Follow-up care after a health fair screening in three Houston neighborhoods in 2008

Background. Each year thousands of people participate in mass health screenings for diabetes and hypertension, but little is known about whether or not those who receive higher than normal screening results obtain the recommended follow-up medical care, or what barriers they perceive to doing so. ^ Methods. Study participants were recruited from attendees at three health fairs in low-income neighborhoods in Houston, Texas Potential participants had higher than normal blood pressure (> 90/140 mgHg) or blood glucose readings (100 mm/dL fasting or 140 mm/dL random). Study participants were called at one, two, and three months and asked if they had obtained follow-up medical care; those who had not yet obtained follow-up care were asked to identify barriers. Using a modified Aday-Andersen model of health service access, the independent variables were individual and community characteristics and self-perceived need. The dependent variable was obtaining follow-up care, with barriers to care a secondary outcome. ^ Results. Eighty-two study participants completed the initial questionnaire and 59 participants completed the study protocol. Forty-eight participants (59% under an intent to treat analysis, 81% of those completing the study protocol) obtained follow-up care. Those who completed the initial questionnaire and who reported a regular source of care were significantly more likely to obtain follow-up care. For those who completed the study protocol the relationship between having a regular source of care and obtaining follow-up care approached but did not reach significance. For those who completed the initial questionnaire, self-described health status, when examined as a binary variable (good, very good, excellent, or poor, fair, not sure) was associated with obtaining follow-up care for those who rated their health as poor, fair, or not sure. While the group who completed the study protocol did not reach statistical significance, the same relationship between self-described health status of poor, fair, or not sure and obtaining follow-up care was present. The participants who completed the study protocol and described their blood pressure as OK or a little high were statistically more likely to get follow-up care than those who described it as high or very high. All those on oral medications for hypertension (12/12) and diabetes (4/4) who were told to obtain follow-up care did so; however, the small sample size allows this correlation to be of statistical significance only for those treating hypertension. ^ The variables significantly associated with obtaining follow-up care were having a regular source of care, self-described health status of poor, fair, or not sure, self-described blood pressure of OK or a little high, and taking medication for blood pressure. ^ At the follow-up telephone calls, 34 participants identified barriers to care; cost was a significant barrier reported by 16 participants, and 10 reported that they didn’t have time because they were working long hours after Hurricane Ike. ^ The study included the offer of access assistance: information about nearby safety-net providers, a visit to or information from the Health Information Center at their Neighborhood Center location, or information from Project Safety Net (a searchable web site for safety net providers). Access assistance was offered at the health fairs and then again at follow-up telephone calls to those who had not yet obtained follow-up care. Of the 48 participants who reported obtaining follow-up care, 26 said they had made use of the access assistance to do so. The use of access assistance was associated with being Hispanic, not having health insurance or a regular source of care, and speaking Spanish. It was also associated with being worried about blood glucose. ^ Conclusion. Access assistance, as a community enabling characteristic, may be useful in aiding low-income people in obtaining medical care. ^

The association between mental health and hypertension in the 2005 Department of Defense Population Survey

Major objectives within Healthy People 2010 include improving hypertension and mental health management of the American population. Both mental health issues and hypertension exist in the military which may decrease the health status of military personnel and diminish the ability to complete assigned missions. Some cases may be incompatible with military service even with optimum treatment. In the interest of maintaining a fit fighting force, the Department of Defense regularly conducts a survey of health related behaviors among active duty military personnel. The 2005 DoD Survey was conducted to obtain information regarding health and behavioral readiness among active duty military personnel to assess progress toward selected Healthy People 2010 objectives. ^ This study is a cross-sectional prevalence design looking at the association of hypertension treatment with mental health issues (either treatment or perceived need for treatment) within the military population sampled in the 2005 DoD Survey. There were 16,946 military personnel in the final cross-sectional sample representing 1.3 million active duty service members. The question is whether there is a significant association between the self-reported occurrence of hypertension and the self-reported occurrence of mental health issues in the 2005 DoD Survey. In addition to these variables, this survey examined the contribution of various sociodemographic, occupational, and behavioral covariates. An analysis of the demographic composition of the study variables was followed by logistic analysis, comparing outcome variables with each of the independent variables. Following univariate regression analysis, multivariate regression was performed with adjustment (for those variables with an unadjusted alpha level less than or equal to 0.25). ^ All the mental health related indicators were associated with hypertension treatment. The same relationship was maintained after multivariate adjustment. The covariates remaining as significant (p < 0.05) in the final model included gender, age, race/ethnicity and obesity. There is a need to recognize and treat co-morbid medical diagnoses among mental health patients and to improve quality of life outcomes, whether in the military population or the general population. Optimum health of the individual can be facilitated through discovery of treatable cases, to minimize disruptions of military missions, and even allow for continued military service. ^

