OBJECTIVES: We examined the association between exclusive breastfeeding, early introduction of feeding formula, early weaning, and asthma in children aged six months to five years in a sample of non-institutionalized US children using a propensity score approach. METHODS: Our study used data from the National Survey of Children's Health (2012-2018) of 3,820 children with physician-diagnosed asthma aged 6 months to 5 years. Propensity score matching (PSM) was applied to control selection bias with age, sex, race, birth weight, Federal Poverty Level, parent's education, and parent smoking history used as covariates in PSM. The total number in the matched sample was 6,904 (3,452 non-asthmatics; 3,452 asthmatics). Matched and unmatched samples were analysed using the χ test and multiple logistic regression. RESULTS: Exclusive breastfeeding was protective against asthma in the pre-matching (AOR 0.72; 95% CI: 0.54-0.97; p = 0.03) and post-matching (AOR 0.66; 95% CI: 0.55-0.81; p < 0.001) samples. Formula feeding before 6 months was associated with asthma in unmatched (AOR 1.38; 95% CI: 1.15-1.66; p < 0.001) and matched (AOR 1.31; 95% CI: 1.16-1.47; p < 0.001) sample. Early weaning before 6 months was associated with asthma in unmatched (AOR 1.62; 95% CI: 1.35-1.54; p < 0.001) and matched sample (AOR 1.37; 95% CI: 1.23-1.54; p < 0.001). CONCLUSION: Public health systems should continue to recommend the implementation of the World Health Organization exclusive breastfeeding guideline in developed countries. Asthma interventions in children under two years should continue to emphasize exclusive breastfeeding to reduce the incidence of infant asthma.

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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.

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.

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Objective: The study assesses the impact of dual enrollment participation on remediation and completion for traditional first time, full-time freshmen at a community college in Northeast Tennessee. Method: This study began with the full population of 1,232 students who enrolled between 2008 and 2012 at a community college in northeast Tennessee the fall semester after finishing high school. The population was required to have American College Testing (ACT) scores, completely fill out the Free Application for Federal Student Aid (FAFSA), enroll full-time as a degree-seeking student, and complete the first fall semester. Propensity score matching was utilized to eliminate self-selection bias and enable parametric comparisons using optimal matching of dual enrollment participants and non-participants while controlling for a range of covariates. Results: The analyses showed that community college students who participated in dual enrollment were (a) 9% or nearly 3.4 times less likely to take remediation, (b) 26% or nearly 2.5 times more likely to graduate in 2 years, and (c) 28% or nearly 1.5 times more likely to graduate in 3 years. Contributions: This study contributes to the literature showing that dual enrollment reduces remediation rates and assists in timely completions for community college students. Policy recommendations are to increase equitable participation, normalize dual enrollment for students academically able to do college coursework, align state terminology with the nation, and improve data for future research.

Enrollment in degree-granting postsecondary institutions in the U.S. is increasing, as are the numbers of students entering academically underprepared. Students in remedial mathematics represent the largest percentage of total enrollment in remedial courses, and national statistics indicate that less than half of these students pass all of the remedial math courses in which they enroll. In response to the low pass rates, numerous studies have been conducted into the use of alternative modes of instruction to increase passing rates. Despite myriad studies into course redesign, passing rates have seen no large-scale improvement. Lacking is a thorough investigation into preexisting differences between students who do and do not take remedial math. My study examined the effect of taking remedial math courses in college on degree attainment and college GPA using a subsample of the Educational Longitudinal Study of 2002. This nonexperimental study examined preexisting differences between students who did and did not take remedial math. The study incorporated propensity score matching, a statistical analysis not commonly used in educational research, to create comparison groups of matched students using multiple covariate measures. Missing value analyses and multiple imputation procedures were also incorporated as methods for identifying and handling missing data. Analyses were conducted on both matched and unmatched groups, as well as on 12 multiply imputed data sets. Binary logistic regression analyses showed that preexisting differences between students on academic, nonacademic, and non-cognitive measures significantly predicted remedial math-taking in college. Binary logistic regression analyses also indicated that students who did not take remedial math courses in college were 1.5 times more likely to earn a degree than students who took remedial math. Linear regression analyses showed that taking remedial math had a significant negative effect on mean college GPA. Students who did not take remedial math had a higher mean GPA than students who did take remedial math. These results were consistent across unmatched groups, matched groups, and all 12 multiply imputed data sets.