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Centre for Public Health in Economics and Business

Faculty of Economics and Business

PhD research

An overview of our latest promotion tracks:








Promotion tracks

Michael Fröhlke
Simultaneous cooperation and competition in healthcare. How ‘coopetition’ influences performance in Dutch regional oncology networks
Status: In uitvoering

Healthcare expenses increase continuously on a global scale creating an unsustainable burden for our society. Reducing costs without forfeiting treatment quality has become a major societal challenge. Value-based healthcare aims to increase treatment efficiency by facilitating shared use of resources through cooperation between healthcare providers and simultaneously limiting treatments to procedures that actively contribute to patients’ health outcomes. In Dutch oncological care, hospitals formed regional networks that cooperate to provide high-quality care at reduced costs. At the same time, care providers compete with each other over prices and volumes in their negotiation with health insurers. How this simultaneous cooperation and competition – coopetition – and the resulting tensions affect care quality and costs is not exactly understood. In my research, I assess the challenges and conditions to high-value healthcare provision in Dutch regional oncology networks impacted by coopetition and integrated treatment pathways.

In multiple case studies and social network analyses with data from Dutch oncology networks and the Netherlands Cancer Registry, I study treatment pathways and resources utilization (e.g., capacities, equipment, expertise) with the aim to stimulate more efficient and effective oncological care. Therefore, this research strives to counter the unsustainable cost development of healthcare provision while optimizing oncological networks.

David Olk
Green means go healthy: how transparent and actionable food labeling helps customers make healthier purchases
Status: In progress

Noncommunicable diseases pose a major health risk as they accounted for 71% of deaths worldwide in 2015. Among various environmental, behavioral, and metabolic factors, obesity and overweight were the third-highest cause of disease globally after high blood pressure and smoking. These consumption-related health-risks related to unhealthy food intake are largely influenced by consumers’ choices in the supermarket.

In the supermarket environment, choosing healthy food items is often challenging due to nutritional information that is hard to evaluate, misleading health claims by producers, and an often-overwhelming number of product options and amount of information. To solve these issues, so-called front-of-package labels have been developed. The goal of these labels is to provide consumers a scientifically-based, transparent, and actionable indication of the health of a product. A popular front-of-package label is the Nutri-Score, a colored scale from A (healthiest) to E (unhealthiest) that is printed on the front of a products packaging.

Together with all major retailers active in the Netherlands, this project analyzes the consumers’ reactions to the introductions of front-of-package labels like the Nutri-Score. Furthermore, we research additional tools based on the Nutri-Score to help consumers make healthy choices.

Supervisors: prof. dr. ir. Koert van Ittersum & prof. dr. Tammo H.A. Bijmolt

Shuye Yu
Use of Home-based Work Following a Health Shock
Status: In progress

A health shock, defined as a sudden decline in one's health condition, negatively impacts various labour market outcomes (e.g., employment and working hours). However, little is known about the association between health shocks and job flexibility. Using eight waves of an Australian household panel survey (HILDA) between 2012 and 2019, this paper examines the effect of a recent health shock occurring within the last 12 months on the uptake of home-based work, as one typical form of job flexibility. We adopt a Heckman-type sample selection model with panel data to account for the potential bias resulting from the non-random sample selection into the labour market and the unobserved heterogeneity. The results show that, for both genders, home-based work is used more frequently following a recent health shock, while this effect is more prominent for women. We also find evidence that non-random selection into the labour market leads to underestimating the uptake of home-based work for women. Once correcting the sample selection, we observe that their uptake is 25%-100% more than the uncorrected model results. Our results indicate that home-based work could be a useful tool to mitigate health shocks' adverse effect on labour market outcomes.

Manuela Fritz
Towards cost-effective prevention of non-communicable diseases in Southeast Asia
Status: In progress

Non-communicable diseases (NCDs), such as cancer, diabetes, cardiovascular and chronic respiratory diseases, have overtaken infectious diseases as the number one cause of death worldwide. Three out of four deaths due to NCDs occur in low and middle-income countries, resulting in a double disease burden, as the countries still face high death rates due to infectious diseases. Specifically, in Southeast Asia, the focus of my research, NCDs kill every year more than 8 million people. My research addresses the challenges in preventing NCDs in Southeast Asia and contributes to the literature at the intersection of health and development economics, which has so far not paid sufficient attention to the role of NCDs in low and middle-income countries.

