Institut für Health Care & Public Management

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Baseline assessment and cost analysis of a supplementary feeding intervention on Adivasi children in West Bengal, India : How to diversify diets with locally available resources cost-effectively to reduce the burden of child and maternal undernutrition and anaemia?
(2022) Golembiewski, Silvia; Sousa-Poza, Alfonso
This dissertation presented and analyzed the living, health and nutrition situation of tribal Adivasi children (aged 6-39 months) as well as of their mothers living in rural Birbhum district, West Bengal, India. It was found that extended families use to have higher incomes (p<0.05) compared to nuclear families and that higher education of mothers (having completed at least class eight) is associated with higher incomes, too (p<0.05). Higher incomes were further found associated with a lesser incidence of moderate and severe anaemia amongst children (p<0.05). Further, active child caring was found to decrease the incidence of stunting (p<0.05, for caring efforts of three hours or more per day) - while mothers tied up in cooking (with cooking efforts of 6 and more hours a day) showed to have bigger likelihood of having a wasted or underweight child (p<0.05). It was suggested that the provision of gas cookers along with cooking gas to Adivasi families may be helpful to free mothers to care more actively for their children and reduce therewith child undernutrition. The dissertation further revealed that either father or mother deciding alone how to expense available income is superior to joint spending decisions - and it was in fact HHs with mothers deciding alone which showed the largest share of children with no or merely mild anaemia (p<0.05). It was suggested, accordingly, that mothers may be entrusted to manage a food budget on their own. Very importantly, the nutritional status of children and their mothers was found to be linked, where mothers with adequate BMI (18.5 and higher) had less often than expected a wasted child (p<0.001) and also less often an underweight child (p=0.001). Severe thin mothers (with a BMI<16.0) showed biggest likelihood of having a child with at least one anthropometric failure. No significant association was found between the anaemia status of the mother and her youngest child (p>0.05). Still, non-anaemic mothers showed bigger likelihood of having non-anaemic children than mothers with poorer Hb statuses, and - the other way around - mothers with severe anaemia showed the biggest likelihood of having children with moderate anaemia. It was argued, accordingly, that not only children but also their mothers should be better nourished in order to break the vicious circle of undernutrition - with a focus on lactating mothers who have highest nutritional intake needs. Overall, 94 percent of tribal Adivasi children were found anaemic (n=307, age range: 6-39 months, Hb<11g/dl) as well as 86 percent of their mothers (n=283, Hb<12g/dl). Anaemia in children was found significantly associated with the age of the child (p<0.001) where Hb was found to rise with increasing age and children above three years reached mild forms of anaemia - while children aged 6-23 months commonly suffered from moderate anaemia. Further, the consumption of fruit was found to decrease the incidence of moderate and severe anaemia (p<0.05). There was also a link between child undernutrition and the occurrence of severe anaemia, where children with no anthropometric failure (CIAF indicator) showed lesser likelihood to develop severe anaemia compared to children with at least one anthropometric failure (p<0.05). Seeing the high incidence of anaemia and interlinking to child undernutrition as well as interlinking of nutritional status of children and their mothers - the question arose how to overcome child as well as maternal undernutrition and anaemia? The present comparative intervention study conducted in 21 tribal villages found that providing diversified meals three times a week to children aged 6-39 months rose their mean Hb by 0.98g/dl (compared to 0.45g/dl in the CG); it was found that after 12 months children receiving the diversified meals showed a bigger share of non-anaemic or only mildly anaemic children compared to the CG (p<0.05). Further, children who had received the diversified meals showed bigger likelihood of achieving Hb increases which belong to the top 30 percent of all reported Hb increases (amounting to 1.40g/dl and more) after 12 months of intervention compared to the CG (p<0.01). It was argued, accordingly, that providing nutritious meals to undernourished tribal Adivasi children increases Hb and reduces anaemia. No significant difference in the distribution of non-anaemic and mildly anaemic children versus moderately and severely anaemic children could be found when comparing a group of children who had received a leaf powder of Moringa and Amaranthus along with diversified meals to the CG (p>0.05) and when comparing a group of children who had received a (low dosed) micronutrient sprinkle along with diversified meals (p>0.05). A cost-effectiveness analysis of 425 locally available foods has been conducted in order to work out those foods delivering highest nutrient density in relation to their retail cost (adjusted for edible portion). Foods from the FGs cereals and millets, vegetables, and roots and tubers belonged more often to the top 30 percent of cost-effective foods as per winter-price analysis (p<0.001) - while also grain legumes became cost-effective as per summer-price analysis (p<0.05). While the overall cost-effectiveness of FGs showed little difference considering winter- and summer price analyses, the cost-effectiveness of specific foods within some of the analyzed FGs did actually change (especially in case of vegetables). It was recommended, accordingly, to use most cost-effective locally available foods to nourish undernourished children and mothers adequately - and to consider also seasonal price changes of foods thereby. The developed aggregate cost-effectiveness indicator covered 38 nutrients. Further, five anti-nutritive elements to be limited in the diet of undernourished individuals had been considered: oxalate, phytate, polyphenols, sodium as well as dietary fibre. The need to process foods rich in anti-nutrients in order to cover the RDAs of undernourished children and mothers was highlighted - working out a categorization of anti-nutritive elements in low (≤ 4th percentile), medium (> 4th until ≤ 8th percentile), high (>8th until ≤ 9.5th percentile) or very high (> 9.5th percentile) contents. On the basis of knowing most cost-effective locally available foods and assessing also their anti-nutritive elements, a weekly meal schedule has been worked out in cooperation with the nutritionist Caroline Stiller (who was the second PhD candidate in this twin PhD project and knows the local setting well). It became clear that the RDAs of moderately malnourished children and their mothers can hardly be fully covered with locally available foods alone - where a deficit of 20 and more percent of the RDA remained with regard to vitamins A, E, B1 and B2, as well as of zinc and linoleic acid (children), with regard to vitamins A, E, B1, B2 and B9, as well as of potassium and linoleic acid (lactating women), with regard to vitamins B1, B2 and B9, as well as of iron, potassium and linolenic acid (pregnant women), and with regard to vitamins B1 and B2, as well as of iron, potassium and linolenic acid (non-pregnant and non-lactating women). It was further found that the costs associated with the suggested cost-effective and nutrient-dense weekly meal schedule exceeded available family budgets (calculated based on n=66 HHs and with respect to consumed portion sizes of children and mothers) by 217 percent in case of children (with a weekly cost of 267 Rs. rather than the available 144 Rs.), and by 200 percent in case of lactating, pregnant as well as non-pregnant non-lactating mothers. The role of government services (AWCs, the PDS, and the MGNREGA), kitchen gardening/wild plant collection, own fishing activities and crop diversification in covering this deficit was enumerated and it was found that AWCs are able to cover the largest part of the weekly financing deficit (amounting to 34 percent in case of children), followed by kitchen gardens/wild plant collection (24 percent). As breastfeeding is deeply rooted in the Santal Adivasi communities (96 percent of mothers, n=275, were found to breastfeed their youngest child - with a mean age of 21.2 months), it is proposed in this dissertation that lactating women should be included as beneficiaries of AWCs in order to cover their nutrient needs and break - finally - the circle of undernutrition where children and mothers need to be seen together, rather than focusing merely on children in the well-known 1000-days window of opportunity.
