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This study estimates and decomposes components of different measures of inequality in health and healthcare use among millennial adolescents, a sizeable cohort of individuals at a critical stage of life. Administrative data from the UK Hospital Episode Statistics are linked to Next Steps, a survey collecting information about millennials born between 1989 and 1990, providing a uniquely comprehensive source of health and socioeconomic variables. Socioeconomic inequalities in psychological distress, long-term illness and the use of emergency and outpatient hospital care are measured using a corrected concentration index. Shapley-Shorrocks decomposition techniques are employed to measure the relative contributions of childhood socioeconomic circumstances to adolescents’ health and healthcare inequality of opportunity. Results show that income-related deprivation contributes to significant inequalities in mental and physical health among adolescents aged between 15 and 17 years old. There are also pro-rich inequalities in the use of specific outpatient hospital services (e.g., orthodontic and mental healthcare), while pro-poor disparities are found in the use of emergency care services. Regional and parental circumstances are leading factors in influencing inequality of opportunity in the use of hospital care among adolescents. These findings shed light on the main drivers of health inequalities during an important stage of human development and have potentially important implications on human capital formation across the life-cycle.

Background: There is sparse evidence on the impact of health information on mental health as well as on the mechanisms governing this relationship. We estimate the causal impact of health information on mental health via the effect of a diabetes diagnosis on depression. Methods: We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value of a biomarker used to diagnose type-2 diabetes (glycated haemoglobin, HbA1c) and information on psycometrically validated measures of diagnosed clinical depression drawn from rich administrative longitudinal individual-level data from a large municipality in Spain. This approach allows estimating the causal impact of a type-2 diabetes diagnosis on clinica ldepression. Results: We find that overall a type-2 diabetes diagnosis increases the probability of becoming depressed, however this effect appears to be driven mostly by women, and in particular those who are relatively younger and obese. Results also appear to differ by changes in lifestyle induced by the diabetes diagnosis: while women who did not lose weight are more likely to develop depression, men who did lose weight present a reduced probability of being depressed. Results are robust to alternative parametric and non-parametric specifications and placebo tests. Conclusions: The study provides novel empirical evidence on the causal impact of health information on mental health, shedding light on gender-based differences in such effects and potential mechanisms through changes in lifestyle behaviours.

Despite a growing literature about the mental health effects of COVID-19, less is known about the psychological costs of providing informal care during the pandemic. We examined longitudinal data from the UK's Understanding Society Survey, including eight COVID surveys, to estimate fixed effects difference-in-differences models combined with matching, to explore the causal effects of COVID-19 among informal carers. While matching accounts for selection on observables into caregiving, multiple period difference-in-differences specifications allow investigation of heterogeneous mental health effects of COVID-19 by timing and duration of informal care. The estimates suggest that while mental health fluctuated following the imposition of social restrictions, informal carers who started caregiving during the pandemic show the largest mental health deterioration, especially during lockdowns. Policies to mitigate the psychological burden of caregiving might be more effective if targeted at those starting to provide care for the first time.

This thesis provides an in-depth analysis of socioeconomic determinants of individuals’ health and well-being in three key moments of their lives. It contains three pieces of applied work, with each chapter investigating a different longitudinal data set (representative of the US, UK and European populations) while employing several econometric techniques (standard and multiple time periods difference-indifferences models, instrumental variable approaches, structural equation models, propensity score matching and factor analysis). Introduction and conclusions of the thesis are presented in chapter 1 and chapter 4, respectively. Chapter 2 explores the effect of parental socioeconomic status and risky health behaviours on offspring’s infant health. To identify such effects, an intergenerational instrumental variable approach is employed, using grandparents’ education and smoking behaviour as instruments for parental characteristics. The National Longitudinal Study of Adolescent to Adult Health (Add Health) is analysed, which contains information on three generations followed over time. Chapter 3 looks at a later life stage (adulthood) investigating the impact of providing informal care on caregivers’ mental health during COVID-19. The UK Household Longitudinal Study (Understanding Society) is analysed, employing a mixture of traditional and novel difference-in-differences models combined with matching. Chapter 4 is a methodological work assessing the performance of multiple-item scale scores formed with different weighting structures (i.e. composite indices and latent variables), while exploring correlations between socioeconomic factors and quality of life in older adulthood. Structural equation modelling is employed on data drawn from the Survey of Health, Ageing and Retirement in Europe (SHARE). The objective of this thesis is to explore socioeconomic factors which affect health and well-being during key periods of individual life-cycle, i.e. childhood, adulthood a