Non-communicable diseases (NCDs), such as cancer, diabetes, cardiovascular and chronic respiratory diseases, have overtaken infectious diseases as the number one cause of death worldwide. Three out of four deaths due to NCDs occur in low and middle-income countries, resulting in a double disease burden, as the countries still face high death rates due to infectious diseases. Specifically, in Southeast Asia, the focus of my research, NCDs kill every year more than 8 million people. My research addresses the challenges in preventing NCDs in Southeast Asia and contributes to the literature at the intersection of health and development economics, which has so far not paid sufficient attention to the role of NCDs in low and middle-income countries.

Embedded in an international and interdisciplinary research project funded by the EU Horizon 2020 Initiative, I will work on three projects. A first project assesses the cost-effectiveness of currently implemented NCD prevention programs in SEA. More specifically, this project addresses the benefits and costs as well as the cost-effectiveness of health interventions that are designed to prevent NCDs in SEA. This will provide evidence about current interventions and how to improve them, which policy makers can use as a decision basis for the resource allocation in their actions to prevent NCDs.

In my second project, I assess the potential health burden for individuals with NCDs under the prospective climate change. Concretely, I assess the short-term impact of periods with extreme temperatures and the variability in temperature on NCD morbidity. To do so, I use data on primary health care visits in Indonesia for the years 2015 and 2016. Assessing health visits below hospital level makes the approach especially innovative, because, until now, the literature focusses exclusively on hospital and emergency visits. The results from this study will provide important information than can help to protect vulnerable groups and to save on health care costs in the context of climate change and the related increasing occurrence of heat waves. More generally, this study can contribute to a better assessment of the social costs of climate change which will be important to inform the Sustainable Development Goal Agenda.

In my third project, I will focus on the demand side of health interventions. The literature shows that individuals forego screening opportunities because of simple procrastination or because they underestimate the associated health benefits. Using a survey experiment in Indonesia, I will test whether disease-related information and encouragement from relatives and religious leaders towards individuals at risk can overcome this hurdle in the context of screening for diabetes.

Rachel Gifford
Through the physician’s lens: A microlevel perspective on the structural adaptation of professional work
Status: In progress

To sustain costs while also improving care quality, scholars and policymakers alike have highlighted the need for the reorganization of care delivery, with increased emphasis on implementing new models of financing and restructuring care delivery processes. However, despite a wide range of scholarship and policy shifts, how best to organize hospital care in order to improve care delivery processes remains an open question. The restructuring of secondary care continues to face many challenges, and many proposed solutions prove difficult to translate from theory to practice, indicating a potential mismatch between the two. With this thesis, I attempt to bridge this divide by offering a micro-level view into the challenges, effects, and complexities of organizing secondary care delivery. Three in-depth case studies were conducted in hospital organizations that recently underwent a structural change. Each study focuses centrally on how to organize hospital based medical specialists and brings forward the often-overlooked perspective of clinicians themselves. The empirical results reveal the relational and cultural barriers that are often overlooked, but play a crucial role in determining the outcome of reform efforts.

Wieteke de Vries
How healthy is your basket? The effect of real-time nutritional feedback on the healthiness of food purchase decisions.
Status: In progress

Obesity is a global health concern with severe negative consequences for personal and societal well-being. In response to the obesity epidemic, the call is growing to develop strategies for improving population-wide consumption by making food environments more conducive to healthy purchases. In particular, grocery stores — the main source of food purchases — hold critical opportunities for improving consumption patterns and personal well-being. Most in-store interventions currently promote healthy within-product category purchases, thereby implicitly and erroneously assuming that a healthy choice triggered by the intervention does not affect subsequent purchases. However, consumers show a tendency to balance (un)healthy choices between-product categories, off-setting the benefits of healthy purchases triggered by within-product category interventions. Therefore, we propose and test interventions for improving the healthiness of the entire shopping basket, which also allows us to better understand the dynamic and complex decision-making environment of grocery stores. In particular, we examine the effects of real-time nutritional feedback on the healthiness of shopping baskets.

