) are well-positioned to play a more central role in this process. The EPA, with its mandate to protect water quality, and the USGS, with its expertise in nationwide data collection, are critical to supporting a collaborative and comprehensive groundwater monitoring system. By facilitating the integration of state-level efforts, these federal agencies can help ensure that groundwater monitoring is both consistent and accurate, enabling effective decision-making at regional and national levels. This policy memo provides a detailed analysis of current state-level efforts, highlights the role of the EPA and USGS in addressing governance challenges, and proposes a transboundary governance mechanism to enhance collaborative groundwater monitoring. The intended audience includes policymakers at the EPA and USGS, as well as water resource managers who are key to implementing these changes.

Uncovering the drivers of CO2 emissions in the United States: The hidden spillover effects

This study explores the applicability of the Environmental Kuznets Curve (EKC) hypothesis in the United States (US) from 2006 to 2020, employing the Spatial Durbin Model (SDM) to analyze the cross-border effects of pollution among states. The results indicate that although economic growth initially decreases environmental degradation, it subsequently contributes to more significant environmental degradation, challenging the EKC hypothesis's validity at the US state level. Factors such as higher energy prices and reliance on fossil fuels are also identified as significant drivers of environmental deterioration, with varying impacts observed across states. Conversely, adopting renewable energy sources is crucial in mitigating pollution levels. The study underscores the importance of coordinated state-level efforts to harmonize economic growth with sustainable environmental practices. It highlights the complexities of policymaking in balancing economic development with environmental conservation and emphasizes the need for targeted interventions to address environmental challenges effectively. This research enhances our understanding of sustainable development pathways amidst diverse regional dynamics within the US by providing empirical evidence and policy insights.

Socialist Sex Education and Its Transnational Entanglements: Monika Krause and the Effort to “Teach Tenderness” to the People

AbstractThis article traces the transnational circulation of socialist reforms in the field of sex education through the work of Monika Krause, a citizen of the German Democratic Republic (GDR) who migrated to Cuba and became the “Cuban Queen of Condoms.” For Krause, the overarching goal of sex education was to “teach tenderness” to the people. The socialist state’s mission to prepare the population for love, marriage, partnership, and family in Cuba and the GDR involved using complex measures. This paper describes these, contextualizes them in transnational debates, and explains some of the internal reasoning behind their institutionalization. It also explains why looking at state-level efforts to “teach tenderness to the people” matters for a transnational history of sex education.

Financial barriers, facilitators, and strategies among syringe services programs in the U.S., and their impact on implementation and health outcomes

Syringe Services Programs (SSPs) provide evidence-based services like drug use equipment to prevent infectious disease, overdose prevention education, and naloxone distribution to people who use drugs (PWUD). However, inadequate funding threatens provision of these interventions. This study aimed to document how the current funding landscape impacted determinants of SSP implementation, particularly describing financial and staffing barriers, facilitators, and proposed strategies, using qualitative methods informed by three implementation research frameworks. We interviewed 20 leaders of SSPs in the United States using a semi-structured interview guide. Participants described how structural stigma against PWUD led to insufficient and restrictive funding, and burdensome reporting for SSPs. This resulted in harming program implementation outcomes like reach, fidelity, and sustainability. Inadequate funding also led to insufficient staffing and subsequent staff stress, burnout, and turnover. Taken together, these barriers threatened the implementation of evidence-based interventions that SSPs provided, ultimately harming their ability to effectively address health outcomes like infectious disease transmission and opioid overdose mortality within their communities. Interviewees described how upstream policy strategies like political advocacy might address structural stigma at the federal level. Participants also highlighted state-level efforts like harm reduction–centered funding, technical assistance and capacity-building, and clearinghouse programs that may facilitate better implementation and health outcomes. A more robust understanding of the relationship between financial barriers, facilitators, and strategies on implementation and health outcomes represents a novel and vital area of research within harm reduction literature.

Expand and extend postpartum Medicaid to support maternal and child health.

