<p>This dissertation investigates whether dual credit students' academic performance in subsequent university courses is comparable to that of non-dual-credit students. The study uses data from a Midwest regional public university over a ten-year period and employs propensity score matching and proportional odds ordinal logistic regression to create balanced comparison groups and analyze the results. The findings indicate that students who completed the prerequisite course as dual credit have similar grades in subsequent university courses as those who completed the prerequisite course as a university student. The study also identifies significant predictors of academic performance in subsequent university courses, such as sex, historically underserved groups status, high school GPA, and course subject, regardless of dual credit status. However, first-generation status, SAT scores, and the time between courses are not statistically significant predictors. These results suggest that dual credit students are as prepared for subsequent university courses as non-dual-credit students. Nevertheless, academic outcomes differ based on certain factors, which should be considered when designing student success initiatives and allocating resources.</p>

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京都大学 / 新制・課程博士 / 博士(農学) / 甲第23964号 / 農博第2513号 / 新制||農||1093(附属図書館) / 学位論文||R4||N5399(農学部図書室) / 京都大学大学院農学研究科生物資源経済学専攻 / (主査)教授 梅津 千恵子, 教授 浅見 淳之, 准教授 三谷 羊平 / 学位規則第4条第1項該当 / Doctor of Agricultural Science / Kyoto University / DFAM

Well-being is fundamental for health. However, health and well-being are under threat by increased prevalence of depression and physical inactivity. Interaction with the natural environment may prevent these critical health issues, as research has shown that walking outdoors contributes to better well-being than walking indoors. The aim of this thesis was to investigate outdoor group walks as a potential public health intervention to enhance positive mental and emotional well-being, reduce stress, and foster resilience. This thesis evaluated Walking for Health, a national group walking programme in England using a nonexperimental, longitudinal design. Individuals who did (Group Walkers) and did not (Non-Group Walkers) take part in outdoor group walks completed two online questionnaires about their mental and emotional well-being, and covariates. To gain a broader understanding of how outdoor group walks may contribute to positive well-being, integrations were proposed between the Attention Restoration Theory and the psycho-evolutionary model, and the theories of coping and resilience. Findings show that Group Walkers had greater mental well-being and positive affect, and less negative affect, depression and perceived stress than Non-Group Walkers. Group walking had no affect on social well-being, connectedness to nature or resiliency. Outdoor group walk participation affected positive well-being through a decrease in perceived stress, and an increase in physical activity. Group Walkers demonstrated resilience against adversity on negative affect. No evidence of resilience from outdoor group walks was found for mental well-being, positive affect or depression. Group walks in farmland and green corridor environments may further boost mental well-being, and reduce negative affect and perceived stress, when compared to group walks in the urban environment. This research suggests that outdoor group walks are effective at improving mental and emotional well-being, and could be a useful public health intervention to reduce stress and foster resilience. Implications for theory are discussed.