Despite a growing literature about the mental health effects of COVID-19, less is known about the psychological costs of providing informal care during the pandemic. We examined longitudinal data from the UK's Understanding Society Survey, including eight COVID surveys, to estimate fixed effects difference-in-differences models combined with matching, to explore the causal effects of COVID-19 among informal carers. While matching accounts for selection on observables into caregiving, multiple period difference-in-differences specifications allow investigation of heterogeneous mental health effects of COVID-19 by timing and duration of informal care. The estimates suggest that while mental health fluctuated following the imposition of social restrictions, informal carers who started caregiving during the pandemic show the largest mental health deterioration, especially during lockdowns. Policies to mitigate the psychological burden of caregiving might be more effective if targeted at those starting to provide care for the first time.

Background Safe consumption sites provide people who use drugs with medical supervision and sterile paraphernalia for drug use. Although the presence of sites in neighborhoods can be controversial, few studies have assessed the preferences of individuals for attributes of safe consumption sites. Methods A discrete choice experiment was conducted to assess public preferences for safe consumption sites. Logit and mixed logit models were used to analyze data. Participants were recruited from Conjointly.com using a sample of the general population in Canada. The sample included adults only, was split approximately evenly by gender, and reflects census data for household income and geographic area. Attributes included: cost of the site to the healthcare system; effectiveness of the site in reducing overdose death; financial compensation to residents if a site opens in their neighborhood; if the site is located in the respondent’s neighborhood; and if the site reduces improperly discarded needles. Results The sample consisted of 203 respondents. Respondents had negative preferences for sites that increased cost to the healthcare system. Conversely, they had positive preferences for sites that would reduce fatal overdoses, that could reduce improperly discarded needles, and sites that provided compensation to those impacted by the establishment of sites. Conclusions Findings suggest that there exist a set of attributes that influence respondents’ preferences for safe consumption sites. By considering these attributes when designing sites and developing messaging for sites, decision-makers may develop sites that are potentially less controversial.

Despite an increasing interest in the effect of health information on health-behaviours, evidence on the causal impact of a diagnosis on lifestyle factors is still mixed and does not often account for long-term effects. We explore the role of health information in individual health-related decisions by identifying the causal impact of a type-2 diabetes diagnosis on body mass index (BMI) and lifestyle behaviours. We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value in the diagnosis of type-2 diabetes provided by a biomarker (glycated haemoglobin) drawn from unique administrative longitudinal data from Spain. We find that following a type-2 diabetes diagnosis individuals appear to reduce their weight in the short-term. Differently from previous studies, we also provide evidence of statistically significant long-term impacts of a type-2 diabetes diagnosis on BMI up to three years from the diagnosis. We do not find perceivable effects of a type-2 diabetes diagnosis on quitting smoking or drinking. Overall, health information appears to have a sustained causal impact on weight reduction, a key lifestyle and risk factor among individuals with type-2 diabetes.

Background Safe consumption sites provide people who use drugs with medical supervision and sterile paraphernalia for drug use. Although the presence of sites in neighborhoods can be controversial, few studies have assessed the preferences of individuals for attributes of safe consumption sites. Methods A discrete choice experiment was conducted to assess public preferences for safe consumption sites. Logit and mixed logit models were used to analyze data. Participants were recruited from Conjointly.com using a sample of the general population in Canada. The sample included adults only, was split approximately evenly by gender, and reflects census data for household income and geographic area. Attributes included: cost of the site to the healthcare system; effectiveness of the site in reducing overdose death; financial compensation to residents if a site opens in their neighborhood; if the site is located in the respondent’s neighborhood; and if the site reduces improperly discarded needles. Results The sample consisted of 203 respondents. Respondents had negative preferences for sites that increased cost to the healthcare system. Conversely, they had positive preferences for sites that would reduce fatal overdoses, that could reduce improperly discarded needles, and sites that provided compensation to those impacted by the establishment of sites. Conclusions Findings suggest that there exist a set of attributes that influence respondents’ preferences for safe consumption sites. By considering these attributes when designing sites and developing messaging for sites, decision-makers may develop sites that are potentially less controversial.

