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Key messages• Natural experimental evaluations can provide useful information to guide decision making about interventions• Most discussion has focussed on what quantitative methods are suitable for natural experimental evaluationsKey definitions and concepts remain contested and there is a lack of consensus about the circumstances in which natural experimental evaluations can provide trustworthy and useful evidence for decision-making• Guidance should help identify the circumstances that make for good natural experimental evaluation, and a range of applicable methods

Background/Aims Musculoskeletal (MSK) disorders are one of the major causes of non-traumatic disability within the global burden of disease. A 2010 Global Burden of Disease study reported that MSK diseases account for 20% of all Years Lived with Disability (YLDs) in low/middle income countries. Significantly contributing to this MSK burden is arthritis. In Tanzania, a lack of data exists on the prevalence, quality of life, economic and societal impact of arthritis. We aim to estimate the health, economic and societal burden of arthritis in Tanzania. Methods A community-based cross-sectional survey was undertaken between January 2021 to Sept 2021 in the Kilimanjaro region of Tanzania working in partnership with the Kilimanjaro Christian Research Institute and Kilimanjaro Christian Medical Centre. Clinical screening tools, including the Gait Arms Legs Spine (GALS) and Regional Examination of the Musculoskeletal system (REMS) were used to screen people with MSK diseases and possible arthritis through a tiered system approach. Economic and quality of life questionnaires were used for a representative sample of all residents (aged over 5 years old) in selected households. Ethiopia and Zimbabwe tariffs were used for the EuroQol EQ-5D. Resource use captured out-of-pocket costs, healthcare costs, absenteeism, presenteeism & work productivity loss. Regression based analysis were undertaken to estimate differences in utility scores and resources use / costs between those presenting as REMS+/- and GALS+/-. Other explanatory variables in the model included age, occupation, marital status, gender, religion, tribe, education. Results Preliminary results on data collected to-date show that for all QoL dimensions those with a positive diagnosis had lower utility scores. Whilst the population norms are in line with utility values for that age group from other countries (30-40 years, ∼0.9 utility), those presenting with a positive diagnosis had a significant reduction in utility of ∼0.12 to 0.15 depending on what country tariff was used. A higher proportion of participants in GALS/REMS +ve groups experienced work loss (6 x more likely) and had visited healthcare facilities/hospitalisation (2.5 x more likely) compared to GALS/REMS -ve. Health-related costs reported by household financial respondents did not show a significant statistical difference albeit a likely economically significant difference (Tanzanian Shillings 13,535 vs 6,683, p = 0.05), when adjusted for age and gender. Conclusion This is the first study to estimate burden and prevalence estimates of MSK in Tanzania using valid screening tools along with estimates of preference-based quality of life, disability impacts and quantification of the economic impacts of MSK. This study quantifies the significant burden of rheumatological conditions both in terms of health and poverty. The results will be used to guide clinical health practices, intervention design, service provision, and health promotion and awareness activities both at KCMC institutional level, Kilimanjaro region and national level. Disclosure E. Grieve: None. P. Hsieh: None. E. McIntosh: None. M. Deidda: None.

Introduction:\ud \ud Regular moderate‐to‐vigorous physical activity (MVPA) is associated with improved mental health, but the evidence for the effect of reducing sedentary behaviour (SB) or increasing light PA (LPA) in older adults, is lacking. Using isotemporal substitution (IS) models, the aim of this paper is to investigate the effect of substituting SB with LPA or MVPA on associations with mental health in older adults.\ud \ud Methods:\ud \ud Data from 1,360 older adults (mean age 75.18 years) in four countries were utilised. PA and SB was measured using ActiGraph wGT3X‐BT+ accelerometers worn for 7 days. Self‐rated mental health was measured using the Hospital and Anxiety Depression Scale (HADS). IS models estimated cross‐sectional associations when 30 minutes of one behaviour was substituted with another. Models were adjusted for age, sex, marital status, educational attainment.\ud \ud Results:\ud \ud Substituting 30 minutes of SB with LPA (β ‐0.37; 95%CI ‐0.42, ‐0.32) or MVPA (β ‐0.14; 95%CI ‐0.21, ‐0.07) and substituting LPA with MVPA (β ‐0.11; 95%CI ‐0.18, ‐0.04) was associated with improvements in anxiety. However, substituting 30 minutes of SB with LPA (β 0.55; 95%CI 0.49, 0.62) was associated with increased depression.\ud \ud Conclusion:\ud \ud Replacing 30 minutes of SB with LPA or MVPA was associated with improved anxiety symptoms in older adults. Greater benefits were observed when shifting SB and LPA to MVPA.