Arlinde Vrooman
The effect of colonial rule on health and health care in Ghana and Côte d’Ivoire, 1900-1960
Status: In progress

Despite a clear effect of changes during the colonial period on health suggested by qualitative sources, the literature on the (long-term) effects of colonial rule largely overlooks this relationship. My PhD project aims to enhance our understanding of the effect of colonial rule on health and health care in a specific place and setting: Ghana and Côte d’Ivoire from ca. 1900 to 1960. Using qualitative and quantitative primary sources, new data sets will be built to capture (the results of) regional colonial government investments in health care provision and regional health outcomes during this time period. These data sets will be employed to show and analyze patterns and trends. In addition, they will be paired with data on relevant control variables in a comparative empirical analysis.

Amber Werkman
Waist versus waste: Understanding the interface between health and sustainability in consumer food consumption
Status: In progress

People make more than 200 food-related decisions each day. We are not always fully aware of these decisions and make a lot of them automatically. This seems harmless but two potential negative consequences loom large in the domain of food decisions and purchases: overconsumption and waste. Overconsumption is a fundamental cause of the growing obesity epidemic, which has become one of the biggest health concerns in communities across the world. Worldwide obesity has nearly tripled since 1975. Equally concerning is food waste. One-third of all edible food destined for human consumption is lost or wasted each year within the food supply chain. In developed countries, consumers can be held responsible for up to 65 percent of the waste.

At first glance, overconsumption and food waste are two separate issues that need to be addressed. In fact, they are more related than previously recognized. People waste more food as they try to eat healthier and people start consuming more food in order to reduce waste. Especially when portions are large, people are confronted with a trade-off between consuming or wasting. This research aims to investigate the tension on the interface between health and sustainability in consumer food decision making and food consumption. By combining insights from the portion and unit size effect, we intend to study in more detail how this mechanism works and how we can use it to it to create win-win solutions that reduce both food intake and food waste.

Martine van der Heide
Healthy Shopping Dynamic: the Healthiness of Sequential Grocery Choices
Status: In progress

According to recent forecasts, half of the global adult population will be overweight or obese by 2030. Even subtle nutrition shifts can have a critical impact on weight management. Hence, consistently replacing unhealthy products with healthier product alternatives may be a feasible way to prevent weight gain, and t his starts at the supermarket, where consumers acquire most of their food. However, healthier shopping baskets require consistently healthier choices, whereas literature suggests that shoppers may also balance the healthiness of their choices. For example, consumers may offset the benefits of a healthy choice in one category (e.g., low-fat milk) by an unhealthy choice at the subsequent category (e.g., sugary cornflakes). This PhD research investigates the nature and malleability of such healthy shopping dynamics . In the first project, we demonstrate across a lab study, an online experiment, and actual purchase data from a brick-and-mortar supermarket that a healthier choice is typically followed by an unhealthier subsequent choice and vice versa. Hence, shoppers indeed balance the relative healthiness of their grocery choices. Furthermore, we find that the strength of this effect depends on the nature of the product category and the stage of the shopping trip. In the second project, we investigate the malleability of these healthy shopping dynamics by assessing the impact of various in-store interventions, as interventions aimed at promoting healthier choices within one category may also change the dynamic impact these choices have on subsequent choices. Overall, this research implies that it is crucial for theory and practice to take a dynamic perspective and account for the interdependence between sequential grocery choices—healthier choices may not necessarily lead to healthier shopping baskets.

Elena Agachi
How effective are health programs?
Status: In progress

As a recent development, an increasing number of health promotion organizations start implementing mobile software apps promoting preventive health behaviors, targeted at improving the lifestyle of their participants. The aim of this project is to assess the effectiveness of a mobile software app health program by analyzing the impact of health program engagement on the healthcare consumption of the participants. This project is a collaboration between the University of Groningen and the insurance agency Menzis.

Willem de Boer
The economic relationship between sport and health
Status: In progress

Much research exists on the relationship between exercise and health. By contrast, much less is known about the relationship between sports and health, since sport is often regarded as a specific form of exercise or physical activity. However, sport has several additional characteristics such as competition and the social context of sport clubs. Recently there has been a shift in many European countries to view sport as a means to generate health and social impacts. The research aim of this study is to investigate the (economic) relationship between sport, as opposed to exercise in general, and health. I will investigate the causal effects on health indicators and health care spending of practicing sports and investigate differences with exercise by using and combining several existing quantitative data sources.