Essays in health economics
(2023) Meng, Fan; Sousa-Poza, Alfonso
As the global economy and healthcare evolve, subjective well-being is increasingly becoming a topic of interest in the field of health economics. In this dissertation, we try to investigate subjective well-being from two related aspects: obesity and marriage. Obesity is a global health crisis that has reached alarming proportions in recent years. Defined as an excessive accumulation of body fat, obesity has far-reaching implications for both individ- ual health and society as a whole. Its prevalence has steadily risen, with over 650 million adults worldwide classified as obese, according to data from the World Health Organization (WHO). This epidemic has led to a surge in obesity-related health problems, including diabetes, cardio- vascular disease, and certain types of cancer, making it a pressing concern for healthcare systems and policymakers. Estimates of the cost of obesity are an important basis for the development and evaluation of obesity-related policies. Previous studies have estimated the direct and indirect costs of obesity, but in addition to these, the intangible costs of obesity are also noteworthy. The intangi- ble costs of obesity are associated with a loss of well-being. In addition, obesity-related inequality may also combine with peer effects to lead to lower well-being in obese individuals. So, ignoring the intangible costs of obesity may lead to underestimating the benefits of obesity control policies. Marriage, without a doubt, is a major event in life. People from almost any socio-cultural back- ground consider marriage-related decisions such as whether to get married, when to get married, and with whom to get married. But nowadays, in increasingly countries around the world, mar- riage rates continue to decline and the age of first marriage continues to be delayed, so we sought to analyze whether these trends are related to marriage-related well-being. The contributions of each chapter are shown below: Chapter 2 uses SOEP 2002-2018 data and a life satisfaction-based compensation approach to quantify the intangible costs of overweight and obesity. Previous literature documents the direct and indirect economic costs of obesity, yet none has attempted to quantify the intangible costs of obesity. This study focuses on quantifying the intangible costs of one unit body mass index (BMI) increase and being overweight and obese in Germany. Our results underscore how existing research into obesity’s economic toll may underestimate its true costs, and they strongly imply that if obesity interventions took the intangible costs of obesity into account, the economic benefits would be considerably larger. Chapter 3 uses data from the German Socio-Economic Panel (GSOEP), investigates the changes in the BMI distribution and obesity inequality among German adults aged 18+ between 2002-2018 and estimates the relationship between obesity inequality and subjective well-being. The results show that the rise in obesity prevalence is mainly due to an overall rightward shift of the BMI distribution, accompanied by an increase in left skewness. Over the entire 16-year period, obe- sity inequality increased significantly, especially among females, those with low education levels, and low-income groups. The results also document a significant association between different measures of obesity inequality and subjective well-being, especially among women. Chapter 4 explores the trends in the subjective well-being (SWB) of never-married people (referenced with the married) and the factors that account for the gaps in SWB between never- married and married people. By employing a harmonized data from surveys conducted in six distinct countries, namely Australia (HILDA), South Korea (KLIPS), Russia (RLMS), Switzerland (SHP), Germany (SOEP), and the United Kingdom (BHPS and UKHLS), our analysis discerns a consistent and statistically significant association between never-married status and lower levels of life satisfaction, a relationship that has exhibited no substantial alteration over time. Particularly noteworthy is the discernible reduction in life satisfaction among never-married individuals in South Korea in comparison to their married counterparts. The thesis concludes with a short summary in chapter five.
Essays on health and nutrition in China
(2015) Nie, Peng; Sousa-Poza, Alfonso
This dissertation aims to investigate several major socio-economic determinants of health and nutrition in China. By using data from the China Health and Nutrition Survey (CHNS) spanning from 1991 to 2009, this enhances the understanding of the transition of health and nutrition with such unprecedented economic and social changes in China. This dissertation contains six chapters: more specifically, Chapter 1 gives a brief description of general background, research aim and also the outline. Then Chapter 2 examines the association between maternal employment and childhood obesity. Chapter 3 takes a comprehensive look at how income changes are related to calorie intake. Chapter 4 investigates the impacts of peers (one of most important aspects of social networks) on childhood and adolescent adiposity. Chapter 5 assesses the nexus between long work hours and health. Finally, Chapter 6 ends with some main conclusions and discussions. Chapter 2 analyses the alarming increase of overweight and obese children and considers the higher female employment participation in China. We analyze how maternal employment is correlated with childhood obesity in China. Our work makes a non-Western comparison in this field, which is useful as it is rather difficult to generalize the results (mostly significant positive association between maternal employment and childhood obesity) from related studies in the Western world. More importantly, we further explore how maternal employment is related to two key transmitters of obesity: diet and physical activities. We find no association of maternal employment and childhood adiposity. Moreover, maternal employment is also not associated with either diet or physical activity of children. However, our results are