Women's empowerment and child anthropometric failures across 28 sub-Saharan African countries: A cross-level interaction by Gender Inequality Index

Background

Child undernutrition remains a major global health issue, particularly in sub-Saharan Africa (SSA). Given the important role mothers play in early childhood health and development, we examined how individual-level women's empowerment and country-level Gender Inequality Index (GII) are jointly related with child undernutrition in SSA.

Methods

We pooled recent Demographic and Health Surveys from 28 SSA countries. For 137,699 children <5 years old, undernutrition was defined using anthropometric failures (stunting, underweight, wasting). Women's empowerment was assessed using three domains of Survey-based Women's EmPowERment (SWPER) index: attitude to violence, social independence, and decision-making; and country-level gender inequality was measured using GII from United Nations Development Programme. Three-level logistic regression was conducted to examine the joint associations of SWPER and GII as well as their interactions with child anthropometric failures, after adjusting for sociodemographic covariates.

Results

Overall, 32.85% of children were stunted, 17.63% were underweight, and 6.68% had wasting. Children of mothers with low-level of empowerment for all domains of SWPER had higher odds of stunting (attitude to violence: OR=1.15; 95% CI, 1.11-1.19; social independence: OR=1.21; 95% CI, 1.17-1.25; decision-making: OR=1.16; 95% CI, 1.12-1.20), and consistent results were found for underweight and wasting. Independent of women's empowerment, country-level GII increased the probability of underweight (ranging ORs=1.46; 95% CI, 1.15-1.85 to 1.50; 95% CI, 1.18-1.90) and wasting (ranging ORs=1.56; 95% CI, 1.24-1.97 to 1.61; 95% CI, 1.27-2.03). Significant interaction was found between women's empowerment and country-level GII for stunting and underweight (p<0.05).

Conclusions

In SSA countries with greater gender inequality, improving women's social independence and decision-making power in particular can reduce their children's risk of anthropometric failures. Policies and interventions targeted at strengthening women's empowerment should consider the degree of gender inequality in each country.

COVID-19 vaccine acceptance: A comparative longitudinal analysis of the association between risk perception, confidence, and the acceptance of a COVID-19 vaccine

Following the outbreak of COVID-19, scientists rushed to develop vaccines to protect individuals and ferry the world out of the pandemic. Unfortunately, vaccine hesitancy is a major threat to the success of vaccination campaigns. Research on previous pandemics highlighted the centrality of perceived risk and confidence as core determinants of vaccine acceptance. Research on COVID-19 is less conclusive, and frequently it relies on one-country, cross-sectional data, thus making it hard to generalize results across contexts and observe these relationships over time. To bridge these gaps, in this article, we analyzed the association between perceived risk, confidence, and vaccine acceptance cross-sectionally at individual and country levels. Then, we longitudinally explored whether a within-country variation in perceived risk and confidence was correlated with a variation in vaccine acceptance. We used data from a large-scale survey of individuals in 23 countries and 19 time-points between June 2020 and March 2021 and comparative longitudinal multilevel models to estimate the associations at different levels of analysis simultaneously. Results show the existence of cross-sectional relationships at the individual and country levels but no significant associations within countries over time. This article contributes to our understanding of the roles of risk perception and confidence in COVID-19 vaccines' acceptance by underlining that these relationships might differ at diverse levels of analysis. To foster vaccine uptake, it might be important to address individual concerns and persisting contextual characteristics, but increasing levels of perceived risk and confidence might not be a sufficient strategy to increase vaccine acceptance rates.

A Network Study of Family Affect Systems in Daily Life

Adolescence is a time period characterized by extremes in affect and increasing prevalence of mental health problems. Prior studies have illustrated how affect states of adolescents are related to interactions with parents. However, it remains unclear how affect states among family triads, that is adolescents and their parents, are related in daily life. This study investigated affect state dynamics (happy, sad, relaxed, and irritated) of 60 family triads, including 60 adolescents (Mage = 15.92, 63.3% females), fathers and mothers (Mage = 49.16). The families participated in the RE-PAIR study, where they reported their affect states in four ecological momentary assessments per day for 14 days. First, we used multilevel vector-autoregressive network models to estimate affect dynamics across all families, and for each family individually. Resulting models elucidated how family affect states were related at the same moment, and over time. We identified relations from parents to adolescents and vice versa, while considering family variation in these relations. Second, we evaluated the statistical performance of the network model via a simulation study, varying the percentage missing data, the number of families, and the number of time points. We conclude with substantive and statistical recommendations for future research on family affect dynamics.

Effects of a Faith-Based Obesity Intervention on African American and Latino Adults' Children

BACKGROUND

Faith-based interventions are promising for promoting healthy behaviors among adults, but their ripple effects on participants' children are unknown. This study is one of the first to assess the effects of a faith-based multilevel obesity intervention on adult participants' children.

METHODS

We analyzed quantitative data from a cluster randomized controlled trial with two African American and two Latino churches in South Los Angeles, California, which invited adult participants to enroll one child (5-17 years) in a sub-study. At baseline and 6-7 months follow-up, parents completed a child health survey, which included the family nutrition and physical activity screening tool, and child height and weight were measured (n = 50).

RESULTS

Results from linear regression models showed children of intervention participants, compared to control, had significantly better dietary patterns at follow-up.

CONCLUSIONS

Findings suggest the health benefits of a faith-based multilevel obesity intervention for adults can extend to children and may help address obesity disparities.

Uptake of Lung Cancer Screening CT After a Provider Order for Screening in the PROSPR-Lung Consortium

BACKGROUND

Uptake of lung cancer screening (LCS) has been slow with less than 20% of eligible people who currently or formerly smoked reported to have undergone a screening CT.

OBJECTIVE

To determine individual-, health system-, and neighborhood-level factors associated with LCS uptake after a provider order for screening.

DESIGN AND SUBJECTS

We conducted an observational cohort study of screening-eligible patients within the Population-based Research to Optimize the Screening Process (PROSPR)-Lung Consortium who received a radiology referral/order for a baseline low-dose screening CT (LDCT) from a healthcare provider between January 1, 2015, and June 30, 2019.

MAIN MEASURES

The primary outcome is screening uptake, defined as LCS-LDCT completion within 90 days of the screening order date.

KEY RESULTS

During the study period, 18,294 patients received their first order for LCS-LDCT. Orders more than doubled from the beginning to the end of the study period. Overall, 60% of patients completed screening after receiving their first LCS-LDCT order. Across health systems, uptake varied from 41 to 87%. In both univariate and multivariable analyses, older age, male sex, former smoking status, COPD, and receiving care in a centralized LCS program were positively associated with completing LCS-LDCT. Unknown insurance status, other or unknown race, and lower neighborhood socioeconomic status, as measured by the Yost Index, were negatively associated with screening uptake.

CONCLUSIONS

Overall, 40% of patients referred for LCS did not complete a LDCT within 90 days, highlighting a substantial gap in the lung screening care pathway, particularly in decentralized screening programs.