Most early maternal deaths are preventable, with many occurring within the first year postpartum (we use the terms "maternal" and "mother" broadly to include all individuals who experience pregnancy or postpartum and frame our recognition of need and policy recommendations in gender-neutral terms. To acknowledge limitations inherent in existing policy and the composition of samples in prior research, we use the term "women" when applicable). Black, Hispanic, and Native American individuals are at the most significant risk of pregnancy-related death. They are more commonly covered by Medicaid, highlighting likely contributions of structural racism and consequent social inequities. State-level length and eligibility requirements for postpartum Medicaid vary considerably. Federal policy requires 60 days of Medicaid continuation postpartum, risking healthcare coverage loss during a critical period of heightened morbidity and mortality risk. This policy position paper aims to outline urgent risks to maternal health, detail existing federal and state-level efforts, summarize proposed legislation addressing the issue, and offer policy recommendations for legislative consideration and future study. A team of maternal health researchers and clinicians reviewed and summarized recent research and current policy pertaining to postpartum Medicaid continuation coverage, proposing policy solutions to address this critical issue. Multiple legislative avenues currently exist to support and advance relevant policy to improve and sustain maternal health for those receiving Medicaid during pregnancy, including legislation aligned with the Biden-Harris Maternal Health Blueprint, state-focused options via the American Rescue Plan of 2021 (Public Law 117-2), and recently proposed acts (HR3407, S1542) which were last reintroduced in 2021. Recommendations include (i) reintroducing previously considered legislation requiring states to provide 12 months of continuous postpartum coverage, regardless of pregnancy outcome, and (ii) enacting a revised, permanent federal mandate equalizing Medicaid eligibility across states to ensure consistent access to postpartum healthcare offerings nationwide.

The reality of backdoored S-Boxes—An eye opener

The real-life incidents researched in academia have revealed that (possibly) state-level efforts are made to camouflage the intentional flaws in the mathematical layer of an S-Box for exploiting the information-theoretic properties, i.e., Kuznyechik. To investigate the common features in the intentionally weakened mappings, this research thoroughly examines the backdoored structures from the perspective of 24 cryptanalytic attack vectors available in the open literature. We have debunked the earlier claims by the backdoor engineers that the proposed designs are stealthy against statistical distinguishers. Although a backdoored architecture fulfils the notions of randomness, it lacks the strength to resist sophisticated cryptanalytic attacks. Our analysis has revealed that during the backdoor insertion phase, a malicious designer compromises vital cryptographic properties, prominently the algebraic degree, differential trails, avalanche characteristics and leaving the open ground for hybrid cryptanalytic attacks. It is also observed that these mappings attain the upper bound of BCT, FBCT and DLCT, paving the way for hybrid attacks with high probability and lower data complexity.

Does Dependence on External Resources Affect Community-Based organizations’ Efforts in Countering Violent Extremism? An Explorative Study of the Northeast Nigeria Experience

ABSTRACT This study examines the funding of community-based organizations (CBOs) as instruments for reducing the extreme behaviors of violent extremist organizations (VEOs). Evidence abounds that CBOs in industrialized nations like the USA and Canada have budget lines designated for government expenditures to deal with extremist behaviors in their local communities. This state-level effort to reduce violent extremism and VEOs behavior is absent throughout Africa, especially in Nigeria. This gap is the focal point of our investigation into how external resource dependence affects CBOs in northeast Nigeria. We triangulated our data sources using secondary data, in-depth interviews, and focus group discussions. However, this study discovered that in Nigeria, external donor agencies, NGOs, and organizations that support CBOs financially, logistically, materially, and in terms of training also tend to impact their programming selection, training content, and accountability.

Beyond Buzzwords: Mandatory Human Rights Due Diligence and a Rights-Based Approach to Business Models

AbstractThis article argues that the trend to zoom into mandatory human rights due diligence (mHRDD) as the sole solution to corporate abuse is misleading. In fact, it might risk missing entirely the main point which, as set out in this article, should be creating economic systems that enable rights-based and rights-driven business models. A small, but growing number of scholarly articles address the economic, fiscal and regulatory institutions needed to create an enabling environment for the fulfilment of human rights. These policy areas constitute what some of us understand as a ‘rights-based economy’ or ‘rights-enabling economies’. State-level efforts would be much more effective in promoting substantive equality if driven by a rights-based approach rather than a market logic. This article contends that while ensuring comprehensive mHRDD is in place as a preventative and mitigation tool, states must also push for transformative macroeconomic policies based on human rights principles as a way to fundamentally change business models.