The Smoking Drinking Drug Use Survey of adolescents aged 11 to 15 years living in England shows that lifetime drug use by adolescents aged 11 to 15 years has increased (15% to 24%) from 2014 to 2018 (NHS Digital, 2017, 2021b). This upward trend is despite the implementation of drug policies focused on reducing supply, possession, and manufacture of illicit drugs. Based on the premise that drug use is a socially learnt behaviour, the main objective of this research is to investigate whether social learning factors (imitation, parental reinforcement, peer association and attitudes to drug use) mediate drug use in adolescents aged 11 to 15 years living in England. The second objective is to identify which social learning factors mediate drug use by ages, region, and gender. Using the Social Structure Social Learning (SSSL) theory as a framework for the research, this study contributes to the literature by identifying a) the strongest social learning behaviour for each age, gender and region in England and b) the mechanism (mediation) by which social learning affects drug use. This research employs rich data on drug use drawn from the Smoking Drinking Drug Use Survey 2016, a cross-sectional survey of adolescents aged 11-15 years across England (as of October 2021 the data for the most recent survey 2018 was not available for analysis). Mediation analysis was used to evaluate which social learning factors mediate the association between age, gender, region and drug use. The results showed that there were differences in learning behaviours that were specific to age, gender and region. For example, the most significant social learning behaviour for drug use among boys was “imitation of friends”, whilst for females, it was “peer association” among females (i.e. having a perception that peers are using drugs). In addition, having “positive attitudes to glue” (i.e. “it is ok to try glue”) was the strongest learning behaviour for drug use among younger individuals (i.

We provide novel evidence on the effects of ill-health on the dynamics of labour state transitions by considering retirement as mobility between full-time work, part-time work, self-employment and inactivity. We employ a dynamic multi-state model which accounts for state dependence and different types of unobservables. Our model allows for both individual heterogeneity and labour-state gravity as well as correlations between labour market states. We estimate this model on rich longitudinal data from the Household, Income and Labour Dynamics in Australia Survey. We find that both ill-health and health shocks greatly increase the probability of leaving full-time employment and moving into inactivity. Simulated dynamic trajectories suggest larger impacts of long-term health conditions than those of a one-off health shock and some evidence of health-driven retirement pathways via part-time work and self-employment. Our findings also indicate that the effects of health changes could be underestimated and the magnitude of true labour market state dependence overestimated if individual effects or labour dynamic transitions are not accounted for in the model.

Background: Cardiovascular diseases are responsible for a large proportion of deaths globally and disproportionately affects developing countries. Diabetes and hypertension are major contributors to the burden of cardiovascular diseases worldwide (WHO, 2017; IDF, 2017; WHO, 2013). In Jamaica, the prevalence of diabetes and hypertension was estimated at 12% and 22% respectively, and has been attributed to an ageing population, increased prevalence of obesity, sedentary living and unhealthy diet (MOHW, 2018; WHO, 2018; WHO Global Data Repository). Access and the appropriate use of essential chronic disease medicines is an effective public health strategy against the morbidity and mortality associated with diabetes and hypertension. The consequences of inappropriate drug therapy are poor health outcomes and increased health care costs to individuals and society. The National Health Fund (NHF), which was implemented in 2003, provides financial assistance for medicines to Jamaicans with one or more of 16 specific chronic diseases, including diabetes and hypertension. This benefit is available to all Jamaicans regardless of age, sex or socio-economic status. To be eligible, individuals are required to have their physician sign an enrollment application confirming their diagnosis (es). Although medicines can be accessed with no fee at point of service at public pharmacies, over 80% of the pharmacies in Jamaica are privately run and may be a more convenient and accessible option for many patients (PAHO, 2012). NHF enrollees have the option of accessing their medicines at a subsidized cost through this network of private pharmacies. Affordability of medicines was highlighted as a barrier to accessing chronic disease medicines, with approximately 25% of Jamaicans reporting not taking medicines due to unaffordability (PAHO, 2012). This study included a literature review, which highlighted multiple barriers to accessing medicines in developing countries. The extent, to which th