Student- and School-Level Factors Associated With Mental Health and Well-Being in Early Adolescence

OBJECTIVE

Adolescence is a key developmental window that may determine long-term mental health. As schools may influence mental health of students, this study aimed to examine the association of school-level characteristics with students' mental health over time.

METHOD

Longitudinal data from a cluster randomized controlled trial comprising 8,376 students (55% female; aged 11-14 years at baseline) across 84 schools in the United Kingdom were analyzed. Data collection started in the academic years 2016/2017 (cohort 1) and 2017/2018 (cohort 2), with follow-up at 1, 1.5, and 2 years. Students' mental health (risk for depression [Center for Epidemiologic Studies Depression Scale], social-emotional-behavioral difficulties [Strength and Difficulties Questionnaire]) and well-being (Warwick-Edinburgh Mental Well-Being Scale) and relationships with student- and school-level characteristics were explored using multilevel regression models.

RESULTS

Mental health difficulties and poorer well-being increased over time, particularly in girls. Differences among schools represented a small but statistically significant proportion of variation (95% CI) in students' mental health at each time point: depression, 1.7% (0.9%-2.5%) to 2.5% (1.6%-3.4%); social-emotional-behavioral difficulties, 1.9% (1.1%-2.7%) to 2.8% (2.1%-3.5%); and well-being, 1.8% (0.9%-2.7%) to 2.2% (1.4%-3.0%). Better student-rated school climate analyzed as a time-varying factor at the student and school level was associated with lower risk of depression (regression coefficient [95%CI] student level: -4.25 [-4.48, -4.01]; school level: -4.28 [-5.81, -2.75]), fewer social-emotional-behavioral difficulties (student level: -2.46 [-2.57, -2.35]; school level: -2.36 [-3.08, -1.63]), and higher well-being (student level: 3.88 [3.70, 4.05]; school-level: 4.28 [3.17, 5.38]), which was a stable relationship.

CONCLUSION

Student-rated school climate predicted mental health in early adolescence. Policy and system interventions that focus on school climate may promote students' mental health.

eHealth, family-based interventions, and multilevel approaches to pediatric weight management: a scoping review

OBJECTIVE

This scoping review examines the current literature on technology-based, eHealth interventions that integrate community and clinical approaches for family-based pediatric weight management.

BACKGROUND

Telehealth and eHealth interventions for weight management are increasingly commonplace; however, it is unclear in the current literature how family-based, pediatric, healthy-weight interventions integrate technology. Additionally, multilevel approaches to address childhood obesity, including working with clinical and community partners, are currently considered best practice and within the socioecological framework for sustainability of outcomes. Little is known how current family based pediatric healthy weight interventions integrate eHealth and multi-level approaches.

METHODS

Guided by Arksey and O'Malley's scoping review framework, a scoping literature review was conducted. Four databases were searched to identify studies conducted between 2010 and 2022 that addressed multilevel, family-based, pediatric weight management interventions that also integrated technology. Studies were excluded that did not include at least 2 of the 4 components and that did not include technology to some degree.

RESULTS

A total of 15 articles were included in the scoping review. All articles included some type of technology in the intervention. Twelve articles included a family-based approach, and only 1 article fully used a holistic approach to family-based, pediatric weight management that included technology and integrated clinical and community approaches to address the complexity of childhood obesity.

CONCLUSIONS

There are several family-based, pediatric weight management interventions that incorporate an eHealth component. There is a gap in the literature about programs that use both technology and integrate multilevel clinical and community approaches for treatment. Additionally, gaps exist in information about adolescent, family-based, weight management interventions, and there are opportunities for nutrition and dietetic professionals to become more involved with technological and multilevel approaches in family-based pediatric weight management.

Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities

The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.

college students: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy

INTRODUCTION

There are documented inequities in eating disorders (EDs) by gender and race/ethnicity, yet, little is known about population-level prevalence of ED risk factors, symptoms, and diagnosis at the intersection of diverse gender and racial/ethnic identities.

METHODS

Data from the Healthy Minds Study 2015-2019 (N = 251,310 U.S. university students) were used in a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). Participants were nested in 35 intersectional strata given by all combinations of 5 gender and 7 racial/ethnic categories. Multilevel logistic models with participants at level 1 and intersectional strata at level 2 were used to estimate stratum-specific predicted prevalence estimates for self-reported thin-ideal internalization, ED symptoms, and ED diagnosis. The variance partition coefficient (VPC) was calculated to quantify the contextual effect of the strata.

RESULTS

There was considerable heterogeneity in the predicted prevalence of our ED outcomes across the strata (e.g., .3%-18.3% for ED diagnoses). There were large disparities in all three outcomes, with transgender participants of color having a higher predicted prevalence than expected based on the additive effects of gender and race/ethnicity. Moderation by race/ethnicity was also apparent, such that racial/ethnic disparities were wider within the cisgender groups relative to the transgender groups. VPCs indicated that ~10% of the total variance in ED outcomes was due to intersectionality between gender and race/ethnicity, over and above variance due to individual-level differences.

CONCLUSION

Findings suggest that gender and racial/ethnic disparities in EDs are interrelated, underscoring the need to develop preventive interventions centering health equity.

PUBLIC SIGNIFICANCE

Despite evidence that sexism, racism, and cissexism (i.e., anti-transgender prejudice) can impact EDs risk, little research examines the social patterning of EDs at the intersection of diverse gender and racial/ethnic identities. Using data from a sample of 250,000 U.S. university students, this study found that gender and racial/ethnic disparities in eating disorder risk are interrelated, highlighting the need to develop health equity centered preventive interventions.

Modern contraceptive use and associated factors among reproductive-age women in Ethiopia: multilevel analysis evidence from 2019 Ethiopia mini demographic and health survey

BACKGROUND

Despite the high fertility and population growth rates, the use of modern contraceptives remains low in low- and middle-income countries. Different pocket-sized studies on the use of modern contraceptive methods conducted in various parts of Ethiopia have been extremely varied and ambiguous. Therefore, this study aimed to assess modern contraceptive use and its associated factors in women of reproductive age in Ethiopia.

METHODS

Cross-sectional data from the Ethiopia Interim Demographic Health Survey (EMDHS) 2019 in a stratified, two-stage, and cluster sampling study. Multilevel binary logistic regression analysis was used to fit the associated factors. The interclass correlation (ICC), median odds ratio (MOR), proportional change variance (PVC), and deviance were used for model comparison and fitness. The adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to identify the significant factors of modern contraceptive use.

RESULT

The multilevel analysis demonstrated that Orthodox religion [AOR = 1.7; 95%CI: 1.4-2.10] protestant religion [AOR = 1.2; 95%CI: 0.93-1.62], married [AOR = 4.2; 95%CI: 1.93-9.07], primary education [AOR = 1.5; 95%CI: 1.26-1.76], secondary education [AOR = 1.36; 95%CI: 1.04-1.77 [AOR = 1.89; 95%CI: 1.37-2.61], middle [AOR = 1.4; 95%CI: 1.14-1.73], rich [AOR = 1.3; 95%CI: 1.06-2.68] were positively associated with modern contraceptive utilization, while the age group of 40-49 [AOR = 0.45, 95% CI: 0.34-0.58], and high community poverty [AOR = 0.62; 95%CI: 0.46-0.83] were negatively associated with modern contraceptive utilization.