State-Level Efforts to Reform Elementary Science Education

This comparative case study explores how 18 state education agencies (SEAs) support school districts in advancing standards-based elementary science reform. We identify how SEAs understand their work in advancing elementary science reform and describe how SEAs sought to engage districts in bridging from standards to classroom practice. Based on our analysis, we argue that the school subject is a critical explanatory variable in understanding SEA efforts to support standards implementation and SEAs lean on a resource-based approach for instructional policy implementation. This study contributes to the growing research base on the role of state policy in supporting standards implementation.

COVID-19 Epidemic in the Kaliningrad Region: Incidence and Infection Control Measures

Introduction: Combating the epidemic of the novel coronavirus disease required decision-making at the state level and joining efforts of medical workers of all specialties. The experience of the Kaliningrad Region deserves special attention since this region is located in Central Europe and the first COVID-19 cases were imported here in March 2020. Objective: To assess COVID-19 epidemic manifestations and effectiveness of preventive measures at the regional level. Materials and methods: We performed a retrospective epidemiological analysis of COVID-19 incidence in the Kaliningrad Region from March 2020 to December 2022. All registered cases were confirmed by PCR or immunochromatography assay. The study included 193,259 cases, 1,879 fatal cases, 1,168 samples with the established SARS-CoV-2 genetic variant, and information on 693,627 people vaccinated against COVID-19. The data were analyzed in Microsoft Excel and WinPepi (version 11.65). Results: In 2020, the COVID-19 incidence rate in the Kaliningrad Region was lower than that in the Russian Federation while in the years 2021 and 2022 the regional rates were, on the opposite, higher than the respective national ones (p < 0.05). All age groups of the population were involved in the outbreak. Periodic rises in the incidence were associated with the replacement of the Delta variant of SARS-CoV-2 with Omicron. We established high efficacy of vaccination against COVID-19: incidence and mortality rates among the unvaccinated were significantly higher than those among vaccinated individuals (p < 0.05). Conclusion: Organization of uniform infection control measures has enabled timely interdepartmental managerial decision-making to control the epidemic. Russian regions have accumulated unique experience in implementing a set of preventive and anti-epidemic measures to combat the epidemic of the novel infection.

Air quality impacts of electric vehicle adoption in California

The transition of onroad vehicles from internal combustion engine vehicles to electric vehicles (EVs) has been promoted in the United States at federal and state levels to reduce emissions of conventional air pollutants and CO2. One state level effort is a plan from California to mandate that all new passenger vehicle sales are EVs by 2035. Using the Community Multiscale Air Quality (CMAQ) model, we analyze the potential air quality impacts of having varying amounts of EVs in the California fleet for a historical (2016) and a future (2028) year, with emphasis on ozone (O3) and fine particulate matter (PM2.5). We find that for both PM2.5 and O3, reductions in concentrations scale approximately linearly with increasing EV fleet turnover. Improvements in air quality are widespread throughout the state, with the largest improvements occurring near Los Angeles and throughout the Central Valley. With full electrification of onroad vehicle fleets, the statewide population-weighted annual average PM2.5 concentration is reduced by about 0.5 μg/m3 for both 2016 and 2028. Reductions in state population-weighted average fourth highest MDA8 O3 are 6.6 ppb and 4.3 ppb for 2016 and 2028. The results indicate that there are air quality benefits, and thus health benefits, to be gained from the transition to EVs and that these benefits do not diminish with increasing rates of EV adoption.

Achieving Reductions in Opioid Dispensing: A Qualitative Comparative Analysis of State-Level Efforts to Improve Prescribing.