Introduction Ghana is undergoing rapid epidemiological and demographic transitions. The proportion of the population aged 60 years and older is projected to reach 12.6% in 2050 from 5.4% in 2010 while the urban population increased from 23.3% in 1960 to 50.9% in 2010. These developments have contributed to a changing disease profile with an increasing burden of chronic noncommunicable diseases (NCDs). The share of total deaths in all ages due to cardiovascular diseases almost doubled from 10.8% in 1990 to 18.2% in 2017. Although hypertension is a major risk factor for cardiovascular diseases, its determinants have not been adequately explored in adults aged 50 years and older in Ghana. ObjectivesThe study sought to assess the prevalence of hypertension, its severity and its determinants of hypertension in community-dwelling older adults at and over two time points. It also estimated the level of awareness, treatment experience and blood pressure (BP) control among people with hypertension as well as the clustering of risk factors among the study participants. MethodsThe study involved two components. One component estimated the prevalence of hypertension in older adults in Ghana within the framework of a systematic review and meta-analysis of community-based studies on the prevalence of hypertension in older adults in Africa published between 1980 and May 2018. The review involved the use of appropriate search terms in major databases to maximise yield. The pooled prevalence was estimated using a random effects model. Measures to assess the quality of the results included independent assessment of the risk of bias in the included studies, sensitivity analysis involving the exclusion of one study at a time to assess its effect on the pooled prevalence and the assessment of the presence of reporting bias. The other component involved the analysis of publicly available datasets of two waves of a nationally representative Study on global AGEing and adult health (SAGE) i

Although uncontrolled diabetes (UD) or poor glycaemic control is awidespread condition with potentially life‐threatening consequences, there issparse evidence of its effects on health care utilisation. We jointly model thepropensities to consume health care and UD by employing an innovativebivariate latent Markov model that allows for dynamic unobserved heterogene-ity, movements between latent states and the endogeneity of UD. We estimatethe effects of UD on primary and secondary health care consumption using apanel dataset of rich administrative records from Spain and measure UD usinga biomarker. We find that, conditional on time‐varying unobservables,UD does not have a statistically significant direct effect on health care use.Furthermore, individuals appear to move across latent classes and increasetheir propensities to poor glycaemic control and health care use over time.Our results suggest that by ignoring time‐varying unobserved heterogeneityand the endogeneity of UD, the effects of UD on health care utilisation mightbe overestimated and this could lead to biased findings. Our approach revealsheterogeneity in behaviour beyond standard groupings of frequent versusinfrequent users of health care services. We argue that this dynamic latentMarkov approach could be used more widely to model the determinants ofhealth care use.

Background Hypertension is the leading driver of cardiovascular disease deaths in Africa. Its prevalence is highest in older populations. Yet, this group has received little attention in many African countries. We conducted a systematic review and meta-analysis (PROSPERO registration: CRD42017056474) to estimate the prevalence of hypertension in older adults living in Africa. Methods We searched grey literature and major electronic databases including PubMed and Embase for population-based studies and published between 1 January 1980 to 28 May 2018 reporting the prevalence of hypertension for adults aged ≥50 years living in Africa. We employed a random effects model to estimate the pooled prevalence across included studies. Findings We screened 10,719 articles and retrieved 103 full-text articles to evaluate for inclusion in the review. Thirty-four unique studies providing 37 data points on 43,025 individuals in 15 African countries were analyzed. The prevalence of hypertension ranged from 22.3% to 90.0% from the individual studies while the overall pooled prevalence was 57.0% (95% CI 52%-61%). The prevalence was not statistically significantly different by sex, residence, or African sub-region. In individual studies, older age and overweight/obesity were independently associated with hypertension. Twenty-nine (78%) data points were deemed to be of low- or moderate-risk of bias. Eliminating high-risk bias studies made little difference to the pooled estimate of hypertension. Sensitivity analyses, omitting one study at a time, identified three studies with significant but relatively small impact on the pooled estimate. We observed substantial heterogeneity (I2 = 98.9%) across the studies which was further explored by meta-regression analyses. Overall, the GRADE assessment suggested moderate quality evidence in the results. Conclusion The persistent high prevalence of hypertension among older adults in Africa, even in rural populations warrants more attention to the c

We propose a dynamic panel data approach to estimate a model that integrates the Becker-Murphy theory of rational addiction with the Grossman model of health investment. We define an individual’s lifetime smoking consumption and investments in health capital as simultaneous choices within a single optimisation problem. We show that this can be estimated using GMM system estimation of two stand-alone single fourth-order difference equations of health capital and smoking. These preserve roots and fundamental dynamics of the original system of four interrelated first-order equations. Monte Carlo simulations confirm that this reduced-form dynamic estimation also produces very similar estimates to the ones of the initial system of equations. We argue that, in the presence of long panel data, this approach may provide a feasible alternative for the estimation of a complex life-cycle model of human capital.