CONCLUSION

The prevalence of modern contraception in Ethiopia remains low. Maternal age, religion, maternal education, marital status, wealth index, region, and community poverty were significant predictors of modern contraceptive utilization in Ethiopia. Governments and non-governmental organizations should expand their public health programs to poorer communities to increase the use of modern contraception in the country.

Intraindividual Changes in Political Identity Strength (But Not Direction) Are Associated With Political Animosity in the United States and the Netherlands

We test if within-person changes in political identities are associated with within-person changes in political animosity in two longitudinal studies (United States N = 552, Waves = 26; Netherlands N = 1,670, Waves = 12). Typical studies examine cross-sectional associations without assessing within-person change. Our work provides a stronger test of the relationship. We find that within-person changes in the strength of people's ideological and partisan identities are associated with increased political animosity. We found no such associations with within-person changes in identity direction. These patterns were robust to covariates and emerged in both studies. In addition to these average effects, we found substantial heterogeneity across participants in the associations among identity strength, identity direction, and political animosity. We did not find robust and replicable moderators for this heterogeneity. These findings suggest that identity strength (but not identity direction) is a key, if heterogenous, factor in changes in political animosity.

Using Dynamic Structural Equation Modeling to Examine Between- and Within-Persons Factor Structure of the DASS-21

The recent integration of traditional time series analysis and confirmatory factor analysis techniques allows researchers to evaluate the psychometric properties of measurement instruments at between- and within-persons levels while accounting for autoregressive dependencies. The current study applies a dynamic structural equation modeling (SEM) latent factor analysis (i.e., DSEM-CFA) to a sample of 333 individuals who completed the DASS-21 at their regular therapy sessions. The results of the DSEM-CFA illuminate the reliability, invariance, and structural features of each DASS-21 subscale both between and within persons. The results suggest that the DASS-21 reliably measures depression, anxiety, and stress symptoms when evaluating differences between persons, but does not reliably assess within-persons fluctuations in symptoms over time. The results also suggest that currently accepted methods of modeling sensitivity to change within an instrument are likely lacking and the DSEM-CFA provides insight into reliability within and between persons, which is extremely important for instruments used across time.

Toward a new conceptualization of resilience at work as a meta-construct?

Organizations of all kinds are faced with multiple demands for adaptation of increasing frequency and amplitude due to such factors as reorganizations, climate change, pandemics, and labor shortages. This new reality requires our organizations to anticipate, adjust, and demonstrate resilience. The study of resilience at work relies on the comprehension of how organizational systems, as well as their work collectives and members, manage to overcome adversity without suffering from irreversible damage. However, the study of this phenomenon of interest contains grey areas concerning both its definition, its conceptualization, and the dynamic processes that underlie it. This theoretical paper addresses these different issues by providing first, a conceptual content analysis of the most frequently used definitions and second, a new conceptualization of resilience at work as a resource, either individual or collective. Moreover, we suggest a multilevel, dynamic, and virtuous conceptual approach to resilience at work, relying on both bottom-up and top-down flows. Accordingly, we formulate different theoretical propositions upon which future empirical research can draw to analyze the relationships between individual, team, and organizational resilience. Building on a conservation of resources lens, we offer a novel contribution to the resilience in the workplace literature, by providing an integrative and multilevel theory of resilience at work that highlights both the processual and interpersonal nature of its emergence, and the organizational levers that can foster it.

Pretrauma risk factors and posttraumatic stress disorder symptoms following subsequent exposure: Multilevel and univariate meta-analytical approaches

The endeavour to comprehend why certain individuals develop posttraumatic stress disorder (PTSD) symptoms subsequent to experiencing traumatic events, while others do not, underscores the paramount importance of pretraumatic risk factors. This meta-analysis summarises the extant results of studies assessing risk factors prior exposure and PTSD symptoms following an index event on the same participants. It includes 43 studies (N = 19,239) yielding 174 effect sizes of pretraumatic risk factors categories such as demographic factors, cognitive factors, personality traits, coping styles, psychopathology, psychophysiological and environmental factors, which were examined using a three-level meta-analysis. Additionally, univariate random-effects meta-analyses were performed to separately investigate individual risk factors reported in more than one study. The findings revealed significant, small and medium associations for all categories, except for demographic factors and coping styles, also highlighting that certain individual risk factor domains (i.e. previous mental disorders, negative emotionality, sleep complaints and PTSD symptoms) represent the strongest predictors for PTSD symptoms after subsequent exposure. Several moderators were also investigated for individual risk factors. Future research could benefit from considering the interplay of pretraumatic risk factors to draw a more complex picture of the aetiology and underlying mechanisms of PTSD symptoms.

Between-Level Incongruences in Human Positivity

Humans now understand the world as multilevel in nature. For example, societies emerge from individuals, and general experiences of life consist of specific aspects and momentary episodes. A critical feature of multilevel phenomena is between-level incongruences. Applied to human positivity, this means that positive higher-level units are not simply composed of positive lower-level units and that what is good for lower-level units may not be good for higher-level units (and vice versa). For example, killjoys may improve societal well-being, personal achievement may require giving up on certain goals, and a happy life may not arise from simply happy moments. In this article, I provide examples (organized by the positive outcome of well-being and performance and by the social, structural, and temporal forms of multilevel phenomena) to show that such between-level incongruences are ubiquitous. Next, I analyze a few mechanisms that may govern the diverse instantiations of between-level incongruences in positivity. Finally, I discuss implications of this perspective, such as why positivity claims should always qualify their level of analysis; how psychological science may benefit from a multilevel, dynamical, and computational perspective; and how to improve human positivity in light of between-level incongruences.

Racial/Ethnic Disparities in Prostate Cancer 5-Year Survival: The Role of Health-Care Access and Disease Severity

INTRODUCTION

Prostate cancer (PCa) exhibits one of the widest racial and socioeconomic disparities. PCa disparities have also been widely linked to location, as living in more deprived regions was associated with lower healthcare access and worse outcomes. This study aims to examine PCa survival across various USA counties in function of different socioeconomic profiles and discuss the role of potential intermediary factors.

METHODS

The SEER database linked to county-level SES was utilized. Five-year PCa-specific survival using the Kaplan-Meier method was performed for five racial/ethnic categories in function of SES quintiles. Multilevel Cox proportional hazards regression was performed to assess the relationship between county-level SES and PCa survival. Multivariate regression analysis was performed to examine the role of healthcare utilization and severity.

RESULTS

A total of 239,613 PCa records were extracted, and 5-year PCa-specific survival was 94%. Overall, living in counties in the worst poverty/income quintile and the worst high-school level education increased PCa mortality by 38% and 33%, respectively, while the best bachelor's-level education rates decreased mortality risk by 23%. Associations varied considerably upon racial/ethnic stratification. Multilevel analyses showed varying contributions of individual and area-level factors to survival within minorities. The relationship between SES and PCa survival appeared to be influenced by healthcare utilization and disease stage/grade.