Determining the association between nativity status and mammography utilization among women in the United States using 2000 and 2005 NHIS data

Objective. To determine the association between nativity status and mammography utilization among women in the U.S. and assess whether demographic variables, socioeconomic factors healthcare access, breast cancer risk factors and acculturation variables were predictors in the relationship between nativity status and mammography in the past two years. ^ Methods. The NHIS collects demographic and health information using face-to-face interviews among a representative sample of the U.S. population and a cancer control module assessing screening behaviors is included every five years. Descriptive statistics were used to report demographic characteristics of women aged 40 and older who have received a mammogram in the last 2 years from 2000 and 2005. We used chi square analyses to determine statistically significant differences by mammography screening for each covariate. Logistic regression was used to determine whether demographic characteristics, socioeconomic characteristics, healthcare access, breast cancer risk factors and acculturation variables among foreign-born Hispanics affected the relationship between nativity status and mammography use in the past 2 years. ^ Results. In 2000, the crude model between nativity and mammography was significant but results were not significant after adjusting for health insurance, access and reported health status. Significant results were also reported for years in U.S. and mammography among foreign-born born women. In 2005, the crude model was also significant but results were not significant after adjusting for demographic factors. Furthermore, there was a significant finding between citizenship and mammography in the past 2 years. ^ Conclusions. Our study contributes to the literature as one of the first national-based studies assessing mammography in the past two years based on nativity status. Based on our findings, health insurance and access to care is an important predictor in mammography utilization among foreign-born women. For those with health care access, physician recommendation should further be assessed to determine whether women are made aware of mammography as a means to detect breast cancer at an early stage and further reduce the risk of mortality from the breast cancer.^

The association between mental health and cigarette smoking in active duty military members

Previous research has shown an association between mental health status and cigarette smoking. This study examined four specific mental health predictors and the outcome variable any smoking, defined as smoking one or more cigarettes in the past 30 days. The population included active duty military members serving in the United States Army, Air Force, Navy and Marine Corps. The data was collected during the 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, a component of the Defense Lifestyle Assessment Program. The sample size included 13,603 subjects. This cross sectional prevalence study consisted of descriptive statistics, univariate analysis, and multivariate logistic regression analysis of the four mental health predictors and the any smoking outcome variable. Multivariate adjustment showed an association between the four mental health predictors and any smoking. This association is consistent with previous literature and can help guide public health officials in the development of smoking prevention and cessation programs.^

Re-emerging Vitamin D deficiency epidemic and its implications on the public health in the US

Vitamin D is essential in maintaining the bone health and Calcium homeostasis in the body. These actions are mediated through the Vitamin D receptors (VDR) present in cells through which the activated vitamin D acts [1]. In the past, it was known that these receptors existed in the intestine and bone cell. However, recent discovery of VDR in other tissues as well, has broadened the action of Vitamin D and increased its adequate intake [1].^ In the past, Vitamin D deficiency was most common among institutionalized, elderly patients and children and thought to be extinct in the healthy population. However, recent evidence has shown that, prevalence of vitamin D deficiency is increasing into an epidemic status in the overall population of the United States, including the healthy individuals [2-3]. The increased daily-recommended requirement and other multiple factors are responsible for the re-emergence of this epidemic [4-5]. Some of these factors could be used to control the epidemic. Studies have also shown the association between vitamin D deficiency and increased risk for developing chronic diseases such as diabetes, hypertension, multiple sclerosis, arthritis, and some fatal cancers like prostate, colon and breast cancers [1, 4, 6-14]. This issue results in increased disease burden, morbidity and mortality in the community [15-20].^ Methods: The literature search was conducted using the University of Texas Health Science Center at Houston (UTHSC) and University of Texas Southwestern Medical Center (UTSW) online library. The key search terms used are “vitamin D deficiency And prevalence Or epidemiology”, “vitamin D deficiency And implication And public health” using PubMed and Mesh database and “vitamin D deficiency” using systematic reviews. The search is limited to Humans and the English language. The articles considered for the review are limited to Healthy US population to avoid health conditions that predispose the population to vitamin D deficiency. Only US population is considered to narrow down the study.^ Results: There is an increased prevalence of low levels of Vitamin D levels below the normal range in the US population regardless of age and health status. Vitamin D deficiency is also associated with increased risk of chronic illnesses and fatal cancers.^ Conclusion: This increased prevalence and the association of the deficiency with increased all-cause mortality has increased the economic burden and compromised the quality of life among the population. This necessitates the health care providers to routinely screen their patients for the Vitamin D status and counsel them to avoid the harmful effects of the Vitamin D deficiency. ^

Performance tiers: Implementing comparative effectiveness analysis in the health care setting through operations research and spatial methods