Jerry Wang
Early Life Adversities and Well-being Later in Life: Evidence from China
Status: Defended on 22 October 2020

As living conditions and healthcare technologies improve, individual life expectancy increases. The pattern is not only evident in developed countries but also in developing countries such as China. According to the World Population Prospect 2017 report by the United Nations, average life expectancy at birth in China has risen from 69.7 between 1990 and 1995 to 76.5 between 2015 and 2020, and it is projected to rise to 81.1 in the period 2045-2050. Yet, the goals of public health are not only about quantity but also about quality of life. Even though people now live longer, they wish to live in good health and financial well-being.
An expanding body of literature has documented that conditions early in life are important determinants of well-being at older ages. Therefore, if we want to understand how to improve financial, physical and mental health of older individuals, it is crucial to take a life-cycle perspective. In this thesis, I study the early life determinants of well-being at older ages in China.
I mainly focus on two factors that might affect old-age well-being: children’s support and early life adversities. Covered by less generous social insurance plans, poor households in China have to seek alternative support to finance their oldage consumption. One natural solution for parents is to find supports from their children. Children’s economic support for their parents might be further determined by parental human capital investment in children when they were at schooling ages. The second factor is the role of early life adversities. In China, the current cohort of older people might have experienced the Chinese Great Famine and/or the Cultural Revolution, potentially resulting in income losses during life and long-term negative health effects.
The main data is drawn from the China Health and Retirement Longitudinal Study (CHARLS). CHARLS is a nationally representative survey focusing on individuals aged above 45 years old, including data on intergenerational transfers, individual lifetime work histories, and blood-based biomarker information.

Read the paper here .

Edin Smailhodzic
Transformative effects of social media: How patients’ use of social media affects roles and relationships in healthcare
Status: Defended on 18 October 2018

Social media have started changing the way that many industries work. However, there is a lack of understanding of these changes, particularly in the context of healthcare, which is known for high information asymmetry between healthcare providers and patients, and authoritative relationships. Yet, the high proliferation of social media in healthcare enables patients to easily communicate with one another, exchanging informational and emotional support. However, it remains unclear how social media is used by patients, how it affects their behavior, their identities and their relationships with healthcare providers. We conduct a literature review and four empirical studies. First, we conduct a systematic literature review on patients’ use of social media and effects of such use. Second, we explore patients’ use of various categories of social media and propose a taxonomy of interactions enabled by social media in healthcare. Third, we explore how the use of social media by two chronic disease patient communities changes their behaviors and identities as well as their relationships with their healthcare providers. Fourth, we explore how healthcare providers’ interactions with patients who use social media change those providers’ occupational identity. Finally, we test to what extent, and through which mechanism, patients’ use of social media changes their relationships with healthcare providers. Taken together, these findings provide a new explanation of the developing role of social media in changing - and strengthening - organization-customer relationships.

Supervisors: Prof. A. Boonstra and Prof. D.J. Langley

Daniel Gallardo Albarrán
Health, well-being and inequality over the long term
Status: Defended on 4 October 2018

Citizens' lives have greatly improved during the 20th century in terms of income and health, but the uneven pace of improvement has led to substantial cross-country inequality. This thesis is an inquiry into the nature of the forces behind these uneven improvements and how they have impacted citizens' well-being since 1900. Understanding the drivers and consequences of these forces is foundational to understanding how the large income and health inequalities we observe today were shaped.  

The first part of my dissertation explores the idea that citizen’s well-being is a much broader concept than their income. Focusing only on material living standards would have missed how people's lives were transformed in terms of health, leisure and inequality in the first half of the 20th century.   

The second part of this project looks into the determinants of income and health differences over time. With respect to income, I show that – contrary to recent periods – the importance of physical and human capital accumulation has long been as important as total factor productivity in accounting for cross-country income inequality. In addition, considering the effects of health on workers’ productivity is both important for accounting for income inequality since 1900 and a source of income convergence after the mid-20th century. Concerning health, I show that the joint effect of water and sewerage systems explains a significant part of the mortality decline in Germany during the early phase of the epidemiological transition.