DISCUSSION

Racial/ethnic categories responded differently under similar county-level SES and individual-level factors to the point where disparities reversed in Hispanic populations. The inclusion of healthcare utilization and severity factors may provide partial early support for their role as intermediaries. Healthcare access (insurance) might not necessarily be associated with better PCa survival through the performance of biopsy and or/surgery. County-level education plays an important role in PCa decision making as it might elucidate discussions of other non-invasive management options.

CONCLUSIONS

The findings of this study demonstrate that interventions need to be tailored according to each group's needs. This potentially informs the focus of public health efforts in terms of planning and prioritization. This study could also direct further research delving into pathways between area-level characteristics with PCa survival.

Using Multilevel Negative Binomial Modeling to Detect Active Smoking in Colorectal Cancer Screening

BACKGROUND

Multilevel analysis, in several forms, has been extensively utilized over the past few decades. While utilizing for colorectal cancer (CRC) screening may be unclear, especially at community level. The study aimed to explain the use of multilevel negative binomial analysis, developed as a practical guide through data obtained from a study of CRC screening in Thailand.

METHOD

We analyzed the data of 2,475 fecal immunochemical test (FIT) cases in treatment arms from a population-based randomized controlled trial for CRC screening in the Khon Kaen province of Thailand. We summarized the statistical methodology, highlighting the advantages and disadvantages of data analysis using a multilevel negative binomial method compared with a standard negative binomial approach based on the data obtained in the randomized controlled trial for CRC screening; where active smoking and fecal hemoglobin (f-Hb) concentration were considered as the main exposure and outcome, respectively.

RESULTS

Our findings showed differences of significant value and magnitude in the effects of both methods. Active smoking was statistical significantly with an f-Hb concentration IRRadj = 1.47 (95%, CI: 1.01-2.14) through the use of the standard negative binomial method, whereas the multilevel negative binomial approach produced a non-statistical significance of IRRadj = 1.30 (95%, CI: 0.89-1.90).

CONCLUSION

Utilizing a standard statistical approach in CRC screening, the data analyzed were equal to zero. Hierarchical data, based on contextual factors and using a multilevel modeling approach, must be addressed. The f-Hb concentration, occurred over-dispersion, which implies that further studies utilize over-dispersion for improved appropriate statistical analysis.

Tunable Resistive Switching Behaviors and Mechanism of the W/ZnO/ITO Memory Cell

A facile sol-gel spin coating method has been proposed for the synthesis of spin-coated ZnO nanofilms on ITO substrates. The as-prepared ZnO-nanofilm-based W/ZnO/ITO memory cell showed forming-free and tunable nonvolatile multilevel resistive switching behaviors with a high resistance ratio of about two orders of magnitude, which can be maintained for over 10³ s and without evident deterioration. The tunable nonvolatile multilevel resistive switching phenomena were achieved by modulating the different set voltages of the W/ZnO/ITO memory cell. In addition, the tunable nonvolatile resistive switching behaviors of the ZnO-nanofilm-based W/ZnO/ITO memory cell can be interpreted by the partial formation and rupture of conductive nanofilaments modified by the oxygen vacancies. This work demonstrates that the ZnO-nanofilm-based W/ZnO/ITO memory cell may be a potential candidate for future high-density, nonvolatile, memory applications.

Utility of a slopes difference test for probing longitudinal multilevel aptitude treatment interactions: a simulation

To determine which interventions work best for which students, precision education researchers can examine aptitude-treatment interactions (ATI) or skill-by-treatment interactions (STI) using longitudinal multilevel modeling. Probing techniques like the slopes difference test fit an ATI or STI framework, but power for using slopes difference tests in longitudinal multilevel modeling is unknown. The current study used simulation to determine which design factors influence the power of slopes difference tests. Design factors included effect size, number of waves, number of clusters, participants per cluster, proportion of assignment to the treatment group, and intraclass correlation. Of these factors, effect size, number of waves, number of clusters, and participants per cluster were the strongest determinants of power, model convergence, and rates of singularity. Slopes difference tests had greater power in longitudinal multilevel modeling than where it is originally utilized: multiple regression.

Effectiveness of multilevel interventions based on socio-ecological model to decrease sedentary time in children: a systematic review of controlled studies

Objectives

Preventive actions of sedentary behavior (SB) based on the socio-ecological model are needed among children and young adolescents. The aim of this systematic review is to ascertain the effectiveness of multilevel interventions (i.e., involving consideration of at least two interventional levels) in reducing sedentary time (ST) in children aged 5-12 years.

Methods

Adhering to PRISMA guidelines, a systematic literature search was conducted in three databases (PsyInfo, PubMed and ERIC) until July 2021.

Results

30 trials met the eligibility criteria and were included. They showed acceptable (< 8, n = 18) and high (≥ 8, n = 12) methodological quality. Among studies targeting 2 (n = 2), 3 (n = 19) and 4 levels (n = 9), 1 (50%), 9 (47%) and 7 (78%) were effective and reported significant reduction of ST, respectively.

Conclusion

Interventions tend to be more effective when they involve 4 levels, using both agentic and structural strategies (targeting intrinsic determinants, in the organizational environment of the child). Findings underline the relevance of multilevel strategies to reduce ST in children, but also raise issues about operationalization of the socio-ecological perspective.

Systematic review registration

PROSPERO, identifier: CRD42020209653.

Clinical Outcomes of Selective Single-Level Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression of Multilevel Lumbar Spinal Stenosis and Risk Factors of Reoperation

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To investigate the usefulness of selective single-level lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) in patients with radiological multilevel lumbar spinal stenosis (LSS) and clarify the predictive factors of reoperation.

METHODS

A total of 128 patients who underwent LE-ULBD of radiological multilevel LSS were retrospectively examined. Single-level decompression was selected clinically and supplemented radiologically. Clinical outcomes were assessed with the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), numeric rating scale (NRS), and Macnab criteria (mean follow-up period, 28.6 months [range, 24-63 months]). Stenosis severity was classified as grades M (moderate) and S (severe) based magnetic resonance imaging findings. Multilevel LSS was classified as SS, SM, and MM according to the number of grade S levels.

RESULTS

The follow-up rate was 74.2%. All domains of the JOABPEQ and NRS significantly improved during follow-up. The Macnab outcome classification was "excellent" or "good" in 77.9% of the patients. The reoperation rate was 10.2%. None of the patients with unilateral symptoms required reoperation. The SS type was a significant risk factor of reoperation for multilevel LSS with bilateral symptoms. Additional LE-ULBD was performed for all the reoperation with the "excellent" or "good" results of the Macnab criteria in 69% of the patients.

CONCLUSIONS

Selective single-level LE-ULBD provided favorable results for multilevel LSS. However, information about the risks of reoperation for multilevel severe stenosis with bilateral symptoms should be shared between surgeons and patients.