This dissertation develops and tests a comparative effectiveness methodology utilizing a novel approach to the application of Data Envelopment Analysis (DEA) in health studies. The concept of performance tiers (PerT) is introduced as terminology to express a relative risk class for individuals within a peer group and the PerT calculation is implemented with operations research (DEA) and spatial algorithms. The analysis results in the discrimination of the individual data observations into a relative risk classification by the DEA-PerT methodology. The performance of two distance measures, kNN (k-nearest neighbor) and Mahalanobis, was subsequently tested to classify new entrants into the appropriate tier. The methods were applied to subject data for the 14 year old cohort in the Project HeartBeat! study.^ The concepts presented herein represent a paradigm shift in the potential for public health applications to identify and respond to individual health status. The resultant classification scheme provides descriptive, and potentially prescriptive, guidance to assess and implement treatments and strategies to improve the delivery and performance of health systems. ^

A study of the determinants of the utilization of preventive health care service among Chicanos

This study examines the individual and health care system determinants of two types of preventive health care practice behaviors, having a routine physical exam or a preventive dental exam, in the past year among Chicanos in the Southwestern United States. The study utilizes the Health System Model, developed by Aday and Andersen in 1974, to analyze the relative effect of education, income and occupation on the use of discretionary health care, controlling for other individual and health care system determinants.^ The study is based on a sample of 4,111 Mexican origin adults, drawn from the Hispanic Health and Nutrition Examination Survey (HHANES). This sample is representative of Mexican American residing in the Southwestern United States.^ The study tests the hypothesis that education is the most important social class predictor of preventive health care practice behavior. The fully elaborated model tests the hypothesis that individual determinants alone are insufficient to explain the use of preventive health care services among Chicanos.^ The study found that education and income are statistically significant social class indicators only as it relates to having a preventive dental exam. Education is not the most important social class predictor of either preventive health care practice behavior. Health care system determinants are key predictors of both behaviors. Need, as measured by self-perceived health status of teeth and gender, is as important a determinant as having dental insurance coverage as it relates to having a preventive dental exam. Implications for health programs to effectively reach Chicano target groups and remove access barriers to their use of discretionary health care services are discussed. ^

Hispanic incorporation and access to health care in Houston and Harris County, Texas: Adopting an Hispanic perspective to the Aday and Andersen model

This study examines Hispanic levels of incorporation and access to health care. Applying the Aday and Andersen framework for the study of access, the study examined the relationship between two levels of Hispanic incorporation into U.S. society, i.e., mainstream versus ethnic, and potential and realized measures of access to health care. Data for the study were drawn from a 1992 telephone survey of 600 randomly selected Hispanics in Houston and Harris County.^ The hypotheses tested were: (1) Hispanics who are incorporated into mainstream society are more likely to have better potential and realized access to health care than those who are incorporated into ethnic-group enclaves regardless of their socioeconomic status (SES), health status and health needs, and (2) there is no interaction between the levels of incorporation (mainstream or ethnic) and SES, health status, and health needs in predicting potential and realized access.^ The data analysis supported Hypothesis One for the two measures of potential access. The results of bivariate and multiple logistic regression analyses indicated that for Hispanics in Houston and Harris County, being in the "mainstream" incorporation category increased their potential access to care, having "health insurance" and a "regular place of care". For the selected measure of realized access, having a "regular check-up", the analysis did not demonstrate statistically significant differences in having a regular check-up among Hispanics incorporated in the ethnic or mainstream incorporation categories.^ Hypothesis Two, that there is no interaction between the levels of incorporation and socioeconomic characteristics, health status, and health needs in predicting potential and realized access among Hispanics was supported by the data. The results of the logistic regression analysis showed that, after adjusting for socioeconomic status, health status, and health needs, the association between "level of incorporation" and the two measures of potential access ("health insurance" and having a "usual place of care") was not modified by the control variables nor by their interaction with level of incorporation. That is, the effect of incorporation on Hispanics' health insurance coverage, and having a usual place of care, was homogenous across Hispanics with different SES and health status.^ The main research implication of this dissertation is the employment of a theoretical framework for the assessment of cultural factors essential to research on migrating heterogeneous subpopulations. It also provided strategies to solve practical and methodological difficulties in the secondary analyses of data on these populations. ^

THE EVALUATION OF PUBLIC HEALTH COMPONENTS OF INTERNATIONAL DISASTER RELIEF OPERATIONS: INDOCHINESE REFUGEES IN THAILAND, 1979-1982