Although uncontrolled diabetes (UD) or poor glycaemic control is awidespread condition with potentially life‐threatening consequences, there issparse evidence of its effects on health care utilisation. We jointly model thepropensities to consume health care and UD by employing an innovativebivariate latent Markov model that allows for dynamic unobserved heterogene-ity, movements between latent states and the endogeneity of UD. We estimatethe effects of UD on primary and secondary health care consumption using apanel dataset of rich administrative records from Spain and measure UD usinga biomarker. We find that, conditional on time‐varying unobservables,UD does not have a statistically significant direct effect on health care use.Furthermore, individuals appear to move across latent classes and increasetheir propensities to poor glycaemic control and health care use over time.Our results suggest that by ignoring time‐varying unobserved heterogeneityand the endogeneity of UD, the effects of UD on health care utilisation mightbe overestimated and this could lead to biased findings. Our approach revealsheterogeneity in behaviour beyond standard groupings of frequent versusinfrequent users of health care services. We argue that this dynamic latentMarkov approach could be used more widely to model the determinants ofhealth care use.

Background Hypertension is the leading driver of cardiovascular disease deaths in Africa. Its prevalence is highest in older populations. Yet, this group has received little attention in many African countries. We conducted a systematic review and meta-analysis (PROSPERO registration: CRD42017056474) to estimate the prevalence of hypertension in older adults living in Africa. Methods We searched grey literature and major electronic databases including PubMed and Embase for population-based studies and published between 1 January 1980 to 28 May 2018 reporting the prevalence of hypertension for adults aged ≥50 years living in Africa. We employed a random effects model to estimate the pooled prevalence across included studies. Findings We screened 10,719 articles and retrieved 103 full-text articles to evaluate for inclusion in the review. Thirty-four unique studies providing 37 data points on 43,025 individuals in 15 African countries were analyzed. The prevalence of hypertension ranged from 22.3% to 90.0% from the individual studies while the overall pooled prevalence was 57.0% (95% CI 52%-61%). The prevalence was not statistically significantly different by sex, residence, or African sub-region. In individual studies, older age and overweight/obesity were independently associated with hypertension. Twenty-nine (78%) data points were deemed to be of low- or moderate-risk of bias. Eliminating high-risk bias studies made little difference to the pooled estimate of hypertension. Sensitivity analyses, omitting one study at a time, identified three studies with significant but relatively small impact on the pooled estimate. We observed substantial heterogeneity (I2 = 98.9%) across the studies which was further explored by meta-regression analyses. Overall, the GRADE assessment suggested moderate quality evidence in the results. Conclusion The persistent high prevalence of hypertension among older adults in Africa, even in rural populations warrants more attention to the c

This thesis is concerned with the role of formal schooling in the production of human capital over the lifecycle. While many studies have documented an associated between education and cognitive outcomes, less is known about the extent this association is causal---or the nature of the underlying mechanisms driving any effect. Chapter 1 examines the causal effect of additional secondary schooling on cognitive function in later life, using new methods in causal mediation analysis to explore the role of occupation choice as a key channel. The findings reveal robust evidence that basic education leads to improved working memory, but detect little support for effects on verbal fluency or numeric abilities. Staying in school for an additional year increases the probability of entering a higher status occupation, and an analysis of mechanisms finds that up to about one-fifth of schooling's effect on cognitive outcomes can be explained by occupation choice. However, the estimates are too imprecise to yield firm conclusions. Chapters 2 and 3 are situated in the school choice literature. The promise of school choice is to allow parental preference to influence which school their child attends, weakening the link between residential location and school quality. However, choice is typically constrained---and markets for schools are no exception. Popular schools tend to be oversubscribed, and inevitably many families miss out on a place at their preferred school. Chapter 2 traces the consequences of missing out on a place at a preferred secondary school in England, focusing on long run outcomes, including high-stakes examination results. The analyses do not find evidence that failing to gain a place at a preferred school leads to poorer academic outcomes---but those who miss out are more likely to engage in risky behaviours, drop out of secondary school, and have poorer mental health in adulthood. Finally, Chapter 3 assesses the effects of missing out on a place at a preferred p