Marleen Fluit
Healthy ageing and neighbourhood revitalization in the city of Groningen
Status: In progress

This PhD project is funded by ZonMw and is conducted in cooperation with the municipality of Groningen. The Healthy Ageing district approach developed by the municipality of Groningen consists of six key aspects related to the social and physical environment which include: Active Residentship, Healthy Housing, Accessible Green, Healthy Transfer and Movement, Healthy Food and Active Relaxation.

Selwerd has been selected as a case study in this research as it is one of the pilot districts in which the healthy ageing approach is implemented. One of the objectives of this research is to examine how informal structures within the district can contribute to the accessibility of formal structures in the district such as social care teams and housing associations etc. In addition, this research will analyse how initiatives within the district such as the Wijkbedrijf can have an influence on the social networks between residents in the district and social participation. Finally, this research will look into ways to develop modular arrangements which include multiple interventions aimed at delivering health care in a cost-efficient way, taking into account the heterogeneity in the demands of residents. In this way, the modular arrangements could provide more integrated and personalised care and better access to health services. The implementation of the Healthy Ageing district approach, the development of an informal structure in the district and modular arrangements could lead to more social cohesion, self-efficacy, better health and reducing health inequalities within the city of Groningen.

Supervisors: Prof. dr. H. Broekhuis and Prof. dr. C.T.B. Ahaus

Jan Andre Koch
Disgusting? No, just different. Understanding consumer skepticism towards sustainable food innovations
Status: In progress

The currently unsustainable Western diet is spreading globally, increasing the worldwide need for interventions. Firms and governments continue to find sustainable consumption alternatives that deviate from established foods, for instance, edible insects and lab-meat. These alternatives, however, are rejected by consumers. Current studies argue that consumers’ rejection is due to ‘rational’ skepticism about the alternatives’ functional attributes (e.g., insects look unpalatable, lab-meat is unnatural); hence marketers focus on addressing these attributes.

We argue that the skepticism towards these attributes is merely a result of post-hoc reasoning and not the cause of the rejection. Instead, we argue that consumers’ rejection is fueled by moral disgust elicited by the violation of what consumers perceive to be normal—consumers’ internalized norms. Seeking support for their foregone rejection, consumers cling to seemingly rational but ultimately flawed arguments, criticizing, for instance, functional attributes.

This novel account has important implications for the positioning of sustainable consumption alternatives: well-meant marketing strategies and consumer policies trying to accommodate for post-hoc rationalizations tackle the wrong cause and cannot effectively accelerate the societal uptake of sustainable consumption alternatives. Instead, the consumers' perception that sustainable consumption alternatives are abnormal needs to be changed.

Marit Drijfhout
What A Waste: Effects Of (Un)planned Consumption On Consumer Food Waste
Status: In progress

While globally one billion people are food insecure and nutrient deprived, one-third of all food produced for human consumption ends up being wasted. Consumers are the single biggest producers of food waste in industrialized countries. To reduce food waste, it is critical to gain a fundamental understanding about the underlying behavioral decision-making process. The present research develops a comprehensive framework that explains the mechanisms behind food waste from a consumer behavioral perspective. It considers all stages of consumer behavior—purchase, consumption and disposal. We aim to help consumers, retailers and policy makers to reduce food waste and improve consumer well-being.

In our first project, we uniquely approach food waste as a discrepancy between planned and actual food consumption and propose that the temporal distance forms a critical determinant of consumer food waste behavior. Three field experiments confirm that while consumers make more virtuous choices (i.e., less tasty but healthy food) while planning their future food consumption, their desire to indulge at the moment of consumption entices them to impulsively acquire and consume vice (i.e., tasty but unhealthy) food when they have an opportunity to do so. This impulsive behavior results in a surplus of food, with the vice foods ending up consumed and the virtue foods ending up wasted. Emphasizing the healthiness of food by displaying traffic light labels, to dampen impulsive choices at the moment of consumption with the aim to reduce food waste, is actually counterproductive and increases waste.