Correlates of age at first birth among women in Ethiopia: use of multilevel survival analysis models

Introduction

the timing of birth of the first child has a direct relationship with fertility in general and health and future career including further education of a mother in particular. The objective of this study was to identify factors significantly associated with the time to the first birth among women in Ethiopia.

Methods

a cross-sectional study was conducted using data from the 2016 Ethiopian Demographic and Health Survey (EDHS). The study subjects were married women and men aged 15 to 49 in randomly selected households across Ethiopia and two stage stratified random sampling technique was used to select study subjects. Log logistic-Gamma shared frailty model was used to identify factors associated with the length of time spent until the first birth.

Results

the median age at first birth for women living in Ethiopia was 20 years, whereas the minimum and maximum ages at first birth were 11 and 49 years respectively. Age at first sex, age at first cohabitation, sex of household head, place of residence, religion, education level, contraceptive use and exposure to media were significant correlates of age at first birth of women in Ethiopia. Higher level of education was associated with increased age at first birth. Women who use contraceptive, women living in urban areas, women having exposure to media and female headed households had longer time to first birth compared to their counterparts.

Conclusion

the different regions of Ethiopia have significant differences in the age of women during their first birth. Most of the factors associated with the time to first child in this study were related to education of women. Investing in education and educating women plays critical roles in regulating fertility of a nation and health of women.

Incomplete HPV Vaccination among Individuals Aged 27-45 Years in the United States: A Mixed-Effect Analysis of Individual and Contextual Factors

Background: In the United States, the human papillomavirus (HPV) vaccine is approved for use in individuals up to age 45. Individuals 15 years and older require three doses of the vaccine to complete the recommended dosing series. Incomplete HPV vaccination rates (i.e., one or two doses) among those over age 26, however, remain high. This study examined the independent effects of individual- and neighborhood-level factors on incomplete HPV vaccination rates in the United States (U.S.) among those aged 27-45 years. Methods: This retrospective cohort study used administrative data from Optum's de-identified Clinformatics® Data Mart Database to identify individuals aged 27-45 years who received one or more doses of HPV vaccine between July 2019 and June 2022. Multilevel multivariable logistic regression models were applied to the data on 7662 individuals identified as being fully or partially vaccinated against HPV, nested within 3839 neighborhoods across the U.S. Results: Approximately half of the patients in this study (52.93%) were not completely vaccinated against HPV. After adjusting for all other covariates in the final model, being older than 30 years old decreased the odds of not completing the HPV vaccine series. Participants living in South-region neighborhoods of the U.S. had enhanced odds of not completing the vaccine series compared with those residing in Northeast-region neighborhoods (aOR 1.21; 95% CrI 1.03-1.42). There was significant clustering of incomplete HPV vaccination rates at the neighborhood level. Conclusions: This study revealed that individual- and neighborhood-level factors were associated with the risk of not completing the HPV vaccine series among individuals aged 27-45 years in the U.S. Interventions to improve HPV vaccination series completion rates for this age group should take into consideration both individual and contextual factors.

Risk Factors of Subsidence after Anterior Cervical Discectomy and Fusion with Double Cylindrical Cages for Cervical Degenerative Diseases: Minimum Two-year Follow-up Results

Cylindrical cages were known to cause subsidence after anterior cervical discectomy and fusion (ACDF); hence, they were gradually replaced by box-shaped cages. However, this phenomenon has been inconclusive due to limited information and short-term results. Therefore, this study aimed to clarify risk factors for subsidence after ACDF using titanium double cylindrical cages with mid-term follow-up periods. This retrospective study included 49 patients (76 segments) diagnosed with cervical radiculopathy or myelopathy caused by disc herniation, spondylosis, and ossification of the posterior longitudinal ligament. These patients underwent ACDF using these cages from January 2016 to March 2020 in a single institution. Patient demographics and neurological outcomes were also examined. Subsidence was defined as a ≥3-mm segmental disc height decrease at the final follow-up lateral X-ray compared to that on the next day postoperatively. Subsidence occurred in 26 of 76 segments (34.7%) within the follow-up periods of approximately three years. Multivariate analysis using a logistic regression model demonstrated that multilevel surgery was significantly associated with subsidence. The majority of patients achieved good clinical outcomes based on the Odom criteria. This study demonstrated that multilevel surgery was the only risk factor of subsidence post-ACDF with double cylindrical cages. Despite the relatively high subsidence rates, the clinical outcome was almost good at least during the mid-term period.

Provider- and Facility-Level Variation in Precancerous Cervical Biopsy Diagnoses

OBJECTIVES

Reproducibility of cervical biopsy diagnoses is low and may vary based on where the diagnostic test is performed and by whom. Our objective was to measure multilevel variation in diagnoses across colposcopists, pathologists, and laboratory facilities.

METHODS

We cross-sectionally examined variation in cervical biopsy diagnoses within the 5 sites of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR I) consortium within levels defined by colposcopists, pathologists, and laboratory facilities. Patients aged 18 to 65 years with a colposcopy with biopsy performed were included, with diagnoses categorized as normal, cervical intraepithelial neoplasia grade 1 (CIN1), grade 2 (CIN2), and grade 3 (CIN3). Using Markov Chain Monte-Carlo methods, we fit mixed-effects logistic regression models for biopsy diagnoses and presented median odds ratios (MORs), which reflect the variability within each level. Median odds ratios can be interpreted as the average increased odds a patient would have for a given outcome (e.g., CIN2 or CIN3 vs normal or CIN1) when switching to a provider with higher odds of diagnosing that outcome. The MOR is always 1 or greater, and a value of 1 indicates no variation in outcome for that level, with higher values indicating greater variation.

RESULTS

A total of 130,110 patients were included who received care across 82 laboratory facilities, 2,620 colposcopists, and 489 pathologists. Substantial variation in biopsy diagnoses was found at each level, with the most occurring between laboratory facilities, followed by pathologists and colposcopists. Substantial variation in biopsy diagnoses of CIN2 or CIN3 (vs normal or CIN1) was present between laboratory facilities (MOR: 1.26; 95% credible interval = 1.19-1.36).

CONCLUSIONS

Improving consistency in cervical biopsy diagnoses is needed to reduce underdiagnosis, overdiagnosis, and unnecessary treatment resulting from variation in cervical biopsy diagnoses.

Disease Focused Integrated Care - a New Model of Healthcare Delivery for the Treatment of Skin Cancer

Introduction

As the most common cancer in Australia, skin cancer generates a considerable health burden. This study outlines the establishment of a new model of integrated care for the diagnosis and management of skin cancer.

Methods

A new model of integrated care was established to provide access to all aspects of skin cancer management. General practitioners (GPs) were upskilled through hands-on training and a 6-month skin cancer education program and partnered with specialist Dermatologists and Plastic Surgeons co-located in the same clinic. Data including median wait times between the initial consultation and treatment were prospectively collected and compared patients seen through the integrated pathway to patients referred from their primary GP to specialist Dermatologists and Plastic Surgeons directly (non-integrated pathway). The percentage of patients needing co-consultation with a specialist in the integrated pathway was also measured over time.