Recent studies on the effects of anti-smoking policies on subjective well-being present mixed results and do not account for potential externalities, especially among couples. We contribute to the literature by evaluating the impact of smoking bans on well-being externalities among smokers and non-smokers as well as couples of different types of smokers. We exploit the policy experiment provided by the timing of the UK public smoking bans and measure well-being via the GHQ. We employ matching techniques combined with flexible difference-in-differences fixed effects panel data models on data from the British Household Panel Survey. The joint use of matching methods with fixed effects specifications allows building more comparable treatment and control groups, producing less model-dependent results and accounting for individual-level unobserved heterogeneity. We find that public smoking bans appear to have a statistically significant short-term positive impact on the well-being of married individuals, especially among women with dependent children. These effects appear to be robust to alternative specifications and placebo tests and are discussed in the light of the economic theory and recent evidence.

Background: Chronic Lower Respiratory Diseases (CLRD), such as asthma, chronic obstructive pulmonary disease (COPD), chronic bronchitis and emphysema are preventable diseases that constitute a serious public health concern. Estimates indicate that there is an increased prevalence of mortality from these diseases worldwide. Low socio-economic positions (SEP) and poor indoor environmental conditions have been identified as risk factors for CLRD among adults. Given the public health burden of CLRD, there is increasing interest among researchers to identify all relevant factors associated with CLRD. However, many studies identified in the literature only controlled for individual or specific risk factors and most of these studies vary in their definition of risk factors. As a result, the evidence was contradictory. Some studies reported statistical associations while other studies reported no statistical association between specific risk factors and CLRD. Furthermore, questions remain on which risk factors mediate the relationships between socio-demographic factors and respiratory health outcomes. Given this, the study will examine if one or more indoor environmental factors and access to healthcare mediates the relationships between socio-demographic factors and CLRD among adult ACBS respondents in the United States (U.S). The study will further examine if the effects of socio-demographic factors on CLRD depend on indoor environmental factors and access to healthcare. Methods: This study examined three different years of secondary cross-sectional data collected from adults 18 years or older by the Behavioral Risk Factor Surveillance Survey (BRFSS) and Asthma Call-Back Survey (ACBS). 15,403 participants from 2009, 17,753 from 2010 and 16,693 from 2011 were included in the study. Bivariate analyses were used to identify significant predictors, and logistic regression models were used to examine mediation and predictor-mediator interaction effects. CLRD was viii the outco

Recent studies on the effects of anti-smoking policies on subjective well-being present mixed results and do not account for potential externalities, especially among couples. We contribute to the literature by evaluating the impact of smoking bans on well-being externalities among smokers and non-smokers as well as couples of different types of smokers. We exploit the policy experiment provided by the timing of the UK public smoking bans and measure well-being via the GHQ. We employ matching techniques combined with flexible difference-in-differences fixed effects panel data models on data from the British Household Panel Survey. The joint use of matching methods with fixed effects specifications allows building more comparable treatment and control groups, producing less model-dependent results and accounting for individual-level unobserved heterogeneity. We find that public smoking bans appear to have a statistically significant short-term positive impact on the well-being of married individuals, especially among women with dependent children. These effects appear to be robust to alternative specifications and placebo tests and are discussed in the light of the economic theory and recent evidence.