The main aim of this study was to assess the criterion validity of the Sedentary Behavior Questionnaire (SBQ) to measure SB in community-dwelling older adults using thigh-measured accelerometry as the criterion method. 801 participants (75.6 ± 6.1 years old, 57.6% females) provided valid thigh-based accelerometer data (activPAL/Axivity) and completed the SBQ. Criterion validity was assessed using Spearman’s Rho coefficients. Bland–Altman plots, including 95% limits of agreement and Intraclass Correlation Coefficient (ICC), were used to assess the agreement between self-report and device-measured daily SB time. Strength of the association was examined using multiple linear regression. There was a weak correlation (Rho = 0.25, p

Background: The SITLESS programme comprises exercise referral schemes and self-management strategies and has been evaluated in a trial in Denmark, Spain, Germany and Northern Ireland. The aim of this qualitative study was to understand the implementation and contextual aspects of the intervention in relation to the mechanisms of impact and to explore the perceived effects. Methods: Qualitative methodologies were nested in the SITLESS trial including 71 individual interviews and 12 focus groups targeting intervention and control group participants from postintervention to 18-month follow-up in all intervention sites based on a semi-structured topic guide. Results: Overarching themes were identified under the framework categories of context, implementation, mechanisms of impact and perceived effects. The findings highlight the perceived barriers and facilitators to older adults’ engagement in exercise referral schemes. Social interaction and enjoyment through the group-based programmes are key components to promote adherence and encourage the maintenance of targeted behaviours through peer support and connectedness. Exit strategies and signposting to relevant classes and facilities enabled the maintenance of positive lifestyle behaviours. Conclusions: When designing and implementing interventions, key components enhancing social interaction, enjoyment and continuity should be in place in order to successfully promote sustained behaviour change., publishedVersion

The study aim was to explore associations between sedentary behavior (SB) bouts and physical function in 1360 community-dwelling older adults (≥65 years old). SB was measured using an ActiGraph wGT3X + accelerometer for seven consecutive days at the dominant hip and processed accordingly. Various SB bout lengths were assessed including: 1- to 9-minutes; 10- to 29-minutes; 30- to 59-minutes; and ≥60-minutes, as well as maximum time spent in a SB bout. Total SB time was adjusted for within the SB bout variables used (percentage SB time in the SB bout length and number of SB bouts per total SB hour). Physical function was assessed using the 2-minute walk test (2MWT), 5-times sit-to-stand (chair stand) test, and unipedal stance test (UST). Hierarchical linear regression models were utilized. Covariates such as moderate-vigorous physical activity (MVPA), demographic and health characteristics were controlled for. Lower percentage time spent in ≥60-minute SB bouts was significantly (P

Research has found that social relationships are central to the health and well-being of an aging population. Evidence exploring the association between physical activity (PA) and sedentary behavior (SB) with social isolation and loneliness is limited. This study uses objectively measured PA and SB (ActiGraph®) and self-reported measures of loneliness (the De Jong Gierveld Loneliness Scale) and social engagement (the Lubben Social Network Scale) from the SITLESS study, a European-wide study of community-dwelling older adults. Social isolation was associated with SB where higher levels of SB were associated with an increase in the level of social isolation, controlling for age, sex, living arrangements, employment status, body mass index, educational background, marital status, and self-reported general health. In contrast, PA was not associated with social isolation, and neither SB nor PA was a statistically significant predictor of loneliness. SB may be linked to social isolation in older adults, but PA and SB are not necessarily linked to loneliness in older community-dwelling adults.