This thesis consists of four self-contained papers. Essay I (with Linuz Aggeborn): Fluoridation of the drinking water is a public policy whose aim is to improve dental health. Although the evidence is clear that fluoride is good for dental health, concerns have been raised regarding potential negative effects on cognitive development. We study the effects of fluoride exposure through the drinking water in early life on cognitive and non-cognitive ability, education and labor market outcomes in a large-scale setting. We use a rich Swedish register dataset for the cohorts born 1985-1992, together with drinking water fluoride data. To estimate the effects, we exploit intra-municipality variation of fluoride, stemming from an exogenous variation in the bedrock. First, we investigate and confirm the long-established positive relationship between fluoride and dental health. Second, we find precisely estimated zero-effects on cognitive ability, non-cognitive ability and education for fluoride levels below 1.5 mg/l. Third, we find evidence that fluoride improves later labor market outcomes, which indicates that good dental health is a positive factor on the labor market. Essay II: I study the associations between cognitive and non-cognitive abilities and mortality using a population-wide dataset of almost 700,000 Swedish men born between 1950 and 1965. The abilities were measured at the Swedish military enlistment at age 18-20. In addition, I investigate if income and education are good proxies for the abilities. The results suggest that both cognitive and non-cognitive abilities are strongly associated with mortality, but that non-cognitive ability is a stronger predictor. The associations are only partly mediated through income and education. For middle and high income earners and individuals with a college education there are no associations with mortality. However, for low income earners and individuals without a college education, both abilities are strongly associated with mortality. The associations are mainly driven by the bottom of the distributions. Essay III (with Matz Dahlberg, Kevin Mani and Anders Wanhainen): We examine how health information affects individuals' well-being using a regression discontinuity design on data from a screening program for an asymptomatic disease, abdominal aortic aneurysm (AAA). The information provided to the individuals is guided by the measured aorta size and its relation to pre-determined levels. When comparing individuals that receive information that they are healthy with those that receive information that they are in the risk zone for AAA, we find no effects. However, when comparing those that receive information that they have a small AAA, and will be under increased surveillance, with those who receive information that they are in the risk zone, we find a weak positive effect on well-being. This indicates that the positive information about increased surveillance may outweigh the negative information about worse health. Essay IV: I estimate the effect of SSRI antidepressants on the risk of mortality for myocardial infarction (MI) patients using Propensity Score Matching on individual health variables such as pharmaceutical drug prescription, patient history and severity of the MI. The effect of antidepressants on mortality is a heavily debated topic. MI patients have an elevated risk of developing depression, and antidepressants are among the most common treatments for depression and anxiety. However, there are indications that some classes of antidepressants may have drug-induced cardiovascular effects and could be harmful for individuals with heart problems, but there is a lack of large-scale studies using credible identification strategies. My findings indicate no increased risk of two-year mortality for MI patients using SSRI. The results are stable for several specifications and robustness checks.

Before market authorization of new medicines, their efficacy and safety are evaluated using randomized controlled trials. While there is no doubt about the scientific value of randomized trials, they are usually conducted in selected populations with questionable generalizability to routine care.  In the digital data revolution era, with healthcare data growing at an unprecedented rate, drug monitoring in routine care is still highly under-utilized. Although many countries have access to data on prescription drugs at the individual level in ambulatory care, such data are often missing for hospitals. This is a growing problem considering the clear trend towards more new and expensive drugs administered in the hospital setting. The aim of this thesis was therefore to develop methods for extracting data on drug use from a hospital-based electronic health record system and further to build and evaluate models for real-time monitoring of effectiveness and safety of new drugs in routine care using data from electronic health records and regional and national health care registers. Using the developed techniques, we were able to demonstrate drug use and health service utilization for inflammatory bowel disease and to evaluate the comparative effectiveness and safety of antiarrhythmic drugs. With a rapidly evolving drug development, it is important to optimize the evaluation of effectiveness, safety and health economic value of new medicines in routine care. We believe that the models described in this thesis could contribute to fulfil this need.

INTRODUCTION: Medicare Part D provides prescription drug coverage to seniors through a benefit plan with a major deductible inserted in the middle. It is important to study the extent to which this structure affects seniors’ adherence to prescription medications. Therefore, this study had the following objectives: (1) To identify characteristics of beneficiaries reaching and not reaching the coverage gap, (2) To study the entry and exit times from the coverage gap, (3) To study the impact of a complete gap in coverage on beneficiaries’ adherence to prescription medications, (4) To study the impact of a partial gap in coverage on beneficiaries’ adherence to prescription medications METHODS: This was a retrospective quasi-experimental analysis with matched control groups using a nationally representative sample of Part D enrollees from 2008 Centers for Medicare and Medicaid (CMS) datasets. Adherence to each oral medication taken for one or more of the seven pre-defined therapeutic classes before and after reaching the coverage gap was measured using the Medication Possession Ratio (MPR). Appropriate statistical tests for significance were performed for each analysis RESULTS: A quarter of our sample (24.42%) reached the coverage gap in 2008. Most of the beneficiaries reaching the coverage gap did so by end of September. Those reaching the coverage gap and losing all coverage experienced significantly greater reductions in adherence (3% more for beta-blockers to 9% more for oral anti-diabetic agents), compared to those not reaching the coverage gap. A considerable proportion of beneficiaries stopped taking medications in both the groups and the proportion of beneficiaries considered adherent also dropped in both the groups during the coverage gap period. CONCLUSIONS: Medicare Part D beneficiaries face significant barriers to adherence and this is especially highlighted among those reaching the coverage gap. Interventions to improve adherence in this group should target all beneficiaries, especially those with several chronic conditions.