Refugee populations suffer poor health status and yet the activities of refugee relief agencies in the public health sector have not been subjected previously to comprehensive evaluation. The purpose of this study was to examine the effectiveness and cost of the major public health service inputs of the international relief operation for Indochinese refugees in Thailand coordinated by the United Nations High Commissioner for Refugees (UNHCR). The investigator collected data from surveillance reports and agency records pertaining to 11 old refugee camps administered by the Government of Thailand Ministry of Interior (MOI) since an earlier refugee influx, and five new Khmer holding centers administered directly by UNHCR, from November, 1979, to March, 1982.^ Generous international funding permitted UNHCR to maintain a higher level of public health service inputs than refugees usually enjoyed in their countries of origin or than Thais around them enjoyed. Annual per capita expenditure for public health inputs averaged approximately US$151. Indochinese refugees in Thailand, for the most part, had access to adequate general food rations, to supplementary feeding programs, and to preventive health measures, and enjoyed high-quality medical services. Old refugee camps administered by MOI consistently received public health inputs of lower quantity and quality compared with new UNHCR-administered holding centers, despite comparable per capita expenditure after both types of camps had stabilized (static phase).^ Mortality and morbidity rates among new Khmer refugees were catastrophic during the emergency and transition phases of camp development. Health status in the refugee population during the static phase, however, was similar to, or better than, health status in the refugees' countries of origin or the Thai communities surrounding the camps. During the static phase, mortality and morbidity generally remained stable at roughly the same low levels in both types of camps.^ Furthermore, the results of multiple regression analyses demonstrated that combined public health inputs accounted for from one to 23 per cent of the variation in refugee mortality and morbidity. The direction of associations between some public health inputs and specific health outcome variables demonstrated no clear pattern. ^

Perceived Health, Physical Activity and Sport among the Elderly of Spain

Purpose: It determines if participating in sports and/or physical activity influences perceived health among the elderly. Basic procedures: Data were drawn from a population subsample of subjects aged 65 - 79 years old that took part in a survey conducted in 2008 by the IESA-CSIC. A regression model was performed with perceived health status with the dependent variable and sociodemographic characteristics and physical activity as independent variables. Results: Physical activity is closely associated to per-ceived health, although sport has little influence on this relationship. Conclusions: Doing exercise or feeling that one is physically active makes the elderly feel better about their health status. However, this age group practises few sports and sport is not found to have an important or constant influence on self-perceived health status among the elderly.

New systems of management to improve the health and welfare of rabbits in farm conditions = Nuevos sistemas de cría y manejo para mejorar la salud y bienestar de conejos de granja