Improving the capacity for physical activity interventions to maintain behavior change is a key public health concern and an important strategy for the health and independence of older adults. Ways of ensuring effective maintenance of physical activity levels in older adults are unclear. This study includes the objective measure of moderate-to-vigorous physical activity (MVPA); self-reported self-efficacy; and self-regulation at four timepoints (baseline, intervention completion at 4 months, 12-, and 18-month follow-up) from the SITLESS study, a clinical trial conducted with a cohort of community-dwelling older adults (≥65 years) from Denmark, Germany, Spain, and the United Kingdom. A cross-lagged analysis found that self-regulation and self-efficacy may be key determinants of MVPA behavior in community-dwelling older adults. More specifically, the use of behavioral support strategies represents an important correlate of MVPA behavior, and its association with MVPA may be mediated by self-regulation and self-efficacy in older adults in the short and long term.

IntroductionSITLESS is a randomised controlled trial determining whether exercise referral schemes can be enhanced by self-management strategies to reduce sedentary behaviour and increase physical activity in the long term, in community-dwelling older citizens. The intervention is complex and requires a process evaluation to understand how implementation, causal mechanisms and context shape outcomes. The specific aims are to assess fidelity and reach of the implementation, understand the contextual aspects of each intervention site, evaluate the mechanisms of impact, and explore perceived effects.Methods and analysisFollowing the Medical Research Council guidance on complex interventions, a combination of qualitative and quantitative procedures is applied, including observational checklists and attendance registries, standardised scales (ie, Marcus’s Self-Efficacy Questionnaire, Physical Activity Self-Regulation Scale and the Lubben Social Network Scale) at baseline, postintervention and follow-up assessments, semistructured questionnaires gathering contextual characteristics, and participant observations of the sessions. Semistructured interviews and focus groups with the participants and trainers are conducted at postintervention and during the follow-up to explore their experiences. Outcomes from the standardised scales are analysed as moderators within the impact evaluation. Descriptive results on context and perceived effects complement results on impact. The qualitative and quantitative findings will help to refine the logic model to finally support the interpretation of the results on the effectiveness of the intervention.Ethics and disseminationThe study design was approved by the respective Ethical Committee of Ramon Llull University, Southern Denmark, Northern Ireland and Ulm University. Participation is voluntary, and all participants are asked to sign informed consent before starting the study. A dissemination plan operationalises how to achieve a social impact by reaching academic and non-academic stakeholders. A data management plan describes the specific data sets and regulates its deposition and curation. All publications will be open access.Trial registration numberNCT02629666; Pre-results.

Background: \ud Potential users’ preferences for telemedicine services directed to cardio-vascular diseases are investigated applying a discrete choice experiment (DCE). Given the potential of telemedicine to minimize costs without reducing overall efficiency, assessing preferences for these types of services represents a priority for policy makers. This is especially true for those pathologies that absorb a relatively high quota of total health expenditure. The empirical setting is Sardinia (Italy) because of its insularity and the underdeveloped internal transport network. Telemedicine is likely to mitigate distance between healthcare providers and final users.\ud \ud Methods: \ud A survey conducted between February and May 2013 was administered to a selected Sardinian population older than 18 (potential users) through face-to-face interviews. A discrete choice experiment was implemented and four attributes (i.e. scanning mode, location, waiting list and cost) assess in what measure these influence potential users’ utility by using a random parameter modelling with heterogeneity (RPH).\ud \ud Results: \ud The empirical findings, based on 2000 interviews, highlight that potential users are not very open to the application of telemedicine services in cardiology, mostly preferring the intromoenia (visit at the hospital) and private system. Besides, remarkable individual heterogeneity has been found.\ud \ud Conclusions: \ud Potential users see the implementation of new technologies in healthcare with a certain caution. However, the relatively higher preferences towards services provided at their own municipality suggests that there is ground to explore further the implementation of telemedicine services through the family doctor and local pharmacy.