Results

A total of 25341 patients were seen from the commencement of the clinic in August 2015 to June 2021. In 2017 and 2018 the median wait time to be treated was 7 days for the integrated model compared to 54 days (2017) and 46 days (2018) for non-integrated care (p < 0.0001). The percentage of GPs requesting specialist co-consultations for assessment of skin cancer fell from 98% in 2015, to 5.6% in 2021. Histopathology shows that 66% of lesions excised by GPs in this model were malignant or pre-malignant.

Conclusions

This study firstly shows a significant reduction in time to treatment in an integrated skin cancer model over traditional models of health. Secondly it demonstrates GP upskilling over time in the integrated program. Integrating GP and specialist medical practitioners in the treatment of skin cancer offers potential for more efficient, accessible, and affordable care. This cooperative, co-located model may provide a template for the integrating the management of other conditions.

Femtosecond Laser Ablation of Quantum Dot Films toward Physical Unclonable Multilevel Fluorescent Anticounterfeiting Labels

Femtosecond laser ablation (FsLA) technology has been demonstrated to achieve programmable ablation and removal of diverse materials with high precision. Owing to the cross-scale and digital processing characteristics, the FsLA technology has attracted increasing interest. However, the moderate repeatability of FsLA limits its application in the fabrication of advanced micro-/nanostructures due to the nonidentity of each laser pulse and fluctuation of environment. Fortunately, moderate repeatability combined with programmable ablation and high precision perfectly matches with the technical requirements of a physical unclonable fluorescent anticounterfeiting label. Herein, we applied FsLA to quantum dot (QD) films to fabricate a physical unclonable multilevel fluorescent anticounterfeiting label. Visual Jilin University logos, quick response (QR) codes, microlines, and microholes have been achieved for the multilevel anticounterfeiting functions. Of particular significance, the microholes with a macroidentical and microidentifiable geometry guarantee the physical unclonable functions (PUFs). Moreover, the fluorescent anticounterfeiting label is compatible with deep learning algorithms that facilitate authentication to be convenient and accurate. This work shows a fantastic future potential to be a core anticounterfeiting technique for commercial products and drugs.

Effects of Housing Deprivation on Health: Empirical Evidence from Spain

Severe housing deprivation rates in Spain have tripled in just four years, affecting 3.4% of the population in 2020, with a higher incidence among the low-income population (9.2%). Despite the social aspect of the problem, minimal research has been carried out in Spain on the effects that the various forms of housing deprivation have on health. This study analyzes the impact of housing deprivation on health outcomes, with the objective of achieving results that facilitate the creation of improved public policies. Microdata are used from the Living Conditions Survey carried out by the National Institute of Statistics for the period 2009-2019, and several multilevel logistic regression models are presented to control for possible regional differences. The results show that the elements with the greatest effect on objective health are noise, leaks and harmful temperatures in housing. In addition, environmental factors, such as pollution, neighborhood crime and the number of units in a given apartment building, can be added to the list. As a result, we conclude that there are certain structural and environmental elements in housing and the environment in which is located that have a more intense impact on objective health and on the subjective perception of a person's state of health.

Teachers' bullying-related cognitions as predictors of their responses to bullying among students

BACKGROUND

Teachers may play a key role in reducing bullying by responding to incidents among students. Inspired by the theory of planned behaviour, several studies have investigated teachers' bullying-related cognitions as predictors of their responses to bullying.

AIMS

This study investigated whether six teachers' bullying-related cognitions (i.e., perceived seriousness, empathy, attitudes, self-efficacy and attribution of the bullying) predicted five student-perceived teachers' responses (i.e., Non-Intervention, Disciplinary Methods, Victim Support, Mediation and Group Discussion) over time. By examining this objective, more insight into student perceptions of teachers' responses to bullying could also be provided.

SAMPLE

In total, 999 upper elementary school students (M _age  = 10.61 at Wave 1, SD _age  = .90; 53.6% girls) and their 59 teachers (M _age  = 39.61 at W1, SD _age  = 11.60; 79.7% female) participated.

METHODS

A bullying questionnaire was administered in three waves to assess students' perceptions of the teachers' responses. Teachers reported bullying-related cognitions in the first wave. Multilevel analyses were used to investigate the relative contribution of the predictors on the teachers' responses over time.

RESULTS

None of the teachers' bullying-related cognitions significantly predicted the teachers' specific responses.

CONCLUSIONS

The findings suggest that teachers' bullying-related cognitions are not reflected in their responses to bullying as perceived by students. Moreover, the findings indicate that students' perceptions of teachers' responses vary widely within classrooms and over time. Student- and teacher-reported teachers' responses might differ, and these possible differences should be taken into account.

Spatial and Multilevel Analysis of Unscheduled Contraceptive Discontinuation in Ethiopia: Further analysis of 2005 and 2016 Ethiopia Demography and Health Surveys

Background

Unscheduled discontinuation of contraceptives is a public health problem among women of reproductive age. Particularly, it is associated with unwanted pregnancies that lead to maternal and child mortality, but little is known about the spatial distribution of the problem. Therefore, this study aims to assess the spatial distribution and associated factors of unscheduled contraceptive discontinuation in Ethiopia.

Method

This study used secondary data from the Ethiopia Demography and Health Survey (EDHS) data of 2005 and 2016. The study population was women who used contraceptives in the preceding 5 years before the survey. A total of 2,327 and 3,858 eligible women were included in the final analysis of the 2005 and 2016 EDHS, respectively. For the spatial analysis, both the 2005 and the 2016 EDHS data were analyzed using ArcGIS version 10.7, while for multilevel regression analysis, the 2016 EDHS data were used. The final model reported an adjusted odds ratio (AOR) with a 95% confidence interval (CI), and a p-value of 0.05 was used to declare statistical significance.

Result

This study revealed that unscheduled discontinuation of contraceptives varied geographically, and hotspots were detected in the central, north, and eastern parts of Ethiopia. Moreover, diploma and higher education (AOR = 1.40; 95% CI: 1.01-1.95), urban residence (AOR = 1.37; 95% CI: 1.08-1.72), history of termination of pregnancy (AOR = 1.47; 95% CI: 1.14-1.94), married women (AOR = 10.79; 95% CI: 6.98-16.69), separated/divorced women (AOR = 1.54: 95% CI: 1.07-2.30), -two to four number of children (AOR = 1.46; 95% CI: 1.15-1.84), and involvement in the decision-making process of contraceptive use (AOR = 39.26; 95% CI: 28.84-53.45) were all factors associated with unscheduled discontinuation of contraceptives.

Conclusion

This study revealed that unscheduled discontinuation of contraceptive distribution was significantly clustered in the central, north, and eastern parts of Ethiopia, as found in two surveys. The magnitude of this discontinuation increased from 2005 to 2016. The finding underscores that further interventions such as the availability of multiple mixed methods and improvement in women's decision-making ability in the choice of contraceptive methods and utilization are needed in hotspot areas of Ethiopia.