El objetivo general de esta Tesis Doctoral fue evaluar nuevos sistemas de alojamiento y cría de conejos de granja, estudiando tanto parámetros comportamentales (experimento 1) como productivos y reproductivos (experimento 3). Además, se evaluaron diferentes técnicas de muestreo con el fin de optimizar el tiempo empleado para el estudio del comportamiento animal (experimento 2). En el experimento 1, se estudió el comportamiento de conejas alojadas en dos tipos de jaulas (TJ), convencionales vs. alternativas con una plataforma elevada, en distintos estados fisiológicos (EF), lactantes y gestantes. Se observó el comportamiento de 12 conejas reproductoras con grabaciones de una duración de 24 h continuas. Independientemente del EF y TJ, las conejas pasaron gran parte de su tiempo sobre el reposapatas (57,7 %, de media). Sin embargo, debido al uso de la plataforma (23,0% del tiempo, de media), las conejas lactantes permanecieron un 36,6 % menos de tiempo (P<0,001) sobre el reposapatas y las gestantes un 27,0% menos (P<0,001) sobre el enrejillado en jaulas alternativas que en convencionales. En las jaulas alternativas, las conejas podían adoptar la postura “levantada”, sin embargo ésta fue observada solamente en conejas gestantes una media de 4,6 veces al día. Las conejas bebieron con mas frecuencia en jaulas convencionales que en alternativas (24,6 vs 19,1 veces al día; P<0,05). Se observó una mayor duración y frecuencia del comportamiento “interactuando con compañeras” en conejas gestantes alojadas en jaulas convencionales (276 s/d y 4,6 veces/d; P<0,05). La frecuencia de “interactuando con gazapos” fue menor en jaulas alternativas que en convencionales (2,4 vs 8,6 veces al día; P<0,01). La hora del día afectó al comportamiento de las conejas, teniendo un comportamiento menos activo durante las horas centrales del día. Durante las horas de oscuridad, las conejas estuvieron más inquietas realizando comportamientos como ‘encabritarse’ o amamantar, coincidiendo éstos en el tiempo en el cual las conejas pasaron más tiempo en la plataforma. Las conejas utilizaron frecuentemente la plataforma, independientemente del estado fisiológico. En la fase de lactación, las conejas utilizaron la plataforma para huir de los intentos de mamar por parte de los gazapos cuando éstas no estaban receptivas. El uso de la plataforma puede dar lugar a problemas higiénicos debidos tanto por la acumulación de heces sobre ella como por la caída de heces y orina sobre los animales que están en la parte inferior. La ausencia de estereotipias por parte de las conejas tanto en jaulas alternativas como en convencionales no sugiere una falta de bienestar debida al sistema de alojamiento. En el experimento 2, se compararon distintos métodos de observación simplificada con respecto un método de referencia usando grabaciones continuas de 24 h para la evaluación del comportamiento de conejas en distintos estados fisiológicos (gestantes y lactantes) alojadas en dos tipos de jaulas (convencionales y alternativas). Se analizaron un total de 576 h de grabaciones continuas de 24 h en 12 conejas reproductoras al final del periodo de lactación y en las mismas conejas después del destete. Los comportamientos observados se clasificaron en tres categorías independientes (localización en la jaula, postura y comportamientos funcionales). Se utilizaron grabaciones continuas de 24 h como método de referencia para validar otros cuatro métodos de observación simplificados, utilizando grabaciones de distinta duración y frecuencia a lo largo del día. Métodos regulares: corto y largo con 2.4 y 8 h de observación respectivamente, y métodos irregulares: corto y largo con 6 y 8 h de observación, respectivamente. Como resultado, se observó que independientemente del sistema de alojamiento, el mejor método para reducir el tiempo de observación necesario para evaluar el comportamiento de conejas reproductoras depende del tipo de variable a estudiar y del estado fisiológico de las conejas. En gestantes, los métodos irregulares no fueron adecuados para estimar comportamientos de larga duración tales como tumbada, sentada, descansando y acicalándose. Sin embargo, en ambos estados fisiológicos, los métodos regulares fueron precisos para los comportamientos de los grupos localización y postura y para comportamientos funcionales de larga duración. Por otro lado, los coeficientes de variación de los comportamientos poco frecuentes realizados principalmente durante el periodo de oscuridad fueron muy altos, y el método irregular largo obtuvo los menores errores de estimación para éstos comportamientos. En el experimento 3, se estudió el efecto de un uso combinado de lactaciones largas (hasta 46 días) con jaulas alternativas sobre los parámetros productivos y reproductivos de 104 conejas y sus camadas durante cinco ciclos reproductivos. La mitad de las conejas fueron alojadas en jaulas polivalentes convencionales (39 cm x 100 cm x 30 cm) y la otra mitad en jaulas polivalentes alternativas (39 cm x 100 cm x 60 cm), con una plataforma elevada. Dentro de cada grupo de alojamiento, la mitad de las conejas se destetaron a 32 días y la otra mitad a 46 días tras el parto. Las lactaciones más largas afectaron negativamente al peso (P<0,001), contenido en grasa y energía (P<0,05) de las conejas al final del periodo de lactación, pero éste efecto disminuyó con el número de partos. La fertilidad, prolificidad y la mortalidad de las conejas no fue afectada por la duración de la lactación. El destete tardío dio lugar a un mayor tamaño y peso de la camada al final del periodo de crecimiento (8,9 y 11,3 %, respectivamente) y a un menor índice de conversión por jaula durante el todo el periodo experimental (13,5 %) con respecto al destete convencional (P<0,001). Éstos resultados fueron paralelos a la menor mortalidad global (12,6 vs 17,6 %; P<0,05) observada en gazapos con destete tardío. Las diferencias en los parámetros productivos con las distintas edades al destete sólo fueron observadas en los ciclos con peor estado sanitario (tercer y quinto ciclo), en los cuales el destete tardío redujo la mortalidad. El tipo de jaula no afectó al peso de la coneja, condición corporal, mortalidad, fertilidad ni tamaño de camada durante los cinco primeros ciclos reproductivos. Sin embargo, el peso de la camada y el índice de conversión a los 21 días de edad fueron 4,2% mayor (P<0,001) y 5,0% menor (P<0,005) en animales alojados en jaulas alternativas que en jaulas convencionales. A día 59 las jaulas alternativas dieron lugar a camadas más pesadas (P<0,01); sin embargo, éste efecto fue influenciado por la densidad alcanzada en cada ciclo, ya que cuando la densidad de los animales