IntroductionChildren who have experienced abuse and neglect are at increased risk of mental and physical health problems throughout life. This places an enormous burden on individuals, families and society in terms of health services, education, social care and judiciary sectors. Evidence suggests that early intervention can mitigate the negative consequences of child maltreatment, exerting long-term positive effects on the health of maltreated children entering foster care. However, evidence on cost-effectiveness of such complex interventions is limited. This protocol describes the first economic evaluation of its kind in the UK.Methods and analysisAn economic evaluation alongside the Best Services Trial (BeST?) has been prospectively designed to identify, measure and value key resource and outcome impacts arising from the New Orleans intervention model (NIM) (an infant mental health service) compared with case management (CM) (enhanced social work services as usual). A within-trial economic evaluation and long-term model from a National Health Service/Personal Social Service and a broader societal perspective will be undertaken alongside the National Institute for Health Research (NIHR)–Public Health Research Unit (PHRU)-funded randomised multicentre BeST?. BeST? aims to evaluate NIM compared with CM for maltreated children entering foster care in a UK context. Collection of Paediatric Quality of Life Inventory (PedsQL) and the recent mapping of PedsQL to EuroQol-5-Dimensions (EQ-5D) will facilitate the estimation of quality-adjusted life years specific to the infant population for a cost–utility analysis. Other effectiveness outcomes will be incorporated into a cost-effectiveness analysis (CEA) and cost-consequences analysis (CCA). A long-term economic model and multiple economic evaluation frameworks will provide decision-makers with a comprehensive, multiperspective guide regarding cost-effectiveness of NIM. The long-term population health economic model will be developed to synthesise trial data with routine linked data and key government sector parameters informed by literature. Methods guidance for population health economic evaluation will be adopted (lifetime horizon, 1.5% discount rate for costs and benefits, CCA framework, multisector perspective).Ethics and disseminationEthics approval was obtained by the West of Scotland Ethics Committee. Results of the main trial and economic evaluation will be submitted for publication in a peer-reviewed journal as well as published in the peer-reviewed NIHR journals library (Public Health Research Programme).Trial registration numberNCT02653716; Pre-results.

This paper explores the challenges posed by insularity to economic development and overall welfare from a novel viewpoint. Using a multidisciplinary approach, we investigated the additional burden that this permanent geographical condition poses to retailers whose profit-maximizing strategy relies upon the exploitation of the economies of density. The analysis results show that a retailer finds it convenient to develop its network on the mainland, exploiting the proximity of his stores and distribution centres. Further, it shows that insularity, an unlikely similar condition such as peripherality and remoteness, prevents retailers from expanding their network on an island, thus lowering competition and affecting consumers’ welfare.

Internationally, policy makers are increasingly focussed on reducing the detrimental consequences and rising costs associated with unhealthy diets, inactivity, smoking, alcohol and other risk factors on the health of their populations. This has led to an increase in the demand for evidence-based, cost-effective Population Health Interventions (PHIs) to reverse this trend. Given that research designs such as randomised controlled trials (RCTs) are often not suited to the evaluation of PHIs, Natural Experiments (NEs) are now frequently being used as a design to evaluate such complex, preventive PHIs. However, current guidance for economic evaluation focusses on RCT designs and therefore does not address the specific challenges of NE designs. Using such guidance can lead to sub-optimal design, data collection and analysis for NEs, leading to bias in the estimated effectiveness and cost-effectiveness of the PHI. As a consequence, there is a growing recognition of the need to identify a robust methodological framework for the design and conducting of economic evaluations alongside such NEs. This paper outlines the challenges inherent to the design and conduct of economic evaluations of PHIs alongside NEs, providing a comprehensive framework and outlining a research agenda in this area.

Background Older adults are the fastest growing segment of the world‘s population. Recent evidence indicates that excessive sitting time is harmful to health, independent of meeting the recommended moderate to vigorous physical activity (PA) guidelines. The SITLESS project aims to determine whether exercise referral schemes (ERS) can be enhanced by self-management strategies (SMSs) to reduce sedentary behaviour (SB), increase PA and improve health, quality of life and function in the long term, as well as psychosocial outcomes in community-dwelling older European citizens from four countries, within a three-armed pragmatic randomised controlled trial, compared with ERS alone and also with general recommendations about PA. Methods A total of 1338 older adults will be included in this study, recruited from four European countries through different existing primary prevention pathways. Participants will be randomly allocated into an ERS of 16 weeks (32 sessions, 45–60 min per session), ERS enhanced by seven sessions of SMSs and four telephone prompts, or a control group. Outcomes will be assessed at baseline, month 4 (end of ERS intervention), month 16 (12 months post intervention) and month 22 (18 months post intervention). Primary outcomes will include measures of SB (time spent sedentary) and PA (counts per minute). Secondary outcomes will include muscle and physical function, health economics’ related outcomes, anthropometry, quality of life, social networks, anxiety and depressive symptoms, disability, fear of falling, executive function and fatigue. A process evaluation will be conducted throughout the trial. The full analysis set will follow an intention-to-treat principle and will include all randomised participants for whom a baseline assessment is conducted. The study hypothesis will be tested with mixed linear models with repeated measures, to assess changes in the main outcomes (SB and PA) over time (baseline to month 22) and between study arms. Discussion The findings of this study may help inform the design and implementation of more effective interventions to reduce SB and increase PA levels, and hence improve long-term health outcomes in the older adult population. SITLESS aims to support policy-makers in deciding how or whether ERS should be further implemented or restructured in order to increase its adherence, impact and cost-effectiveness. Trial registration ClinicalTrials.gov, NCT02629666. Registered 19 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1956-x) contains supplementary material, which is available to authorized users.