Biomechanical Comparison of Unilateral and Bilateral Pedicle Screw Fixation after Multilevel Lumbar Lateral Interbody Fusion

STUDY DESIGN

Human Cadaveric Biomechanical Study.

OBJECTIVES

Lumbar Lateral Interbody Fusion (LLIF) utilizing a wide cage has been reported as having favorable biomechanical characteristics. We examine the biomechanical stability of unilateral pedicle screw and rod fixation after multilevel LLIF utilizing 26 mm wide cages compared to bilateral fixation.

METHODS

Eight human cadaveric specimens of L1-L5 were included. Specimens were attached to a universal testing machine (MTS 30/G). Three-dimensional specimen range of motion (ROM) was recorded using an optical motion-tracking device. Specimens were tested in 3 conditions: 1) intact, 2) L1-L5 LLIF (4 levels) with unilateral rod, 3) L1-L5 LLIF with bilateral rods.

RESULTS

From the intact condition, LLIF with unilateral rod decreased flexion-extension by 77%, lateral bending by 53%, and axial rotation by 26%. In LLIF with bilateral rods, flexion-extension decreased by 83%, lateral bending by 64%, and axial rotation by 34%. Comparing unilateral and bilateral fixation, LLIF with bilateral rods reduced ROM by a further 23% in flexion-extension, 25% in lateral bending, and 11% in axial rotation. The difference was statistically significant in flexion-extension and lateral bending (P < .005).

CONCLUSIONS

Considerable decreases in ROM were observed after multilevel (4-level) LLIF utilizing 26 mm cages supplemented with both unilateral and bilateral pedicle screws and rods. The addition of bilateral fixation provides a 10-25% additional decrease in ROM. These results can inform surgeons of the incremental biomechanical benefit when considering unilateral or bilateral posterior fixation after multilevel LLIF.

Association of alcohol consumption with abortion among ever-married reproductive age women in Ethiopia: A multilevel analysis

Background

A miscarriage or a spontaneous loss of a pregnancy that occurs before the 20th week is an abortion. Even though numerous recommendations state that pregnant women should abstain from alcohol at all stages of pregnancy, alcohol intake among pregnant women is common. However, there are few papers addressing the effect of alcohol use on miscarriage using nationally representative data. Moreover, the association of alcohol use with abortion and its mechanisms is not well studied in the Ethiopian region. Therefore, the objective of the current study was to estimate the association of alcohol use with abortion rates among reproductive age (15-49) women in Ethiopia.

Methods

Using the most recent findings of the Ethiopian Demographic and Health Survey (EDHS), secondary data analysis was performed among pregnant women in Ethiopia. A total of 11,396 women between the ages of 15 and 49 years who were of reproductive age were included in the research. To characterize the study population, descriptive statistics were used. The variability was considered using the multilevel binary logistic regression model. A multilevel binary logistic model was used to determine the effect of alcohol intake on abortion while controlling for potential confounders. In the multivariable analysis, variables with a P-value of less than 0.05 were considered statistically significant for the response variable.

Results

The proportion of women who had an abortion was 10.46% with a 95% CI of 9.92-11.03. In the final model of the multilevel analysis, age group [adjusted odds ratio (AOR) = 6.13; 95% CI: 3.86-9.73], education level (AOR = 1.29; 95 and CI: 1.10-1.51), alcohol consumption (AOR = 1.38; 95% CI: 1.18-1.61), age at first sex (AOR = 1.20; 95% CI: 1.03-1.39), media exposure (AOR = 1.28, CI: 1.10-1.48), contraceptive use (AOR = 1.34, CI: 1.16-1.56), and occupation of respondent (AOR = 1.21, CI: 1.06-1.38) were identified to be significant determinants of abortion in Ethiopia.

Conclusion

Sexual and reproductive health education and family planning programs should target older women in the reproductive age group, women with primary educational status, working women, and those who initiated sexual intercourse at a younger age considering it could reduce abortion and unintended pregnancy. Furthermore, as part of sexual and reproductive health education, the adverse effect of alcohol consumption on abortion should be emphasized.

Disentangling motivation and engagement: Exploring the role of effort in promoting greater conceptual and methodological clarity

Conflation over motivation and engagement has historically impeded research and practice. One reason for this is because definition and measurement have often been too general or diffuse-especially in the case of engagement. Recently conceptual advances aimed at disentangling facets of engagement and motivation have highlighted a need for better psychometric precision-particularly in the case of engagement. To the extent that engagement is inadequately assessed, motivation research involving engagement continues to be hampered. The present study investigates multidimensional effort (a specific facet of engagement) and how it relates to motivation. In particular, we examine the associations between specific positive and negative motivation factors and dimensions of effort, thereby shedding further insight into how different types of motivation interplay with different types of engagement. Drawing on data from a sample of 946 Australian high school students in 59 mathematics classrooms at five schools, this study hypothesized a tripartite model of academic effort in terms of operative, cognitive, and social-emotional dimensions. A novel nine-item self-report Effort Scale measuring each of the three factors was developed and tested for internal and external validity-including its relationship with multidimensional motivation. Multilevel confirmatory factor analyses were conducted to test the factor structure and validity of multidimensional effort. Additionally, doubly-latent multilevel structural equation models were conducted to explore the hypothesized motivation → engagement (effort) process, and the role of student- and classroom-level background attributes as predictors of both motivation and effort. Results supported the hypothesized model of tripartite effort and its distinctiveness from motivation, and showed that key dimensions of motivation predicted effort at student- and classroom-levels. This study provides implications and suggestions for future motivation research and theorizing by (1) establishing evidence for the validity of a novel engagement framework (multidimensional effort), and (2) supporting future measurement and practice in academic engagement juxtaposed with multidimensional motivation-critical for better understanding engagement, and motivation itself.

Multilevel factors associated with inequities in multidisciplinary cancer consultation

OBJECTIVE

To assess changes in the prevalence of multidisciplinary cancer consultations (MDCc) over the last decade and examine patient, surgeon, hospital, and neighborhood factors associated with receipt of MDCc among individuals diagnosed with cancer.

DATA SOURCE

Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2006 to 2016.

STUDY DESIGN

We used time-series analysis to assess change in MDCc prevalence from 2007 to 2015. We also conducted multilevel logistic regression with random surgeon- and hospital-level effects to assess associations between patient, surgeon, neighborhood, and health care organization-level factors and receipt of MDCc during the cancer treatment planning phase, defined as the 2 months following cancer diagnosis.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries >65 years of age with surgically resected breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) stages I-III (n = 103,250).