A diversidade é uma característica central dos modos de vida rurais campesinos. As explicações para tal são principalmente duas. Por um lado, porque a diversificação de produtos e atividades pode promover ganhos econômicos e, por outro, porque reduz os riscos. A teoria de escolha racional prediz que unidades domésticas semiautárquicas buscariam maximizar uma função utilidade e, para isso, ao se integrarem ao mercado, tenderiam a se especializar nos produtos e nas atividades com maior retorno econômico. Contudo, em contextos de incerteza, como aqueles rurais remotos, estas unidades tenderiam a diversificar os produtos e as atividades de que dependem para tamponar eventuais flutuações no consumo e na renda. A esse respeito, resultados de estudos prévios que avaliaram o efeito da introdução de novas fontes de renda monetária sobre a diversidade de produtos e atividades baseados em recursos naturais que unidades domésticas rurais dependem são inconclusivos. Parte mostra que incrementos nas fontes de renda estão associados à redução na diversidade de atividades e produtos que as unidades domésticas dependem, enquanto outros indicam manutenção ou mesmo aumento da diversidade. Há, contudo, poucas evidências sobre os efeitos das transferências condicionadas de renda sobre o uso de recursos naturais por unidades domésticas rurais. Portanto, este estudo teve por objetivo investigar se as transferências de renda do Programa Bolsa Família (PBF) estavam associadas à diversidade de produtos e fontes de renda baseados em recursos naturais que os domicílios rurais do Vale do Ribeira dependem. Para isso, o estudo baseou-se em um survey por entrevistas presenciais aos chefes (homem ou mulher) de 123 domicílios rurais. Os domicílios foram amostrados em oito setores censitários com concentração de pobreza e variabilidade no nível de cobertura florestal. Para a análise dos dados, foram adotados procedimentos descritivos, testes não paramétricos de Wilcoxon e o método de Pareamento por Escore de Propensão. Os resultados indicaram que o PBF não teve efeitos significativos na diversidade de produtos agropecuários ou ambientais que os domicílios dependeram no último mês, ou no número de fontes de renda baseadas em recursos naturais. Possíveis explicações da ausência de efeitos passam por motivadores na base de tomada de decisão, limitações do delineamento adotado ou particularidades da localidade. A conclusão é que o PBF não afeta as decisões quanto à diversificação do uso de recursos naturais que dependem os domicílios rurais nos locais do estudo. / Diversity is a central feature of peasant rural livelihoods. The enlightenments for this are mainly two. On the one hand, the diversification of products and activities can promote economic improvements and, on the other hand, it can reduce risks. The theory of rational choice predicts that semi-autonomous domestic units would aim to maximize a utility function and, in order to do so, once market-integrated, would tend to specialize in the products and activities with the highest economic return. However, in contexts of uncertainty, such as in remote rural areas, these units would lean towards the diversification of products and activities they rely on, in order to overcome possible fluctuations in consumption and income. In this regard, results from previous studies that have evaluated the effect of introducing new sources of monetary income on the diversity of products and activities based on natural resources, which rural households depend on, are inconclusive. Part shows that increases in sources of income are associated with a reduction in the diversity of activities and products that households rely on, while others indicate maintenance or even an increase in diversity. There is, however, little evidence on the effects of conditional cash transfers on the usage of natural resources by rural households. Therefore, the purpose of this study was to investigate whether income transfers from the Bolsa Família Program (PBF) were associated to the diversity of products and sources of income based on natural resources that rural households in the Ribeira Valley depend on. In order to do so, the study was based on a survey, applied by interviews held personally to family leaders (man or woman) of 123 rural households. Households were sampled within eight census tracts according to poverty concentration and variability at the level of forest cover. For the data analysis, were applied descriptive procedures, non-parametric Wilcoxon tests and the Method of Propensity Score. The results indicated that the PBF had no significant effect on the diversity of agricultural or environmental products that households relied on in the last month or on the number of natural resource-based sources of income. Possible explanations to this absence of effects go through motivators based on decision-making, limitations on the adopted proposal design, or particularities of the locality. The conclusion is that the PBF does not affect decisions regarding the diversification of the usage of natural resources that rural households at these study sites depend on.