Although it is often asserted that the housing cost burden is one of the key determinants of household economic hardship, in practice the linkage between the two has been rarely explored. The focus has been instead on the role played by income or other socio-economic determinants of household hardship. However, housing costs represent one of the most significant outlays in a household balance. The burden represented by housing costs may indeed cause households to reduce non-housing expenditure such as health care, education, food and clothing, thus creating serious household economic hardship. The primary goal of this study is to contribute on the literature on poverty by looking at households economic hardship in relation to the housing cost burden. In particular, our focus is to relate economic hardship with home-ownership status, by jointly estimating the burden of housing costs for renters versus home-owners paying mortgage. Using microdata from the European Union Statistics on Income and Living Conditions dataset (EU-SILC) regarding five European countries (Italy, Germany, UK, Spain and France) we are able to exploit two indicators of housing cost burden and several indicators of household economic and financial hardship to examine the predictive power of housing costs in explaining family economic hardship. Furthermore, we jointly estimate the effect of the housing cost burden for renters versus home-owners paying mortgage. Results show that housing costs represent a non negligible burden in all the five European countries. Moreover, home ownership is found to significantly reduce household hardship status.

This paper examines the economic efficiency of cableways in the Autonomous Province of Bolzano, Italy, and relates it to sustainability and tourism issues. Cableways represent an environmental-friendly mode of transport that enables access to remote and environmentally delicate areas. Thus, examining cableways efficiency informs policies that foster regional competitiveness from a sustainable development perspective. Employing annual data from 2002 up to 2008, the pure technical efficiency and scale efficiency are computed using a panel Data Envelopment Analysis. Overall, the empirical findings reveal that this type of transport in the Italian Alps can be regarded as relatively economically inefficient and most of the cableways denote decreasing returns to scale. Nevertheless, some distinctive features are detected amongst cableways classified by district. Policy implications are drawn to help economic agents improve their efficiency scores.

This paper analyzes the dynamic efficiency of the hospitality sector in the province of Bolzano (Italy) to identify similar behavior of firms across the period 2002–2008. A data envelopment analysis is run as a basis to analyze the efficiency evolution of the firms by employing two complementary measures of distance (i.e. correlation and average distances). Via a hierarchical clustering approach, results show the existence of homogeneous groups with similar dynamical characteristics. Structural factors (e.g. size, number of stars and sub-sector of activity) are found to affect the evolution of hotel efficiency over time. Policy and management implications are drawn from the present analysis. Copyright © 2013 John Wiley & Sons, Ltd. Received 13 December 2012; Revised 22 October 2013; Accepted 30 October 2013

I empirically investigate precautionary savings under liquidity constraints in Italy using a unique indicator of subjective variance of income growth to measure the strength of the precautionary motive for saving, and a variety of survey-based indicators of liquidity constraints. The main contribution of the paper is twofold. First of all, I attempt to differentiate between the standard precautionary saving caused by uncertainty from the one due to liquidity constraints using an endogenous switching regression approach, which allows me to cope with endogeneity issues associated with sample splitting techniques. Second, I move one step further with respect to previous studies on consumption behaviour by taking explicitly expected liquidity constraints into account. I eventually found the precautionary motive for savings to be stronger for those households who face binding constraints, or expect constraints to be binding in the future. Indeed, a complementarity relation exists between precautionary savings and liquidity constraints.