BACKGROUND: The health of older persons has not been a major priority in many African countries. Hypertension is one of the common health problems of older persons. However, there is little information on the prevalence of hypertension in older adults in Africa. This is in spite of the fact that Africa has the highest age-standardized prevalence of hypertension in the world. We therefore present this protocol to conduct a systematic review and meta-analysis on the prevalence of hypertension and the level of its awareness among older persons living in Africa. METHODS: Major databases (EMBASE, MEDLINE, Academic Search Complete, CINAHL, PsycINFO) and unpublished literature will be searched to identify population-based studies on hypertension in adults aged 50 years and older living in Africa. Eligible articles are those which use the 140/90-mmHg cutoff to diagnose hypertension and were published from 1980 to present. We will exclude subjects in restricted environments such as patients and refugees. Articles will be independently evaluated by two reviewers to determine if they meet the inclusion criteria. They will also evaluate the quality of included studies using a validated tool by Hoy and colleagues for prevalence studies. The main outcome is the prevalence of hypertension while the explanatory variables include demographic, socio-economic, dietary, lifestyle and behavioural factors. Effect sizes in bivariate and multivariate analyses will be presented as odds or prevalence ratios. We will explore for heterogeneity of the standard errors across the studies, and if appropriate, we will perform a meta-analysis using a random-effects model to present a summary estimate of the prevalence of hypertension in this population. DISCUSSION: The estimates of the prevalence, the risk factors and the level of awareness of hypertension could help in galvanizing efforts at prioritizing the cardiovascular health of older persons in Africa. SYSTEMATIC REVIEW REGISTRATION: PROSPERO

There is sparse evidence on the effects of personality traits on high school dropout, especially on whether combinations of different traits may uniquely influence dropout decisions. We employ single and multiple treatment matching together with rich data on US adolescents to explore the relationship between personality traits and their combinations on school attrition. Using the Big Five inventory, we find that introversion, and to a lesser extent neuroticism, are individually associated with higher probabilities of dropping out from school. Multiple treatment estimates show that blends of low levels of conscientiousness and neuroticism present higher likelihoods of an early exit. Furthermore, we exploit information on forgone health care and explore its role as a predictor of dropout, potentially proxying relevant traits associated with psychological maturity of judgement such as responsibility, perspective and temperance. These traits refer to the capacity of assessing the long-term consequences of actions and may influence an individual’s decision-making process, including dropout choices. Forgone health care appears to be a statistically significant predictor of dropout throughout our models. Individuals who forgo their health care and present low conscientiousness and introversion have the highest risk of dropout. Overall, our results are robust to alternative specifications and increasing levels of selection on unobservables. We suggest that given its predictive power, forgone health care could be used as a signalling device to help identifying individuals at higher risk of school dropout.

Despite size and relevance of uncontrolled diabetes, robust evidence on its effects on health care utilisation is very limited, especially among European countries. We employed longitudinal administrative data from Spain (2004–2010) to explore the relationship between uncontrolled type 2 diabetes and health care utilisation. We used a biomarker (glycated haemoglobin, HbA1c) to detect the presence of uncontrolled diabetes and explore its effects on both primary and secondary health care. We estimated a range of panel count data models, including negative binomials with random effects, dynamic and hurdle specifications to account for unobserved heterogeneity, previous utilisation and selection. We found uncontrolled diabetes in between 27 and 30% of patients of both genders. Our estimates suggested that although women appeared to systematically consume more health care compared to men, their consumption levels did not seem to be influenced by uncontrolled diabetes. Conversely, among men uncontrolled diabetes increased the average number of GP visits per year by between 3 and 3.4%, specialist visits by 5.3–6.1%, depending on specifications, and also extended annual hospital length of stay by 15%. We also found some evidence of heterogeneity in utilisation based on the level of uncontrolled diabetes among male individuals. Overall, our results suggested the need for different diabetes management plans depending on gender and levels of glycaemic control.

BACKGROUND: The health of older persons has not been a major priority in many African countries. Hypertension is one of the common health problems of older persons. However, there is little information on the prevalence of hypertension in older adults in Africa. This is in spite of the fact that Africa has the highest age-standardized prevalence of hypertension in the world. We therefore present this protocol to conduct a systematic review and meta-analysis on the prevalence of hypertension and the level of its awareness among older persons living in Africa. METHODS: Major databases (EMBASE, MEDLINE, Academic Search Complete, CINAHL, PsycINFO) and unpublished literature will be searched to identify population-based studies on hypertension in adults aged 50 years and older living in Africa. Eligible articles are those which use the 140/90-mmHg cutoff to diagnose hypertension and were published from 1980 to present. We will exclude subjects in restricted environments such as patients and refugees. Articles will be independently evaluated by two reviewers to determine if they meet the inclusion criteria. They will also evaluate the quality of included studies using a validated tool by Hoy and colleagues for prevalence studies. The main outcome is the prevalence of hypertension while the explanatory variables include demographic, socio-economic, dietary, lifestyle and behavioural factors. Effect sizes in bivariate and multivariate analyses will be presented as odds or prevalence ratios. We will explore for heterogeneity of the standard errors across the studies, and if appropriate, we will perform a meta-analysis using a random-effects model to present a summary estimate of the prevalence of hypertension in this population. DISCUSSION: The estimates of the prevalence, the risk factors and the level of awareness of hypertension could help in galvanizing efforts at prioritizing the cardiovascular health of older persons in Africa. SYSTEMATIC REVIEW REGISTRATION: PROSPERO