To determine whether any combinations of state-level public health activities were necessary or sufficient to reduce prescription opioid dispensing. We examined 2016-2019 annual progress reports, 2014-2019 national opioid dispensing data (IQVIA), and interview data from states to categorize activities. We used crisp-set Qualitative Comparative Analysis to determine which program activities, individually or in combination, were necessary or sufficient for a better than average decrease in morphine milligram equivalent (MME) per capita. Twenty-nine US state health departments. State health departments implementing the Centers for Disease Control and Prevention's Prevention for States (PfS) program. Combinations of prevention activities related to changes in the rate of prescription opioid MME per capita dispensing from 2014 to 2019. Three combinations were sufficient for greater than average state-level reductions in MME per capita: (1) expanding and improving proactive reporting in combination with enhancing the uptake of evidence-based opioid prescribing guidelines and not moving toward a real-time Prescription Drug Monitoring Program; (2) implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with enhancing the uptake of evidence-based opioid prescribing guidelines; and (3) not implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with not enhancing the uptake of evidence-based opioid prescribing guidelines. Interview data suggested that the 3 combinations indicate how state contexts and history with addressing opioid overdose shaped programming and the ability to reduce MME per capita. States successful in reducing opioid dispensing selected activities that built upon existing policies and interventions, which may indicate thoughtful use of resources. To maximize impact in addressing the opioid overdose epidemic, states and agencies may benefit from building on existing policies and interventions.

Obesity prevention across the US: A review of state-level policies from 2009 to 2019.

Uniquely, state legislators may enact obesity prevention policies tailored to each state's needs and take diverse policy approaches to address obesity prevalence. The objective of this study was to identify and describe state-level obesity-related policies between 2009 and 2019. Using a database of legislation covering 2009-2019, researchers categorized obesity-related legislation by status (proposed/enacted), topic, and environment impacted. Researchers determined the number of policies proposed; enacted, by political party control; obesity prevalence, by states over time. 3256 obesity-related policies were proposed among 50 states and Washington DC between 2009 and 2019. Collectively, 18% (593) of policies were enacted; California (96), New and Jersey (57) enacted the most. Across environment and topics, the most enacted policies categorized in school environment (226) and school nutrition (150) topic area. Most policies were proposed (496) and enacted (77) in 2011. On average, Democrat-controlled states had higher enactment rates than Republican-controlled states, as did states with lower (vs. higher) obesity prevalence. States have actively pursued obesity-related legislation across multiple topics and environments from 2009 to 2019, with mixed enactment rates. Evaluating the impact of these policies, alone and in combination, will be important to determine whether these state-level efforts reduce obesity.

Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured.

Paediatric integrated care (PIC), which involves primary care and behavioural health clinicians working together with patients and families, has been promoted as a best practice in the provision of care. In this context, behavioural health includes behavioural elements in the care of mental health and substance abuse conditions, chronic illness and physical symptoms associated with stress, and addressing health behaviours. Models of and contexts in which PIC has been applied vary, as do the outcomes and measures used to determine its value. Thus, this study seeks to better understand (1) what paediatric subpopulations are receiving integrated care, (2) which models of PIC are being studied, (3) what PIC outcomes are being explored and what measures and strategies are being used to assess those outcomes, and (4) whether the various models are resulting in positive outcomes. These questions have significant policy and clinical implications, given current national- and state-level efforts aimed at promoting integrated health care. This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to identify relevant articles published between January 1994 and 30 June 2020. The search utilized three databases: PubMed, PsycInfo and CINAHL. A total of 28 articles met the eligibility criteria for inclusion. Overall, acceptability of PIC appears to be high for patients and providers, with access, screening and engagement generally increasing. However, several gaps in the knowledge base on PIC were uncovered, and for some studies, ascertaining which models of integrated care were being implemented proved difficult. PIC has the potential to improve access to and quality of behavioural health care, but more research is needed to understand what models of PIC prove most beneficial and which policies and conditions promote cost efficiency. Rigorous evaluation of patient outcomes, provider training, institutional buy-in and system-level changes are needed.