Highlights? A dynamical tool to describe the performance of economic efficiency is introduced. ? Static DEA, clustering and metric distances are the ingredients of the methodology. ? Case study is used to demonstrate the validity of the methodology. ? Policy and management implications for the Italian hospitality sector are presented. This paper introduces a methodology to describe and compare the economic relative performance of the hospitality sector of the Italian regions during the period 2000-2004. Dynamics of the hospitality sector of each region is represented by the evolution of its economic efficiency. The investigation involves the following steps: a static Data Envelopment Analysis (DEA) to estimate the pure economic efficiency; two different notions of distances between time series and hierarchical clustering techniques are used to classify the economies in the sample. By using a correlation-based distance, three main clusters are detected, while two clusters are identified when the average distance is used. The trend patterns, identified by employing the correlation distance, can be interpreted in terms of exogenous factors that influence the economic efficiency of the group of regions, causing shocks picked up by the high volatility as well as structural breaks. By employing the average distance, one infers information on the cluster that have had similar efficiency values over the period under analysis. This efficiency can be also interpreted in terms of a particular type of hospitality management as well as the firm structure. Following the analysis, some policy and management implications are presented.

IntroductionPromoting physical activity (PA) and reducing sedentary behaviour (SB) may exert beneficial effects on the older adult population, improving behavioural, functional, health and psychosocial outcomes in addition to reducing health, social care and personal costs. This paper describes the planned economic evaluation of SITLESS, a multicountry three-armed pragmatic randomised controlled trial (RCT) which aims to assess the short-term and long-term effectiveness and cost-effectiveness of a complex intervention on SB and PA in community-dwelling older adults, based on exercise referral schemes enhanced by a group intervention providing self-management strategies to encourage lifestyle change.Methods and analysisA within-trial economic evaluation and long-term model from both a National Health Service/personal social services perspective and a broader societal perspective will be undertaken alongside the SITLESS multinational RCT. Healthcare costs (hospitalisations, accident and emergency visits, appointment with health professionals) and social care costs (eg, community care) will be included in the economic evaluation. For the cost-utility analysis, quality-adjusted life-years will be measured using the EQ-5D-5L and capability well-being measured using the ICEpop CAPability measure for Older people (ICECAP-O) questionnaire. Other effectiveness outcomes (health related, behavioural, functional) will be incorporated into a cost-effectiveness analysis and cost-consequence analysis.The multinational nature of this RCT implies a hierarchical structure of the data and unobserved heterogeneity between clusters that needs to be adequately modelled with appropriate statistical and econometric techniques. In addition, a long-term population health economic model will be developed and will synthesise and extrapolate within-trial data with additional data extracted from the literature linking PA and SB outcomes with longer term health states.Methods guidance for population health economic evaluation will be adopted including the use of a long-time horizon, 1.5% discount rate for costs and benefits, cost consequence analysis framework and a multisector perspective.Ethics and disseminationThe study design was approved by the ethics and research committee of each intervention site: the Ethics and Research Committee of Ramon Llull University (reference number: 1314001P) (Fundació Blanquerna, Spain), the Regional Committees on Health Research Ethics for Southern Denmark (reference number: S-20150186) (University of Southern Denmark, Denmark), Office for Research Ethics Committees in Northern Ireland (ORECNI reference number: 16/NI/0185) (Queen’s University of Belfast) and the Ethical Review Board of Ulm University (reference number: 354/15) (Ulm, Germany). Participation is voluntary and all participants will be asked to sign informed consent before the start of the study.This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement number 634 270. This article reflects only the authors' view and the Commission is not responsible for any use that may be made of the information it contains.The findings of the study will be disseminated to different target groups (academia, policymakers, end users) through different means following the national ethical guidelines and the dissemination regulation of the Horizon 2020 funding agency.Use of the EuroQol was registered with the EuroQol Group in 2016.Use of the ICECAP-O was registered with the University of Birmingham in March 2017.Trial registration numberNCT02629666; Pre-results.