fue menor que 40kg/m2 (tercer y quinto ciclo), el efecto del tipo de jaula sobre el peso de la camada no fue significativo. De los resultados obtenidos se puede concluir que el uso combinado de lactaciones más largas y jaulas con mayor superficie disponible con una plataforma elevada podría ser una alternativa para mejorar el bienestar animal en determinadas situaciones productivas. ABSTRACT The general aim of this PhD Thesis was to evaluate new housing and husbandry systems of farmed rabbits, studying behavioral (experiment 1), productive and reproductive (experiment 3) parameters. Moreover, different sampling techniques were evaluated in order to optimize the assessment of rabbit behaviour (experiment 2). In experiment 1, the behaviour of rabbit does housed in two different types of cage (TC), conventional vs. alternative with an elevated platform, at different physiological stages (PS), lactation and gestation was to study. Behavioural observations were carried out on 12 commercial rabbit does using continuous 24 hour video recording. Independently of PS and TC, rabbit does spent most of their time on foot mats (57.7 %, as average). However, due to the use of platforms (23.0% of time, as average), lactating does spent 36.6% less time (P<0.001) on foot mats and gestating does spent 27.0% less (P<0.001) time on wire mesh in alternative cages than in conventional cages. Alternative cages allowed for standing posture but this behaviour was only observed in gestating does (4.6 times a day, as average). Frequency of drinking was higher in conventional than in alternative cages (24.6 vs. 19.1 times a day; P<0.05). Gestating does housed in conventional cages reached the highest duration and frequency of interacting with neighbours (276 s/d and 4.6 times/d; P<0.05). The frequency of interacting with kits was lower in alternative than in conventional cages (2.4 vs. 8.6 times a day; P<0.01). Does’ behaviour was influenced by hour of day, being less active at the midday hours. During dark hours rabbit does more frequently performed restless behaviour such as hyperactivity or nursing, matching the time at which rabbit does spent more time on the platform. The platform was frequently used by rabbit does, independent of their physiological state, and during late lactation phase, when mothers were not receptive to nursing, does housed in alternative cages used the platform as a mean to flee from kids trying to suckle. The use of the platform might lead to hygienic problems due to retained faeces on the platform and faeces and urine falling onto animals located in the lower part of the cage. Stereotypies were not observed in any housing system, therefore conventional cages do not suggest lack of animal welfare. In experiment 2, it was compared the results of different simplified sampling methods of behavioural data with respect to reference records of 24-h in order to assess rabbit does behaviours at different physiological stages (gestation and lactation) in animals housed in two types of cages (conventional and alternative). A total of 576 h of continuous video of 12 rabbit does at the end of lactation and on the same females after weaning were analysed. The behavioural observations were studied using three independent categories of classification (location in the cage, posture and functional behaviours). Continuous behavioural recordings of 24 h were considered as the reference method to validate another 4 sampling methods of data collection by aggregated video recordings of different frequency and duration (regular short and long methods with 2.4 and 8 h of observation respectively, and irregular short and long methods with 6 and 8 h of observation, respectively). The current results showed that, independently of housing system, the best method to reduce the total observation time required to assess rabbit does behaviour depends on the trait studied and physiological stage of does. In gestating does, irregular methods were not suitable to estimate behaviours of long duration such as lying, sitting, resting and grooming. However, in both physiological stages, regular methods were accurate for location behaviours, postures and functional behaviours of long duration. Instead, for the study of infrequent behaviours performed mainly during dark period, where coefficients of variation were high, the irregular long method led to the lowest mean estimation errors. In experiment 3, the effects of the combined use of long lactation periods (46 days) with alternative cages on the reproductive and growth performance of 104 rabbit does and their litters during five consecutive reproductive cycles were studied. Half of does were housed in conventional polyvalent cages (39 cm x 100 cm x 30 cm) and the other half in alternative polyvalent cages (39 cm x 100 cm x 60 cm), with a raised platform. Half of the rabbit does in each type of cages were weaned at 32 and the other half at 46 days after parturition. Longer lactations affected negatively to body weight (P<0.001), fat and energy content (P<0.05) of rabbit does at the end of the lactation period, but this effect decreased with the number of parturitions. Fertility, prolificacy and doe mortality were not affected by lactation length. Late weaning led to higher litter size (by 8.9 %) and litter weight (by 11.3 %) at the end of growing period and lower feed conversion ratio per cage during the overall experimental period (13.5 %) than standard weaning (P<0.001). These results were parallels to a lower mortality (12.6 vs 17.6 %; P<0.05) of young rabbit weaned later during the overall experimental period. Differences in performances at different weaning ages were only observed during cycles with worst health status (third and fifth cycles) in which late weaning decreased mortality. Type of cage did not affect doe body weight and body condition, mortality, fertility, prolificacy and litter size during the five firsts reproductive cycles. Nevertheless, at day 21 litter weight and feed conversion ratio were 4.2 % higher (P<0.001) and 5.0 % lower (P<0.005) in animals housed in alternative than in conventional cages. Alternative cages also led to heavier litters at 59 days (P<0.01); however, this effect was influenced by density reached in each cycle, as when the density of animals was lower than 40 kg/m2 (cycles three and five), the difference of litter weight between alternative and conventional cages was not significant. From the results obtained it can be concluded that the combined use of longer lactations and cages with higher available surface with a raised platform could be an alternative to improve animal welfare in some productive situations.