well consistent with some recent evidence in Europe (Greve, 2011; Gwozdz et al., 2013), supporting the evidence that maternal employment might not necessarily be detrimental to child adiposity. One tentative explanation is that, the major source of informal childcare in China is grandparents, who are more likely to provide childcare with a high quality. In Chapter 3, we provide an empirical analysis that looks at the association between income and calorie intake via a variety of parametric, nonparametric and semiparametric approaches. By means of panel data settings, we are capable of capturing time-invariant individual heterogeneity. It is worth noting that taking a close look at calorie-income elasticities is crucial and implicative of the effectiveness of income-mediated policies for food security in China. Our findings provide strong evidence that calorie-income elasticities are small, irrespective of using parametric, nonparametric, or semiparametric techniques. Furthermore, these elasticities remain small when taking nonlinearities into consideration, and also for sub-analysis for gender, individuals with differences in calorie intake or even impoverished households. Although calorie-income are small, our results are well in line with some prior studies (Bishop et al., 2010; Lu and Luhrmann, 2012; Shankar, 2010; Zhong et al., 2012), suggesting that households might be quite successful in maintaining calorie intake stable as income changes. Also note, despite the marked increase in income, the Chinese demand for better food quality, food diversity and food safety have amplified (Gale and Huang, 2007; Liu et al., 2013b), instead of an increased demand for calorie intakes. Chapter 4 takes a detailed look at how peer effects are associated with childhood and adolescent obesity in China. It expands the empirical work beyond the Western domain in light of different cultural backgrounds between individualistic and collective societies. Furthermore, it broadens the dominant front of adolescents and adults by analyzing children as well. Note that, understanding peer effects on childhood adiposity is of great significance primarily because, as emphasized by Dishion and Tipsord (2011), children’s consumption behaviors are influenced by their peers. More importantly, childhood adiposity could result in persistent adulthood overweight or obesity (Loh and Li, 2013). In addition, the use of self-perceived perceptions of body weight allows for an exploration of the relation between peer effects and individual perceptions of weight status, thereby providing insights into understanding pathways by which peer effects operate within a relatively broader environment. We provide further evidence that peer effects exist not only among adolescents, but also children, suggesting that the formation of health lifestyles associated with peers is important for young children. In addition, we find that the magnitudes of peer effects change greatly over the distribution of individual BMI and stronger effects are observable at the upper end than at the bottom or median. This finding implies that obese individuals are more vulnerable to peers. Furthermore, females are more susceptible compared to males, which mirrors some U.S studies among adolescents (see, for instance, Trogdon et al., 2008). More importantly, we find that community-level average peer BMI is associated with self-perceived bodyweight in adolescents, providing evidence that a higher average peer BMI is related to the probability of a self-assessed perception of overweigh, in particular, for adolescent girls. All in all, our results support the existence of peer effects on childhood and adolescent obesity, but the magnitudes fall within the broader range for the U.S. adolescent studies using similar specification to ours. Therefore, it implies that peer effects do not necessarily strengthen within a collectivistic society, like China, as in comparison to the counterparts of an individualistic society, like the U.S. In Chapter 5, we provide a comprehensive picture of how long work hours are related to health, using not only subjective but also objective measures. Also, it provides a valuable comparison with existing studies predominantly in the Western world. More importantly, it explores several potential mechanisms through which long work hours could impact upon one’s health. In particular, it investigates the relation between long work hours and specific lifestyles, such as sleep, diet (calorie and fat intakes, time spent food preparation and cooking), physical activities (sports participation and time spent on sedentary activities). Apart from a cross-sectional settings, it also adopts a panel analysis, which allows for controlling for unobserved individual heterogeneity. Because, to the best of our knowledge, the only three studies in China (Fritjers et al., 2009; Verité, 2004; Zhao, 2008) all investigate subjective measures of health via cross-sectional data. We reveal that working above 50 hours per week (31-40 hours per week as the comparison), increases the probability of suffering from high blood pressure, though the effects are relatively small. Also, self-evaluated health is poorer for individuals working long hours compared with those weekly working 31-40 hours, however the effect is not so strong. Eventually, long work hours have various impacts of different aspects of individual lifestyles. Specifically, we cannot find a positive correlation between long work hours and obesity. Nevertheless, long work hours seem to be related to a decreased fat intake and less time spent on sedentary activity like watching TV. But, long work hours decrease the probability of sports participation. In summary, we provide limited evidence that long work hours in China have deleterious influences on health or lifestyles. Therefore, further research needs to explore the potential impacts of long work hours on other health or lifestyle measures. References Bishop, J.A. Liu, H.Y. & Zheng, B.H. 2010. Rising incomes and nutritional inequality in China. . In: BISHOP, J. A. (ed.) Studies in Applied Welfare Analysis: Papers from the Third ECINEQ Meeting. Bingley: Emerald Group Publishing. Dishion, T.J. & Tipsord, J.M. 2011. Peer contagion in child and adolescent social and emotional development. Annual Review of Psychology, 62, 189-214. Fritjers, P. Johnston, D.W. & Meng, X. 2009. The mental health cost of long working hours: the case of rural Chinese migrants. Mimeo. Greve, J. 2011. New results on the effect of maternal work hours on childrens overweight status: does the quality of child care matter? Labour Economics, 18(5), 579-590. Gwozdz, W. Sousa-Poza, A. Reisch, L.A. Ahrens, W. Henauw, S.D. Eiben, G. Fernandéz-Alvira, J.M. Hadjigeorgiou, C. De Henauw, S. Kovács, E. Lauria, F. Veidebaum, T. Williams, G. & Bammann, K. 2013. Maternal employment and childhood obesity - a European perspective. Journal of Health Economics, 32(4), 728-742. Gale, F. & Huang, K.S. 2007. Demand for food quantity and quality in China, Economic Research Report. No.32. Washington D.C. : US Department of Agriculture. Lu, L. & Luhrmann, M. 2012. The impact of Chinese income growth on nutritional outcomes. Available from Liu, R.D. Pieniak, Z. & Verbeke, W. 2013b. Consumers attitude and behaviour towards safe food in China: a review. Food Control, 33(1), 93-104. Loh, C.P. & Li, Q. 2013. Peer effects in adolescent bodyweight: evidence from rural China. Social Science & Medicine, 86, 35-44. Shankar, B. 2010. Socio-economic drivers of overnutrition in China. Journal of Human Nutrition and Dietetics, 23(5), 471-479. Trogdon, J.G. Nonnemaker, J. & Pais, J. 2008. Peer effects in adolescent overweight. Journal of Health Economics, 27(5), 1388-99. Verité 2004. Excessive overtime in Chinese supplier factories: causes, impacts and recommendations for action. Verité Research Paper, Amherst, Massachusetts. Zhong, F.N. Xiang, J. & Zhu, J. 2012. Impact of demographic dynamics on food consumption: a case study of energy intake in China. China Economic Review, 23(4), 1011-1019. Zhao, Z. 2008. Health demand and health determinants in China. Journal of Chinese Economic and Business Studies, 6(1), 77-98.
Food insecurity among older Europeans : evidence from the survey of health, ageing, and retirement in Europe
(2016) Sousa-Poza, Alfonso; Nie, Peng
Using data from the fifth wave of the Survey of Health, Ageing and Retirement in Europe, this study investigates the association between food insecurity (FI) and several demographic, socioeconomic, and health-related characteristics in a sample of European residents aged 50 and over. Our initial analysis reveals that in 2013, the proportions of 50+ individuals reporting an inability to afford meat/fish/poultry or fruit/vegetables more than 3 times per week were 11.1% and 12.6%, respectively. It also indicates that not only income but also functional impairment and chronic disease are significantly associated with an increased probability of food insecurity. In a subsequent nonlinear decompositional analysis of the food unaffordability gap between European countries with high versus low FI prevalence, our rich set of covariates explains 36–39% of intercountry differences, with household income, being employed, and having functional impairment and/or chronic disease as the most important contributors.
It is not about spinach : a food justice perspective on urban agriculture in Cape Town and Maputo
(2021) Paganini, Nicole Maria; Sousa-Poza, Alfonso
The world’s rapid urbanisation has presented multiple challenges to societies and the environment and strained the sustainability and equity of urban food systems. In discussions on the future of the world’s cities and their food security, urban agriculture has gained attention for its potential to contribute to food supply and dietary diversity, generate income for urban producers, and provide various multifunctional benefits such as environmental services, education, and community building. The dissertation followed a conceptual approach that applies a food systems perspective on urban agriculture and uses urban agriculture as a means to identify food justice patterns. In addition, this thesis contributes to participatory action research methodology by shifting focus to the concept of democratisation processes in research. Co-research is a more radical and inclusive form of participatory action research that involves actors and groups from marginalised communities in all research steps. Communities are involved in the study design, problem posing, decision-making around methodology, data collection, analysis and triangulation, and scaling of activities. This process fosters ownership of the gathered results through mutual and transformative learning, and hence, could become more valuable than the results themselves. The food system in Cape Town is highly segregated, as is the city itself: the legacy of apartheid-era planning left an affluent and prosperous city centre surrounded by lower-income areas populated largely by People of Colour who face daily challenges in accessing food. Urban agriculture is practised in the townships of Cape Town by hundreds of farmers—most of them People of Colour, unemployed, elderly, female home growers—and thousands of backyard growers who cultivate a variety of vegetables mostly on small plots. The food gardens are either on public or private land: land is leased for short periods from public institutions such as schools or clinics or leased from municipalities, which is a lengthy and—for many farmers—opaque process. NGOs, with support from the Municipality, introduced urban agriculture as a poverty alleviation strategy to combat high rates of food security in the marginalised parts of the city. Decades of support have hampered the establishment of community-driven food solutions and led to dependencies on NGOs for inputs, marketing, and acquisition of new knowledge. These farming activities play an insignificant role when it comes to household contribution. Food is produced in highly confined and troubled spaces in informal settlements, almost exclusively for a niche market of middle/upper class consumers in the wealthier city centre. Maputo’s food system is strongly influenced by food imports from neighbouring South Africa, by its rapid