Porcine brucellosis is a zoonotic disease caused by Brucella suis and hosted by pigs (Sus scrofa). Both domestic pigs and wild boars are affected. We measured the prevalence of antibody to Brucella spp. in wild boars in Sardinia, Italy. During 1 November 2009 to 31 January 2010, we collected 570 serum samples from legally hunted wild boars and tested them using a commercial competitive enzyme-linked immunosorbent assay. Sex and age class of the sampled wild boars were also recorded. Thirty-five samples were positive for an apparent antibody prevalence of 6.1%. Antibody prevalences did not differ between sexes or among age classes.

We analyse the effects of an active labour market program for disadvantaged workers recently implemented in an Italian depressed area. Our sample includes 859 workers, mostly women, who entered the program before April 2008 and were subsequently interviewed in 2009-10. We complement the existing administrative data with survey data that enables us to control for numerous individual and labour market characteristics for both treated and non-treated individuals. Using propensity-score matching methods, we do find that the employment subsidy had a positive and significant effect (ATT) on both the probability of finding a job for participants and on their level of income. We also control for effect heterogeneity and find that the outcome of the policy was higher for women and, among them, we also find that the program was more effective on less educated and older female workers. Finally, we exploit unique information on previous contacts between workers and firms and on the use of informal channels for job search activity to explore the role of underground employment relations for the effectiveness of the policy.

In this paper we analyse the efficiency of primary care centres (PCCs) adopting Information and Communication Technology (ICT) devices, using a new database on primary care centres in the Basque Region in Spain. Using a four-stage Data Envelopment Analysis methodology, we are able to explicitly take into account the role of ICT in affecting the efficiency of primary care centres. We understand that this is the first time that ICT enters into the determination of efficiency of the health sector. The role of exogenous factors is explicitly considered in this analysis and shows that including these variables is not neutral to the efficiency evaluation, but leads to an efficiency indicator that only encompasses the effect of managerial skills. The paper provides some useful policy implications regarding the role of ICT in improving the efficiency of primary care units.

This survey reviews theoretical and empirical evidence on the impact of insularity on regional economic development. Far from being a mere geographical condition, insularity can be regarded as a permanent phenomenon of economic and social peripheralization that prevents islands to reach the goals of sustainable development that are reached by the mainland. Even if the issue of the consequences of insularity on economic development is garnering greater interest in the light of the growing recognition of the significant economic disadvantage faced by islands, both the theoretical and empirical literature in this regard are fragmented. More importantly, the effects of insularity on economic development are not disentangled from similar conditions such as remoteness, smallness and peripherality. The survey focuses as well on the two-sided nature of insularity, since if it is true that islands suffer from permanent handicaps, adequate policy interventions may not only mitigate insularity effect, but also transform insularity into an asset leading a great potential for growth. Finally, some policy suggestions are drawn, highlighting the need for custom-tailored policy measures.

We analyse the effects of an active labour market program for disadvantaged workers recently implemented in an Italian depressed area. Our sample includes 859 workers, mostly women, who entered the program before April 2008 and were interviewed in 2009-10. We complement the existing administrative data with survey data that enables us to control for numerous individual and labour market characteristics for both treated and non-treated individuals. Using propensity-score matching methods, we find that the employment subsidy had a positive and significant effect (ATT) for participants on both the probability of finding a job and on their level of income. We also control for effect heterogeneity and find that the outcome of the policy was higher for women and, among them, we also find that the program was more effective on less educated and older female workers. Finally, we exploit unique information on previous contacts between workers and firms and on the use of informal channels for job search activity to explore the role of the program in promoting the transition from informal employment to a salaried economy.

This paper provides a comparative analysis of the hospitality sector using the island of Sardinia and the autonomous province of Bolzano as a case study. The comparison holds its own interest since they are both tourism destinations, though characterized by different features as far as seasonality is concerned. Employing a large sample set, pure technical and scale efficiency are computed using a panel Data Envelopment Analysis. Overall, the empirical findings reveal that the hospitality sector in Sardinia and in Bolzano can be regarded as economically inefficient and mostly depicting decreasing returns to scale. Nevertheless, some distinctive features are detected amongst firms classified by size. Policy implications are drawn to help economic agents to improve their efficiency scores.