VAR models and methods for monetary and health economics

Negli ultimi anni i modelli VAR sono diventati il principale strumento econometrico per verificare se può esistere una relazione tra le variabili e per valutare gli effetti delle politiche economiche. Questa tesi studia tre diversi approcci di identificazione a partire dai modelli VAR in forma ridotta (tra cui periodo di campionamento, set di variabili endogene, termini deterministici). Usiamo nel caso di modelli VAR il test di Causalità di Granger per verificare la capacità di una variabile di prevedere un altra, nel caso di cointegrazione usiamo modelli VECM per stimare congiuntamente i coefficienti di lungo periodo ed i coefficienti di breve periodo e nel caso di piccoli set di dati e problemi di overfitting usiamo modelli VAR bayesiani con funzioni di risposta di impulso e decomposizione della varianza, per analizzare l'effetto degli shock sulle variabili macroeconomiche. A tale scopo, gli studi empirici sono effettuati utilizzando serie storiche di dati specifici e formulando diverse ipotesi. Sono stati utilizzati tre modelli VAR: in primis per studiare le decisioni di politica monetaria e discriminare tra le varie teorie post-keynesiane sulla politica monetaria ed in particolare sulla cosiddetta "regola di solvibilità" (Brancaccio e Fontana 2013, 2015) e regola del GDP nominale in Area Euro (paper 1); secondo per estendere l'evidenza dell'ipotesi di endogeneità della moneta valutando gli effetti della cartolarizzazione delle banche sul meccanismo di trasmissione della politica monetaria negli Stati Uniti (paper 2); terzo per valutare gli effetti dell'invecchiamento sulla spesa sanitaria in Italia in termini di implicazioni di politiche economiche (paper 3). La tesi è introdotta dal capitolo 1 in cui si delinea il contesto, la motivazione e lo scopo di questa ricerca, mentre la struttura e la sintesi, così come i principali risultati, sono descritti nei rimanenti capitoli. Nel capitolo 2 sono esaminati, utilizzando un modello VAR in differenze prime con dati trimestrali della zona Euro, se le decisioni in materia di politica monetaria possono essere interpretate in termini di una "regola di politica monetaria", con specifico riferimento alla cosiddetta "nominal GDP targeting rule" (McCallum 1988 Hall e Mankiw 1994; Woodford 2012). I risultati evidenziano una relazione causale che va dallo scostamento tra i tassi di crescita del PIL nominale e PIL obiettivo alle variazioni dei tassi di interesse di mercato a tre mesi. La stessa analisi non sembra confermare l'esistenza di una relazione causale significativa inversa dalla variazione del tasso di interesse di mercato allo scostamento tra i tassi di crescita del PIL nominale e PIL obiettivo. Risultati simili sono stati ottenuti sostituendo il tasso di interesse di mercato con il tasso di interesse di rifinanziamento della BCE. Questa conferma di una sola delle due direzioni di causalità non supporta un'interpretazione della politica monetaria basata sulla nominal GDP targeting rule e dà adito a dubbi in termini più generali per l'applicabilità della regola di Taylor e tutte le regole convenzionali della politica monetaria per il caso in questione. I risultati appaiono invece essere più in linea con altri approcci possibili, come quelli basati su alcune analisi post-keynesiane e marxiste della teoria monetaria e più in particolare la cosiddetta "regola di solvibilità" (Brancaccio e Fontana 2013, 2015). Queste linee di ricerca contestano la tesi semplicistica che l'ambito della politica monetaria consiste nella stabilizzazione dell'inflazione, del PIL reale o del reddito nominale intorno ad un livello "naturale equilibrio". Piuttosto, essi suggeriscono che le banche centrali in realtà seguono uno scopo più complesso, che è il regolamento del sistema finanziario, con particolare riferimento ai rapporti tra creditori e debitori e la relativa solvibilità delle unità economiche. Il capitolo 3 analizza l’offerta di prestiti considerando l’endogeneità della moneta derivante dall'attività di cartolarizzazione delle banche nel corso del periodo 1999-2012. Anche se gran parte della letteratura indaga sulla endogenità dell'offerta di moneta, questo approccio è stato adottato raramente per indagare la endogeneità della moneta nel breve e lungo termine con uno studio degli Stati Uniti durante le due crisi principali: scoppio della bolla dot-com (1998-1999) e la crisi dei mutui sub-prime (2008-2009). In particolare, si considerano gli effetti dell'innovazione finanziaria sul canale dei prestiti utilizzando la serie dei prestiti aggiustata per la cartolarizzazione al fine di verificare se il sistema bancario americano è stimolato a ricercare fonti più economiche di finanziamento come la cartolarizzazione, in caso di politica monetaria restrittiva (Altunbas et al., 2009). L'analisi si basa sull'aggregato monetario M1 ed M2. Utilizzando modelli VECM, esaminiamo una relazione di lungo periodo tra le variabili in livello e valutiamo gli effetti dell’offerta di moneta analizzando quanto la politica monetaria influisce sulle deviazioni di breve periodo dalla relazione di lungo periodo. I risultati mostrano che la cartolarizzazione influenza l'impatto dei prestiti su M1 ed M2. Ciò implica che l'offerta di moneta è endogena confermando l'approccio strutturalista ed evidenziando che gli agenti economici sono motivati ad aumentare la cartolarizzazione per una preventiva copertura contro shock di politica monetaria. Il capitolo 4 indaga il rapporto tra spesa pro capite sanitaria, PIL pro capite, indice di vecchiaia ed aspettativa di vita in Italia nel periodo 1990-2013, utilizzando i modelli VAR bayesiani e dati annuali estratti dalla banca dati OCSE ed Eurostat. Le funzioni di risposta d'impulso e la scomposizione della varianza evidenziano una relazione positiva: dal PIL pro capite alla spesa pro capite sanitaria, dalla speranza di vita alla spesa sanitaria, e dall'indice di invecchiamento alla spesa pro capite sanitaria. L'impatto dell'invecchiamento sulla spesa sanitaria è più significativo rispetto alle altre variabili. Nel complesso, i nostri risultati suggeriscono che le disabilità strettamente connesse all'invecchiamento possono essere il driver principale della spesa sanitaria nel breve-medio periodo. Una buona gestione della sanità contribuisce a migliorare il benessere del paziente, senza aumentare la spesa sanitaria totale. Tuttavia, le politiche che migliorano lo stato di salute delle persone anziane potrebbe essere necessarie per una più bassa domanda pro capite dei servizi sanitari e sociali.