State Policy Responses to COVID-19 in Nursing Homes

Context: COVID-19 has a high case fatality rate in high-risk populations and can cause severe morbidity and high healthcare resource use. Nursing home residents are a high-risk population; they live in congregate settings, often with shared rooms, and require hands-on care.Objectives: To assess state responses to the coronavirus pandemic related to nursing homes in the first half of 2020.Methods: An in-depth examination of 12 states’ responses to the COVID-19 pandemic in nursing homes through June 2020, using publicly reported information such as government decrees, health department guidance, and news reports.Findings: No state emerged as a model of care. All states faced difficulty with limited availability of testing and Personal Protective Equipment (PPE). State-level efforts to increase pay and benefits as a strategy to enable infected staff to quickly physically separate from residents were minimal, and other separation strategies depended on the ability to obtain test results rapidly and on state rules regarding accepting discharged COVID-19 patients into nursing homes. Visitor restrictions to reduce risk were ubiquitous, though based on a slim evidence-base.Limitations: The information used was limited to that which was publicly available.Implications: Overall, the results suggest that the states that handle the ongoing pandemic in nursing homes best will be those that find ways to make sure nursing homes have the resources to follow best practices for testing, PPE, separation, and staffing. Evidence is needed on visitor restrictions and transmission, as states and their citizens would benefit from finding safe ways to relax visitor restrictions.

Policy Diffusion in a Redistributive Policy: Affordable Housing and State Housing Trust Funds

Diffusion models explore the reasons policies transfer across governments. In this study, we focus on U.S. state level efforts in affordable housing. Drawing predominately from policy diffusion literature, our research examines the determinants of the creation of state Housing Trust Funds (HTFs). We utilize event history analysis with logit regressions and survival modeling to examine how problem severity, neighbor adoption, economic standing, elected leadership, housing investment, and demographics predict state HTF adoption. Results indicate that both problem severity and elected leadership predict the adoption of HTFs. This work improves our understanding of state policy diffusion and efforts in housing affordability.

Preventing Adolescent and Young Adult Suicide: Do States With Greater Mental Health Treatment Capacity Have Lower Suicide Rates?

PurposeYouth suicide is increasing at a significant rate and is the second leading cause of death for adolescents. There is an urgent public health need to address the youth suicide. The objective of this study is to determine whether adolescents and young adults residing in states with greater mental health treatment capacity exhibited lower suicide rates than states with less treatment capacity. MethodsWe conducted a state-level analysis of mental health treatment capacity and suicide outcomes for adolescents and young adults aged 10–24 spanning 2002–2017 using data from Centers for Disease Control and Prevention, U.S. Bureau of Labor Statistics, Federal Bureau of Investigation, and other sources. Multivariable linear fixed-effects regression models tested the relationships among mental health treatment capacity and the total suicide, firearm suicide, and nonfirearm suicide rates per 100,000 persons aged 10–24. ResultsWe found a statistically significant inverse relationship between nonfirearm suicide and mental health treatment capacity (p = .015). On average, a 10% increase in a state’s mental health workforce capacity was associated with a 1.35% relative reduction in the nonfirearm suicide rate for persons aged 10–24. There was no significant relationship between mental health treatment capacity and firearm suicide. ConclusionsGreater mental health treatment appears to have a protective effect of modest magnitude against nonfirearm suicide among adolescents and young adults. Our findings underscore the importance of state-level efforts to improve mental health interventions and promote mental health awareness. However, firearm regulations may provide greater protective effects against this most lethal method of firearm suicide.

Opportunities for U.S. State Governments and in-Region Partners to Address Ocean Acidification through Management and Policy Frameworks

Increasing OA, combined with other stressors like warming and loss of oxygen, threatens marine species and ecosystems, including those that sustain jobs and support coastal economies. For the last 10 years, U.S. coastal states have played a key role in responding to OA specifically. In 2019, OA practitioners from the U.S. east and west coasts assembled for a multi-day conference focused on sharing and documenting advances in OA collaborations, governance and management strategies. Since that time, conference attendees, supported by conference organizer the International Alliance to Combat Ocean Acidification, have worked to distill the lessons learned and to synthesize collective experiences. To assist governments, agencies, and organizations in addressing OA, this paper describes state-level efforts to develop and implement OA actions within policy and management frameworks. We outline pathways to action and illustrate approaches that link OA with climate policy and environmental management.

Towards reducing cancer burden within the Medicaid program: Impact of Medicaid expansion on cancer stage at diagnosis.

1572 Background: Studies to date have shown post-Medicaid expansion (M-exp) decreases in the percentage of cancer patients who are uninsured and improvements in cancer stage at diagnosis in states that expanded Medicaid as part of the Affordable Care Act. However, most studies have examined impact of M-exp on stage outcomes at the population level, or among Medicaid and uninsured, rather than solely in the Medicaid population. Using cancer registry data from a non M-exp state (Georgia (GA)) and two M-exp states (Ohio (OH) and New Jersey (NJ)), we compared changes in cancer stage in patients on Medicaid, accounting for individual- and contextual-level characteristics at the Zip Code Tabulation Area (ZCTA) level. Methods: We used GA, OH, and NJ cancer registry data for individuals 20-64 years of age and diagnosed with incident invasive female breast (BC), cervical (CC), and colorectal cancer (CRC). Data spanned from 2010-2017 for GA and OH, and from 2011-2016 for NJ (for BC and CRC only), with 2014 marking the year in which Medicaid was expanded in OH and NJ. We retrieved demographic data (age, race/ethnicity, sex for CRC, insurance status, and cancer stage from the cancer registries), and obtained ZCTA-level data from the American Community Survey (e.g., income, education, and female-headed households). We defined late-stage diagnosis as regional- or distant- stage. We conducted multivariable logistic regression models by state and cancer site to examine changes in late-stage cancer diagnosis pre- and post-M-exp, accounting for individual- and ZCTA-level covariates. Results: The number of patients with incident cancer who were on Medicaid increased by 41.7% (n = 1757 to 2490), 59.6% (327 to 522), and 76.4% (953 to 1681) for BC, CC, and CRC cancers, respectively, in Ohio; by 92.4% (433 to 833) for BC and by over 100% for CRC (232 to 496) in NJ; but by 12.7% (662 to 746) among CRC patients in GA, where the number of BC and CC patients on Medicaid remained relatively stable. Adjusting for individual and contextual-level factors, the adjusted risk ratio (ARR and (95% Confidence Interval)) for late-stage disease was lowest for BC patients in OH (0.93 (0.87, 0.99)) and for CRC patients in GA (0.94 (0.89, 0.99)). The ARR for BC and CRC in NJ were not statistically significant, though they trended towards improvement. Similarly, changes in late-stage for CC were not statistically significant in OH or in GA. Conclusions: The increased number of cancer patients in Medicaid and the reductions in late-stage diagnosis observed may potentially translate into reduced, or at least stabilized, cancer-related morbidity and mortality burden among Medicaid beneficiaries over time. However, reductions in late-stage diagnosis were not consistent across cancer sites or states, possibly due to differences in population demographics, health behaviors, healthcare seeking patterns, and state-level cancer prevention efforts.

"Nothing About Us Without Us": Insights from State-level Efforts to Implement Community Health Worker Certification.

As community health workers (CHWs) have increasingly become recognized as members of health care teams, several states have considered or implemented processes to certify them. Between April and September 2017, we interviewed 41 stakeholders (e.g., CHWs, employers, and state health officials) in seven states that had considered or developed CHW certification to gather information about their processes and lessons learned. Interviewees reported several areas to consider in developing certification such as requiring training and education, deciding whether to certify based on experience, ensuring that CHWs are members of communities served, and avoiding marginalization of some groups of CHWs. Participants highlighted strategies for ensuring active CHW leadership in decision-making about certification. Interviewees identified best practices for supporting CHW workforce development such as using national models and standardized training, supporting CHW leadership, involving CHW professional groups, convening workgroups, and educating stakeholders. Findings are relevant to states seeking to grow their CHW workforce.