La médecine fondée sur les preuves a conféré à l’essai contrôlé randomisé (ECR) le plus haut niveau de preuve dans l’évaluation de l’effet des médicaments, et par extension de toute intervention en santé. Cependant, le recours aux études observationnelles s’avère également nécessaire (i) pour conforter, en situation réelle, les résultats issus des ECR dont la validité externe est limitée, (ii) dans des situations, notamment lorsqu’il s’agit d’interventions complexes, où l’ECR n’est pas toujours réalisable pour des questions éthiques et/ou organisationnelles. Toutefois, les études observationnelles sont sujettes à différents types de biais, et notamment au biais d’indication. Ce travail de thèse explore les différentes techniques d’analyse statistique des résultats permettant de maîtriser ce biais. Dans une première partie, les aspects théoriques ont été abordés. Les différentes techniques disponibles ont été identifiées, analysées et comparées : les techniques d’ajustement multivarié, celles utilisant un score de propension (SP) et celles utilisant une variable instrumentale (VI). Pour approfondir les connaissances sur la question, une revue systématique de la littérature a été effectuée. Elle a mis en évidence la faible concordance entre les résultats obtenus en utilisant un SP et ceux obtenus en utilisant une VI, lorsque ces deux techniques étaient utilisées dans une même étude pour évaluer la même intervention. Dans une seconde partie, l’utilisation de SP et/ou VI a été testée dans trois exemples d’évaluation d’interventions complexes à partir de données de pratiques courantes recueillies dans le cadre de deux études observationnelles de cohorte : (i) l’évaluation de l’effet d’un réseau de soins spécialisé dans l’insuffisance cardiaque (IC) sur la mortalité ; (ii) l’évaluation de l’effet des stratégies médicamenteuses appropriées dans l’IC sur la mortalité ; (iii) l’évaluation de l’effet des stratégies antithrombotiques chez les patients hémodialysés sur le risque hémorragique. / Evidence-based medicine placed randomized controlled trials (RCT) at the highest level of evidence to evaluate the effects of medications and, by extension, of all health interventions. Nevertheless, observational studies are necessary (i) to support, in real-world settings, the results of RCTs, the external validity of which is limited, and (ii) in situations where RCTs are not feasible for ethical or practical reasons, particularly when evaluating complex interventions. However, observational studies are particularly prone to confounding by indication. This thesis focuses on analytical methods to reduce this bias. In its first part, the theoretical aspects were addressed. Available methods were identified, reviewed and compared: multivariate adjustment methods, methods using a propensity score (PS) and methods using an instrumental variable (IV). To further knowledge on this issue, a systematic literature review was performed. This review revealed that more and more observational studies simultaneously use PS and IV approaches to evaluate the same intervention, often leading to nonconcordant results that may be dif?cult to interpret. In a second part, the use of PS and/or VI methods was tested in three evaluations of complex interventions in real-world settings, using data from two cohort studies: (i) to evaluate the effectiveness on mortality of a community-based multidisciplinary disease management programme for heart failure (HF) patients; (ii) to evaluate the effectiveness of recommended drug prescriptions on mortality in patients with HF; (iii) to evaluate the effect of antiplatelet and anticoagulant therapies on the risk of major bleeding events in chronic hemodialysis patients