Despite size and relevance of uncontrolled diabetes, robust evidence on its effects on health care utilisation is very limited, especially among European countries. We employed longitudinal administrative data from Spain (2004–2010) to explore the relationship between uncontrolled type 2 diabetes and health care utilisation. We used a biomarker (glycated haemoglobin, HbA1c) to detect the presence of uncontrolled diabetes and explore its effects on both primary and secondary health care. We estimated a range of panel count data models, including negative binomials with random effects, dynamic and hurdle specifications to account for unobserved heterogeneity, previous utilisation and selection. We found uncontrolled diabetes in between 27 and 30% of patients of both genders. Our estimates suggested that although women appeared to systematically consume more health care compared to men, their consumption levels did not seem to be influenced by uncontrolled diabetes. Conversely, among men uncontrolled diabetes increased the average number of GP visits per year by between 3 and 3.4%, specialist visits by 5.3–6.1%, depending on specifications, and also extended annual hospital length of stay by 15%. We also found some evidence of heterogeneity in utilisation based on the level of uncontrolled diabetes among male individuals. Overall, our results suggested the need for different diabetes management plans depending on gender and levels of glycaemic control.

There is sparse evidence on the effects of personality traits on high school dropout, especially on whether combinations of different traits may uniquely influence dropout decisions. We employ single and multiple treatment matching together with rich data on US adolescents to explore the relationship between personality traits and their combinations on school attrition. Using the Big Five inventory, we find that introversion, and to a lesser extent neuroticism, are individually associated with higher probabilities of dropping out from school. Multiple treatment estimates show that blends of low levels of conscientiousness and neuroticism present higher likelihoods of an early exit. Furthermore, we exploit information on forgone health care and explore its role as a predictor of dropout, potentially proxying relevant traits associated with psychological maturity of judgement such as responsibility, perspective and temperance. These traits refer to the capacity of assessing the long-term consequences of actions and may influence an individual’s decision-making process, including dropout choices. Forgone health care appears to be a statistically significant predictor of dropout throughout our models. Individuals who forgo their health care and present low conscientiousness and introversion have the highest risk of dropout. Overall, our results are robust to alternative specifications and increasing levels of selection on unobservables. We suggest that given its predictive power, forgone health care could be used as a signalling device to help identifying individuals at higher risk of school dropout.

Background: Tuberculosis remains an important public health problem especially in sub-Saharan Africa. Nigeria currently ranks 4th among the 22 high Tuberculosis (TB) burden countries with an estimated prevalence of 338/100,000 population. Few studies have utilized spatial data analysis techniques in the understanding of the pattern of distribution and possible correlates of TB especially in Africa. This study examines the spatial distribution of TB and its associated socioeconomic determinants in Nigeria. Methods: The study used an ecological design based on the 774 Local Government Areas (LGAs) in Nigeria as the spatial units. Initial exploratory analysis used measures of spatial autocorrelation (Global and Local Moran’s test statistics). The associations between TB incidence and nine covariates were assessed using a spatial regression analysis in the R statistical package. Result: A total of 100,217 TB cases were notified in 2013. There is significant spatial autocorrelation among case notifications rates (CNR). Spatial regression analysis identifies 138 (17%) of LGAs with high TB risks and finds a significant relationship between household size, urban residence access to transportation, population density, number of TB diagnostic services and TB. An index defining socioeconomic status, living in a single room, TB treatment centres and total health facilities are not significantly associated with TB CNR. Conclusion: The study presents a national picture of TB spatial heterogeneity at the lowest administrative level in Nigeria with the identification of high risk LGAs. This information can assist policy makers to rationally plan targeted specific interventions to effectively control TB while addressing the underlying socioeconomic risk factors in the country.