growth, and by migration from the rural areas of the country where selfsustaining family farming is a primary livelihood strategy. In the urban and peri-urban area of Mozambique’s capital, the zonas verdes (green zones) were established to combat the city’s severe food insecurity crisis after the colonial era. These horticultural production sites have remained vibrant production areas. Urban agriculture is largely commercialised and plays a key role supplying the city with specific horticultural products, mainly cabbage and lettuce. Informal traders buy crops directly from the fields and sell them in Maputo’s local markets and street stands. Four of five farming families indicate that the income they generate in this activity is their main source of revenue. Another estimated 40,000 people earn their livings by supporting urban agriculture through activities such as trading, selling, pesticide application, and transportation. Like Cape Town, it is mainly women who are involved in urban agriculture in Maputo’s fields. Understanding urban agriculture through a food systems lens was crucial in examining the potentials and challenges of urban agriculture. Applying a co-research approach in Cape Town allowed investigations that fostered participating farmers’ agency over the findings and led to the creation of a strong network that carried the research beyond the scope of this project. The mutual contextualisation of the results gathered in an inclusive research process into food justice theory revealed farmers’ in-depth understanding of structural inequalities within food systems in cities. Food justice theory is mainly applied in case studies in the North and looks at historical context and trauma, systemic challenges, and marginalisation in ethnicity, class, place, time, and gender. These research findings from two case studies in the South add to our understanding of marginalisation in urban agriculture in Cape Town and Maputo and shed light on the importance of intersectionality as a contextual component of food justice.
Mulitdimensionale Informationen im Kontext wertorientierte Unternehmensführung von Versicherern
(2017) Trautinger, Max-Josef; Schiller, Jörg
The cumulative dissertation analyzes how multi-dimensional information influences customer behavior and how insurers can use that information efficiently as a key factor in customer interaction. Information per se is multilayered and can be multidimensional. Multidimensional information in this context is understood as known or generally available information about customers, which should help in the interaction between the insurer and the customer to fulfill the customer expectations. As an additional research question, this dissertation analyzes how insurers can use the information economically profitably and generate added value. Provided that information can be used effectively value orientation can be generated. For example, having data in a pure form does not add value to insurers. If this information can at least be used to satisfy customer expectations, it can be assumed that customers want to use offered services and are disposed to a higher willingness to pay. In three analyzes this question is taken up separately and discussed. Analysis 1: In a competitive insurance market, claims settlement is a central task of insurers. Customers indicate after an event of loss specific expectations and further the adept service is of customers point of view a ‘moment of truth’. Insurers may align their claims settlement and optimise it. This paper analyse which determinants influence the customer satisfaction. The hypotheses were shown in a model and discussed by the author. Also, the hypotheses evaluated on the basis of empirical data which is derived from a set of interviews by a german insurer. The results of the analysis show variables which can be influenced in order to improve the customer satisfaction. Analysis 2: Customer behavior is managed by customer satisfaction in two dimensions: Insurer can profit by a higher customer loyalty und in addition, by a sensitive price behavior of customers. The findings of moderating effects are mean considered and thus, customer satisfaction is a too strong indicator of economic success in established concepts. To manage an insurance company effective, it is a good advice to implement a model that is specific for each company. This model should respect the heterogeneous factors of influence due to customer satisfaction by multidimensional instruments. Hence, insurer may identify drivers of service and work with analysis of correlations to describe the coherence between customer satisfaction and economic success exactly. The alignment for customer satisfaction is worth for traditional insurance companies, but only, if customer satisfaction is understood as an economic valued management that is culturally based in the firm. Manager should account for this suggestion to follow a sustainable story in a saturated competitive environment. Analysis 3: In this analysis we analyze in a project selection effects in the German market for private complementary long-term care insurance contracts (CompLTCI) within a static and dynamic framework. Using data on more than 98,000 individuals from a German insurance company, we provide evidence that advantageous selection is dominating in this market, with respect to both the decision to buy a CompLTCI policy and the decision about the extent of CompLTCI coverage. We identify occupational status, residential location and the holding of further supplementary health insurance policies as unused observables contributing to selection effects in this market. Our results suggest that non-linearities in the relationship of potential sources of selection to insurance coverage and risk should be considered. A panel data analysis shows that an increase in health insurance payouts is positively correlated with the uptake of CompLTCI, while a decrease in those costs is positively associated with the lapse of CompLTCI. In addition, we find that people in financial distress and of lower socioeconomic status are more likely to let their CompLTCI policies lapse.