In our second project, we will examine whether increasing the convenience of food products decreases waste. Despite its increasing popularity, little is known concerning how convenience products affect disposal behavior and whether providing convenient virtue options can circumvent the substitution of planned virtue options by impulsive vice consumption.

Laura Viluma
Economy, incentives, and health
Status: In progress

In their lives, consumers pursue good health and other objectives, while subject to budget and time constraints. The interactions between objectives pursued and constraints observed result in incentives for specific behaviours which in turn have long-term consequences for health and health care utilization. Traditionally, these interactions are described by quantities demanded at a given price of various goods. In the healthcare market, the quantity of healthcare demanded is largely determined by the health status of the consumer while the price consumers face is usually covered by insurance thus giving space for complex interactions.

My thesis focuses on two aspects of these interactions. First, since the demand for healthcare is largely determined by the health status of individuals, it is important to understand the determinants of good health. The common determinants of health have been widely studied before in medical sciences, epidemiology and health economics; however, a fairly new line of research suggests a relationship between the economic circumstances at birth and health over the life cycle, which we investigate further using data from the Lifelines cohort study.

Second, health insurance, that covers the cost of healthcare, creates incentives for moral hazard and selection. We investigate the moral hazard and selection effects of a voluntary deductible on healthcare utilization in the Dutch health insurance context. Overall, our results contribute to the wider discussion on the optimal insurance design.

Julia Storch
Mixed Feelings, Mixed Baskets: How Shopping Emotions Drive the Healthiness of Shopping Baskets
Status: In progress

The prevalence of obesity has almost tripled since the 80s, negatively influencing the well-being of individuals and society at large. Although healthy diets start with healthy shopping baskets, previous research primarily investigated factors influencing the healthiness of isolated food purchases. Instead, we propose that dependencies exist between the healthiness of shoppers’ sequential choices; the healthiness of a choice influences the subsequent choice. We address this research gap and investigate if emotions shoppers experience while shopping underlie these dependencies. Based on our insights, we develop a real-time health intervention to assist policy makers, retailers, and consumers in curbing the obesity epidemic.

Beatriz Rodriguez Sanchez
The economic approach to diabetes among older adults
Status: Defended on 9 July 2018

Given the projected increase in the costs associated with the management of people with diabetes due to the ageing of the population and the higher costs per capita among older adults, this thesis aims to contribute to the existing literature by bringing a new and broader insight on the diabetes burden among older populations. I examine the traditional healthcare resource use and costs associated with diabetes in older people (costs of care for people with diabetes), and other costs less frequently evaluated, such as nursing home expenditures, and the impact of diabetes on quality of life and productive activities. Additionally, I build on the existing literature by including in the analysis not only the clinical complications that might be suffered at the same time and due to diabetes, but also functional impairment.

Functional status not only helps to explain the associations between diabetes and the different outcomes studied in the thesis (productive activities, nursing home cost and quality of life), but it is the main one. Moreover, the findings from this thesis shows that this relationship is age-dependent, being more prominent among the oldest old individuals. Through prevention of chronic diseases, as it is diabetes, and prevention of disability would avoid quality of life losses due to these conditions, leading to a healthy and active ageing process. More specific data covering the particularities of ageing individuals would help to increase the existing economic evidence on this certain and relevant population.

Bart Noort
Financial incentives in chronic care
Status: In progress

In chronic care supply chains, patients rely on provision of care from multiple providers. Improving the way these providers divide their tasks and collaborate with each other remains challenging, thereby leaving room for improving quality and outcomes of care. In this project we explore how a healthcare purchaser (health insurer) can use its unique position in the supply chain to improve provision of COPD care. Our aim is to understand how financial incentives provided by the purchaser influence task division and collaboration between medical specialists, general practitioners and other providers in the COPD care chain. Furthermore we will study the role of contractual and relational governance mechanisms used between the purchaser and providers. By conducting a longitudinal case study we expect to gain an in-depth understanding about the purchaser's role in the supply chain and how this affects future quality and outcomes of care.