The health care needs of UK pensioners living in Spain: an agenda for research

There is a growing interest in learning how older migrants adapt to their new country of residence, in understanding their motivations for migration and the factors that influence international retirement migration patterns. However, there has been little research into the health and health care needs of international migrants retiring to other countries. This paper presents findings on health status and utilisation of health services with a particular focus on UK pensioners retiring to Spain. Future research should focus on the health needs of pensioners and their perspectives as to whether and how these health needs are met.

Self-rated health and mortality: a follow-up study of a Spanish population

Objectives: Self-rated health (SRH) is known to be a valid indicator for the prediction of health outcomes. The aims of this study were to describe and analyse the associations between SRH and health status, socio-economic and demographic characteristics; and between SRH and mortality in a Spanish population. Study design: Longitudinal study. Methods: A sample of 5275 adults (age ≥21 years) residing in the Valencian Community (Spanish Mediterranean region) was surveyed in 2005 and followed for four years. SRH was categorized into good and poor health. The response variable was mortality (dead/alive), obtained from the local mortality register. Logistic regression models were adjusted in order to analyse the associations between SRH and health status, socio-economic and demographic characteristics; odds ratios were calculated to measure the associations. Poisson regression models were adjusted in order to analyse the associations between mortality and explanatory variables; the relative risk of death was calculated to measure the associations. Results: Poor SRH was reported by 25.9% of respondents, and the mortality rate after four years of follow-up was 3.6%. An association was found between SRH and the presence of chronic disease and disability in men and women. A perception of poor health vs good health led to a mortality risk of 3.0 in men and 2.7 in women. SRH was predictive of mortality, even after adjusting for all other variables. In men and women, the presence of disability provided additional predictive ability. Conclusions: SRH was predictive of mortality in both men and women, and acted as a mediator between socio-economic, demographic and health conditions and mortality.

From the boom to the crisis: changes in employment conditions of immigrants in Spain and their effects on mental health

Background: Migrant workers have been one of the groups most affected by the economic crisis. This study evaluates the influence of changes in employment conditions on the incidence of poor mental health of immigrant workers in Spain, after a period of 3 years, in context of economic crisis. Methods: Follow-up survey was conducted at two time points, 2008 and 2011, with a reference population of 318 workers from Colombia, Ecuador, Morocco and Romania residing in Spain. Individuals from this population who reported good mental health in the 2008 survey (n = 214) were interviewed again in 2011 to evaluate their mental health status and the effects of their different employment situations since 2008 by calculating crude and adjusted odds ratios (aORs) for sociodemographic and employment characteristics. Findings: There was an increased risk of poor mental health in workers who lost their jobs (aOR = 3.62, 95%CI: 1.64–7.96), whose number of working hours increased (aOR = 2.35, 95%CI: 1.02–5.44), whose monthly income decreased (aOR = 2.75, 95%CI: 1.08–7.00) or who remained within the low-income bracket. This was also the case for people whose legal status (permission for working and residing in Spain) was temporary or permanent compared with those with Spanish nationality (aOR = 3.32, 95%CI: 1.15–9.58) or illegal (aOR = 17.34, 95%CI: 1.96–153.23). In contrast, a decreased risk was observed among those who attained their registration under Spanish Social Security system (aOR = 0.10, 95%CI: 0.02–0.48). Conclusion: There was an increase in poor mental health among immigrant workers who experienced deterioration in their employment conditions, probably influenced by the economic crisis.