Older adults’ internet use, outdoor activity, and the urban environment : empirical analysis
(2021) Schehl, Barbara; Kirn, Stefan
In an ageing society, information technology (IT) can be a powerful tool to support older adults in staying physically, mentally, and socially active. A growing number of studies show positive effects of Internet use on active ageing. Specifically, understanding the relationship between older adults’ Internet use and their participation in outdoor activity has gained attention. However, little is known about the role of specific online activities, as previous research mainly considered general Internet use, e.g., writing emails and browsing the Web, which does not provide a rationale for increased outdoor activity. Another important factor affecting outdoor activity is the urban environment in which older adults live, especially as the environment can either motivate or hinder participation in outdoor activity. Against this backdrop, the aim of this thesis is to get a better understanding of the association between Internet use, the urban environment, and participation in outdoor activity. By adopting an ecological perspective, this dissertation is first in comprehensively assessing this association. Three studies provide empirical insights into patterns of factors and contribute an enhanced understanding of the association between older adults’ Internet use, the urban environment, and outdoor activity. In summary, this thesis contributes to a relevant growth of knowledge on older adults’ Internet use and outdoor activity. The approach in this thesis uncovered important differences in the roles of individual factors as well as environmental factors in explaining older adults’ outdoor activity. Based on this contributions, important implications for research can be identified. For instance, future research can use the conceptual framework as a basis to investigate further types of outdoor activities and further types of online activities, such as social networks and messaging services which attain increasing relevance for the group of older adults. Further, this dissertation also has some practical implications, for example, as all three studies showed that socio-demographic predictors play important different roles, the findings are specifically relevant to identify specific groups of older adults. For instance, developers and providers can tailor their services to the needs of older adults, e.g., by designing responsive and barrier-free interfaces that adapt to individual capabilities in cognition, vision, and motor function. Concluding, older adults should be encouraged to go online because the Internet increasingly provides information about opportunities and offerings in the city. The findings of this dissertation provide a rationale for the development of online services that offer neighborhood information and ultimately support older adults to be active outdoors.
Smarte Städtebauliche Objekte für eine adaptive Stadt : ein Verfahren der Künstlichen Intelligenz zur Erhöhung der Wohlfahrt
(2021) Hubl, Marvin; Kirn, Stefan
The objective of the thesis is the advancement of urban areas with intelligent information technology to enhance urban life. In doing so, social inclusion of people with motor impairments is of particular interest. At this, an important group is the set of older adults. The aspired advancement aims at enabling self-determined participation in urban life, and hence in social life, up until old age: Participation in social life essentially depends on the opportunities for self-determined exertion of outdoor activities. Motor impairments in old age lead to a perceived significant reduction of safety in urban areas and hence concerned people are worried of using the urban area. To counteract the resulting avoidance of outdoor activities the thesis pursues the approach to transform urban objects by means of technologies of the Internet of Things into novel so-called Smart Urban Objects that actively provide support in outdoor activities. Smart Urban Objects are equipped with sensors, actuators and information processing capabilities and can adapt to individual requirements of pedestrians. Due to age-correlated motor impairments, there are for example special requirements for seating. Besides the information technological transformation of single urban objects, there are furthermore important requirements for networked Smart Urban Objects. By means of intelligently coordinated, goal-oriented availability of the supportive functionalities of single Smart Urban Objects, the urban area as overall system is enabled for adaptivity with respect to pedestrians requirements. The thesis studies the conception for an adaptive city with a safety-engineering approach at the example of smart seating and develops a method for an intelligent coordination of the networked Smart Urban Objects. For an accurate allocation of single smart seats as public objects with respect to individual requirements a welfare criterion is applied which shall avoid unfairness. Using methods of Artificial Intelligence the thesis develops a heuristic procedure for finding a solution according to the welfare criterion. This implements aspects of the theory of justice by John Rawls that underlie the welfare criterion for the example of the urban area. A scenario-based simulation substantiates that the developed solution approach can effectively enhance the safety-oriented welfare in the urban area.