Oskar Roemeling
Lean beyond waste; Towards the reduction of variability and buffers in healthcare
Status: Defended on 9 June 201

Being Lean has become a popular approach towards process improvement in health care. The reduction of waste is considered central to a Lean approach. Next to the reduction of obvious waste, Lean initiatives are expected to reduce variability and consequential buffers. Variability can be classified as natural or artificial. The latter stems from one’s own actions and should be reduced. Where variability leads to buffering in general, time and capacity buffers are especially prevalent in health care. In addition to these well-established buffer types, this thesis also exposes the role of an unexplored buffering mechanism through adjustments of processing times.

Findings in this thesis contribute to the grounding of Lean theory, based on four research projects that investigated the roles of variability and buffers, mature Lean aspects, in a Lean context. Despite the large number of interventions investigated in the first project, only a few are shown to reduce variability and improve throughput time performance. Instead, the focus of interventions is skewed towards reducing specific types of obvious waste. Yet, knowledge on the roles of variability and buffers is shown to broaden the focus of interventions. This thesis shows several opportunities for improved lean applications in healthcare.

Raun van Ooijen
Life cycle behavior under certainty; Essays on savings, mortgages and health
Status: Defended on 21 January 2016

Households must take into account various sources of uncertainty when making financial decisions. In the aftermath of the financial crisis of 2007-2008 some of these uncertainties have increased and, arguably, households may have become more aware of the uncertainties they encounter. The purpose of this thesis is to examine to what extent different sources of uncertainty influence household financial decision making, in particular regarding saving, portfolio choice and the choice of financial products such as mortgages. We show that uncertainty related to the outcome of future policies (i.e. limiting the mortgage interest deduction), induce households to save more than optimal to absorb possible financial setbacks. We further demonstrate that financially less sophisticated households, who do not fully understand the complex nature of mortgage loans, tend to choose less risky mortgages, unless they consult a mortgage broker. Using detailed tax records, we provide evidence that elderly households are on average wealthy, but do not dissave. This contrasts with the prediction of the life-cycle theory of saving and cannot be explained by uncertainty regarding income or out-of-pocket medical expenses. Health plays an important role in explaining differences in wealth between households. Using self-reported health combined with objective health measures from medical records, we show that health is more persistent and deteriorates at a faster rate in old age than can be inferred from subjective health measures alone. We further show that mental ill-health combined with an unhealthy lifestyle (smoking and being overweight) is a major contributor to long-term sickness among self-employed (with income insurance).

Evelien Hage
How can online communication enhance older adults' social connectivity? Implementation and adoption issues
Status: Defended on 24 September 2015

It is often assumed online communication can enhance older adults’ social connectivity. However, previous studies have indicated two obstacles. First, older adults tend to be late adopters, or laggards. This raises the question how online communication tools can be implemented among a population that on average is less likely to adopt. Second, the effects of online communication on older adults’ social connectivity are debated. This thesis addresses both issues in a multi-method study of a project implementing online communication tools among the older population of three villages in the north of The Netherlands. This thesis underlines that, first, caution is in place with generic investments in, and promotion of, online communication when aiming to enhance the social connectivity of older laggards. Second, without interventions that aim to change pre-existing socio-economic structures, the implementation of online communication tools reinforces socio-economic inequality. Third, online communication tends to have a disproportional negative effect on the older “have nots” because it benefits the well connected while harming isolated older adults. Fourth, to understand the effect of online communication on older laggards’ social connectivity, a situated change perspective on adoption is required that goes beyond the identification of adoption factors. Finally, implementation and adoption mechanisms are proposed that implementers can use to stir local change.

Stefanie Salmon
Health on impulse. Exploring low self-control and its consequences for food choice
Status: Defended on 17 September 2015

Impulsive tendencies towards temptations sometimes seem stronger than wise deliberations. People succumb to a tempting dessert, they postpone getting out of bed and arrive late for work, or scream at someone they are angry with. Such self-control failures are often explained by a limited capacity or limited willingness to exert self-control. After exerting self-control on an initial occasion (e.g., suppressing emotions for the sake of being polite), people are less able or willing to exert self-control in another task (e.g., resisting to buy a new pair of shoes, because one needs to save money). The state that results from this impaired exertion of self-control after repeated self-control exertion has been labeled ego-depletion. In the first part of this dissertation, the focus is on an antecedent of the ego-depletion effect. We demonstrate that people differ in their sensitivity to ego-depleting tasks and situations, and that as a consequence some individuals are better able to repeatedly exert self-control than others. In the second part of the present dissertation, we aimed to qualify a consequence of self-control failures. Contrary to the predominant view on the negative consequences of self-control failures, we demonstrated that ego-depletion does not necessarily have to result in unhealthy choices. Impulsive food choices under low self-control conditions can be steered into the direction of healthy ones, by associating healthy food products with social cues. Applying these social cues to food products in everyday purchase settings may be a new and promising method to provoke more health on impulse.