This paper introduces a methodology to describe and compare the economic relative performance of the hospitality sector of the Italian regions during the period 2000-2004. Dynamics of the hospitality sector of each region is represented by the evolution of its economic efficiency. The investigation involves the following steps: a static Data Envelopment Analysis (DEA) to estimate the pure economic efficiency; two different notions of distances between time series and hierarchical clustering techniques are used to classify the economies in the sample. By using a correlation-based distance, three main clusters are detected, while two clusters are identified when the average distance is used. The trend patterns, identified by employing the correlation distance, can be interpreted in terms of exogenous factors that influence the economic efficiency of the group of regions, causing shocks picked up by the high volatility as well as structural breaks. By employing the average distance, one infers information on the cluster that have had similar efficiency values over the period under analysis. This efficiency can be also interpreted in terms of a particular type of hospitality management as well as the firm structure. Following the analysis, some policy and management implications are presented.

Relying on a direct question about the desired amount of precautionary wealth from the 2002 wave of the Italian Survey of Household Income and Wealth, I assess the main determinants of precautionary motive for saving. In particular, I focus on the role played by financial risk on households' saving decisions. Actually, households investing mainly in safe assets do not need to protect themselves against future and unexpected financial losses. Consequently, controlling for households' sources of risk beside financial ones, the amount of precautionary savings of a household who invest exclusively in safe assets should be lower compared to households who instead detain a non-negligible share of risky assets in their portfolio. Moreover, portfolio diversification, reducing households' total exposure to financial risk, should reduce the amount of wealth households need to save for precautionary reasons. In this paper, I provide an empirical assessment of the linkage existing between the composition of households' portfolio and the amount of wealth households wish to have to protect themselves against unexpected contingencies. As expected, a strong and negative correlation exists between the desired amount of precautionary wealth and the ownership of a portfolio made exclusively of safe assets. However, households do not seem to use portfolio diversification to reduce exposure to total risk. Finally, I address the issue of complementarity vs. substitution between formal and informal insurance schemes. Actually, trust in capital market would lower substantially the amount of wealth households wish to detain for precautionary reasons. However, there is no evidence in favour of a negative and strong linkage between precautionary saving and insurance.

Thyroid hormones regulate cell growth, cell differentiation, and metabolic functions via interaction with the thyroid hormone nuclear receptors (TRs). Recently, a small class of halogen-free high-affinity thyroid hormone agonists has been developed that are highly selective for the TRbeta subtype. Because of the selective hyperthyroidism generated by one of these agonists, GC-1, this compound has the potential to be developed as a new therapeutic agent for the treatment of a variety of metabolic disturbances, including lipid disorders and obesity; thus, it becomes important to determine whether GC-1 has other unknown effects on potential target organs. The purpose of this study was to investigate the effect of GC-1 on cell proliferation in rat liver and pancreas. Rats treated with GC-1 (50 or 100 mug/100 g body weight) were killed at different time points. Hepatic and pancreatic cell proliferation was monitored by immunohistochemical determination of bromodeoxyuridine incorporation. The expression of cell cycle-related genes was analyzed by Northern and Western analysis. The results show that GC-1 strongly stimulates rat hepatocyte proliferation in the absence of tissue injury. Although GC-1-induced hepatocyte proliferation was associated with a rapid increase in cyclin D1 mRNA levels, no change in the expression of c-jun and c-fos was observed. GC-1 also induced massive pancreatic cell proliferation. The results indicate that the TRbeta-selective agonist GC-1 is a strong mitogen for hepatocytes and pancreatic acinar cells. Furthermore, they suggest that the TRbeta receptor is the mediator for the mitogenic activity of thyroid hormone and other thyromimetics.

This paper provides a comparative analysis of the hospitality sector using the island of Sardinia and the autonomous province of Bolzano as a case study. The comparison holds its own interest since they are both tourism destinations, though characterised by different features as far as seasonality is concerned. Employing a large sample set, pure technical and scale efficiency are computed using a panel data envelopment analysis. Overall, the empirical findings reveal that the hospitality sector in Sardinia and in Bolzano can be regarded as economically inefficient and mostly depicting decreasing returns to scale. Nevertheless, some distinctive features are detected amongst firms classified by size. Policy implications are drawn to help economic agents to improve their efficiency scores, thus leading to an optimal revenue management strategy.