The impacts of conflict and climate change on food security and nutrition in Chad
(2023) Bachofer, Robert Paul; Sousa-Poza, Alfonso
This dissertation aims at providing an overview of how armed conflict and climate impact food security and nutrition in the African country of Chad. It analyzes the impacts of the Boko Haram insurgency on food security and nutrition, and those of annually recurrent droughts on households’ coping strategies. Placing the Republic of Chad in the context of the administrative regions of surrounding countries, where Boko Haram and its splinter groups operated at the time of their greatest territorial expansion (Extreme Nord in Cameroon, Lac in Chad, and Diffa in Niger, as well as the Nigerian states of Borno, Yobe, and Adamawa), it covers the timeframe from late 2009 to 2016. On the qualitative side, a systematic literature review on the impacts of Boko Haram on food security and related concepts in the study area, a review of conflict databases and press coverage of Boko Haram’s activities, and semi-structured interviews of Chadian security experts help to locate where and when the insurgency was active, the violence it perpetrated, and the impacts it had. On the quantitative side, the thesis leverages DHS data of 1997 and 2010, MICS data of 2000 and 2015 for childhood malnutrition indicators. The 2011, 2013, 2014, 2015 and 2016 ENSA waves are used for household food security indicators. Across the broader Lake Chad region, Boko Haram activity led to the displacement of food producers, interruption of migration routes of pastoralists, increased exposure to cattle rustling, and transport restrictions affecting food markets. It is also associated with changes in trade routes and border closures leading to price fluctuations, market closure and decrease in market activity, reduction in smallholder farmers’ income, and curbing physical access of consumers to food markets due to the destruction of infrastructure and security concerns. These factors contributed to increases in wasting, stunting, and child mortality rates, decreases in school enrolment and years of schooling, and limitations in access to health care. On the macroeconomic level, agricultural output, GDP, and other development indicators have been affected negatively. However, on the micro level, many studies focus on the insurgency’s impacts on displacement, in the form of refugees and IDPs within specific camps. These populations struggle with their loss of agro-pastoralist livelihoods, and with limited access to land and water to sustain them. Coupled with low employment rates, this results in low income across camps. However, whether this results in lack of food availability and diversity differs significantly from camp to camp, and access to health, education, and other basic service is highly unequally distributed as well. Concerningly, trading food for sex is a practice in at least some camps. Centering in on Chad itself, the thesis exploits the fact that Boko Haram perpetrated only criminal but not political violence between 2010 and 2014. During this period, insurgents plundered and pillaged Chadian villages in the seasonal wetlands of Lake Chad, and committed other criminal acts, but did not engage Chadian security forces for political gains; hence, this setup allows to isolate the impacts that terrorist organizations can achieve through purely criminal violence. Applying a DID approach, the dissertation finds that such criminal violence causes deteriorations in the z-scores of underweight and wasting of children under the age of five years by -0.085 points and -0.305 points, respectively. It finds that the insurgency’s criminal violence causes a decrease of 31.7 percentage points in the participation of households in agricultural activities and a decrease of their dietary diversity by 53.7 points. These impacts are large, especially considering that criminal violence perpetrated by Boko Haram in Chad received little to no international attention. The impacts of seasonal drought on food security, however, are much more measured. Out of five coping strategies assessed, seasonal drought has impacts to a statistically significant degree on only two: The prevalence of households selling non-productive assets and the prevalence of using their savings increases by 7.1 percentage points and 7.6 percentage points, respectively, when drought exposure increases by 1 percentage point on a low administrative level. Estimates of heterogeneous treatment effects and other robustness tests support a causal interpretation of these coefficients, which are obtained through two-way fixed effect estimations. These findings do not mean that drought-affected households do not enact other coping strategies, too. It merely means that seasonal drought likely causes them to use only two very specific coping strategies, but it does not cause the use of others.

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