Monique Eissens-van der Laan
The feasibility of modularity in professional service design. Towards low cost person-centred care
Status: Defended on 26 June 2015

A challenge facing many professional service organisations, and especially healthcare institutes, is how to meet the heterogeneous and complex demands of customers while, at the same time, minimising costs. Recently, attention has been drawn to the managerial concept of modularity as a means of providing low-cost person-centred variety. However, only limited conceptual clarity exists as to what constitutes a module in a service offering and how to appropriately design a modular professional service offering. This thesis starts with a theoretical analysis of the literature seeking conceptual clarity on service modularity, and identifies six ways to decompose a service offering into modules. Subsequently, a two-stage design process for service modularity is described. The first step involved a segmentation study in the healthcare sector that used a finite mixture model to group older adults into five segments based on their experienced biopsychosocial needs. In the second step, a multidisciplinary group of professionals, using the results of the person-centred segmentation study, developed a set of care and service modules. Finally, in a multiple case study, various modular professional service architectures were identified, each with its own merits. This final element highlighted the role of interfaces in modular design as well as boundaries to applying modularity in professional services. In explicating the underlying central design choices, I stress that modular service design is not something that ‘just happens’ or slowly evolves. This thesis demonstrates the influence of design choices made within a modular design on how person-centred variety and costs are balanced.

Katrin Reber
Studies on pharmaceutical markets
Status: Defended on 7 February 2013

The pharmaceutical market is a complex system in which various participants meet and which is continually changing: new drugs enter the market, public health issues are reassessed, and regulatory guidelines change.

This thesis aims to contribute to the development of new and relevant knowledge in the field of healthcare and pharmaceutical marketing. In Chapter 2, we investigate which product, store, customer, and competitor characteristics enhance over-the-counter sales in a retail pharmacy setting. We find that assortment and promotions are crucial determinants of pharmacy performance. The results further suggest that store and location factors that are critical for traditional retailers may be less important for pharmacies.

In Chapters 3 and 4, we assess the impact of Direct Healthcare Professional Communications (DHPCs) on new drug use. Half of the drugs that received a DHPC show a decrease in use in the short-term, but only a minority of drugs with a DHPC show substantial long-term reductions in use. Moreover, the impact of a DHPC on drug use varies greatly depending on drug and DHPC characteristics.

Drug innovation success depends on how fast a new drug is adopted by how many prescribers. In Chapter 5, we analyse the interplay between stage in the adoption process, marketing efforts, and physician characteristics on prescriptions. We find considerable variation in physicians’ propensity to prescribe and their detailing sensitivity. These differences can be related to physician characteristics and their stage in the adoption process. The results of our analyses may help pharmaceutical marketing managers target physicians more effectively.

Sara Kremer
Examining the effectiveness of promotional expenditures for pharmaceutical products
Status: Defended on 11 February 2010

In this thesis dissertation, promotional effectiveness for pharmaceutical products is studied. Several studies attempt to determine this effectiveness, but defining generalisations remains difficult or impossible. Meta-analytic findings are that pharmaceutical promotional elasticities are modest in size and differ among promotional instruments. Effects of instruments aimed at prescribers (DTP) are higher than effects of instruments aimed at consumers (DTC), but relative effectiveness of DTP instruments depends on the disease category. Higher elasticities appear in studies that include price as an independent variable in the models, whereas studies that account for endogeneity find lower elasticities. New empirical results are based on a large database, while accounting for endogeneity and heterogeneous parameters over two regimes. Price reveals the expected negative sign, DTC advertising has a negative sign, and the DTP instrument has an expected positive sign. The effects of both types of advertising are greater during the market development period compared to the introductory period. Prescribers appear less price sensitive when DTC investments are higher. Deploying both instruments simultaneously positively affects sales.

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