PRINCIPAL FINDINGS

From 2007 to 2015, the prevalence of MDCc increased from 35.0% to 61.2%. Overall, MDCc was most common among patients with breast cancer compared to CRC and NSCLC. Cancer patients who were Black, had comorbidities, had dual Medicare-Medicaid coverage, were residing in rural areas or in areas with higher Black and Hispanic neighborhood composition were significantly less likely to have received MDCc. Patients receiving surgery at disproportionate payment-sharing or rural-designated hospitals had 2% (95% CI: -3.55, 0.58) and 17.6% (95% CI: -21.45, 13.70), respectively, less probability of receiving MDCc. Surgeon- and hospital-level effects accounted for 15% of the variance in receipt of MDCc.

CONCLUSIONS

The practice of MDCc has increased over the last decade, but significant geographical and health care organizational barriers continue to impede equitable access to and delivery of quality care across cancer patient populations. Multilevel and multicomponent interventions that target care coordination, health system, and policy changes may enhance equitable access to and receipt of MDCc.

Cultural stressors, internalizing symptoms, and parent-child alienation among Mexican-origin adolescents

Objective

The current study investigated the relation of various cultural stressors, parent-child alienation, and Mexican-origin adolescents' internalizing symptoms at both between- and within-person levels across the course of adolescence.

Background

Positive parent-child relationships can be a critical buffer against cultural stressors for Mexican-origin adolescents. However, it is unclear whether low levels of parent-child alienation (a) buffer the negative effects of different types of cultural stressors on internalizing symptoms and (b) function at the individual level more generally or during specific periods when adolescents experience high cultural stressors.

Method

The current study used a three-wave longitudinal dataset of 604 Mexican-origin adolescents (Wave 1: Mage = 12.41, SD = 0.97, 54% female, 75% born in the United States) and conducted multilevel regression analysis.

Results

At the between-person level, overall low parent-child alienation buffered the adverse effects of ethnic discrimination on anxiety and cultural misfit on depressive symptoms. There were no significant within-person-level interactions of parent-child alienation and cultural stressors on adolescent internalizing symptoms.

Implication

The findings suggest that interventions should aim to reduce parent-child alienation throughout the course of adolescence to alleviate the impact of cultural stressors on internalizing symptoms among Mexican-origin adolescents.

Improvements and Maintenance of Clinical and Functional Measures Among Rural Women: Strong Hearts, Healthy Communities-2. 0 Cluster Randomized Trial

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact.

METHODS

A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance.

RESULTS

Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: -3.15 kg [95% CI, -4.98 to -1.32]; P=0.008) and several secondary clinical (eg, waist circumference: -3.02 cm [-5.31 to -0.73], P=0.010; systolic blood pressure: -6.64 mmHg [-12.67 to -0.62], P=0.031; percent body fat: -2.32% [-3.40 to -1.24]; P<0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks.

CONCLUSIONS

This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03059472.

Substantive model compatible multilevel multiple imputation: A joint modeling approach

BACKGROUND

Substantive model compatible multiple imputation (SMC-MI) is a relatively novel imputation method that is particularly useful when the analyst's model includes interactions, non-linearities, and/or partially observed random slope variables.

METHODS

Here we thoroughly investigate a SMC-MI strategy based on joint modeling of the covariates of the analysis model. We provide code to apply the proposed strategy and we perform an extensive simulation work to test it in various circumstances. We explore the impact on the results of various factors, including whether the missing data are at the individual or cluster level, whether there are non-linearities and whether the imputation model is correctly specified. Finally, we apply the imputation methods to the motivating example data.

RESULTS

SMC-JM appears to be superior to standard JM imputation, particularly in presence of large variation in random slopes, non-linearities, and interactions. Results seem to be robust to slight mis-specification of the imputation model for the covariates. When imputing level 2 data, enough clusters have to be observed in order to obtain unbiased estimates of the level 2 parameters.

CONCLUSIONS

SMC-JM is preferable to standard JM imputation in presence of complexities in the analysis model of interest, such as non-linearities or random slopes.

Perinatal intimate partner violence and postpartum contraception timing among currently married women in Southern Ethiopia: A multilevel Weibull regression modeling

Background

Adopting contraception on time is a critical intervention for postpartum women, but violence exposure around pregnancy may interfere with postpartum contraceptive use behaviors. Hence, this study aimed to investigate the time duration of the first modern contraceptive adoption and its individual-and community-level predictors among postpartum women in the Wolaita zone, South Ethiopia.

Methods

A community-based prospective follow-up study was conducted among 1,292 postpartum women nested in 38 "Kebles" (clusters) using multistage-clustered sampling techniques. A multilevel Weibull regression model was employed to investigate predictors of time-to-method initiation after childbirth using STATA Version 14. Kaplan-Meier curve and Wilcoxon log-rank test were used to estimate time-to-modern contraceptive use across different variables. All variables with p-values <0.05 were considered for multivariate analysis. Adjusted time ratios (ATR) with 95 % CI were computed using Weibull accelerated failure time models.

Results

Of the respondents, 62% (95% CI: 59.1-64.5) had started the first modern contraception within a year after childbirth. The restricted mean survival time-to-postpartum modern contraceptive use was 6.28 months. Being a rural dweller (aTR: 1.44; 95% CI: 1.06-1.99) and living in the middle household wealth quintiles (aTR: 1.10; 95% CI: 1.02-1.19) predicted longer time duration to adopt first modern contraception by 44 and 10%, respectively. The women from the community with a high early marriage (aTR: 1.14; 95% CI: 1.01-1.28) took longer time to initiate modern postpartum methods. Furthermore, women who had no history of perinatal abuse took less time than those who had a history of abuse to start postpartum contraception (aTR: 0.71; 95% CI: 0.66-0.78).

Conclusion

Rural residence, poor household wealth status, history of perinatal abuse, and a high rate of early marriage in the community are predicted to lengthen the time duration to start modern postpartum contraception. Thus, community-level women's empowerment, particularly among rural women and integration of intimate partner violence screening into family planning counseling throughout the continuum of care will likely to improve postpartum contraception timing.

Porous Polyetheretherketone Interbody Cages for Anterior Cervical Discectomy and Fusion at 3 or More Levels: Clinical and Radiographic Outcomes

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) at 3 or more levels remains challenging, with reported high pseudarthrosis rates and implant-related complications. Porous surface polyetheretherketone (PEEK) interbody cages are newer implants for ACDF with limited data available for their use in ACDF procedures at 3 or more levels. The objective of this study was to assess the clinical and radiographic outcomes of porous PEEK devices for ACDF at 3 or more levels.

STUDY DESIGN

Retrospective case series.

METHODS

Consecutive patients who underwent primary ACDF for degenerative cervical disc disease at 3 or more levels with porous PEEK cages with anterior plate instrumentation were included. Clinical outcome scores, radiographic parameters, pseudarthrosis rates, and cage subsidence rates were assessed. Preoperative and postoperative clinical outcomes and radiographic measures were compared using paired t tests.

RESULTS

A total of 33 patients with ACDF at 3 or more levels with porous PEEK cages were included, with minimum 1-year follow-up. Two patients had cage subsidence (6.1%), and 1 patient had pseudarthrosis (3.0%). There were significant postoperative increases in overall cervical lordosis, sagittal vertical axis, fusion segment lordosis, T1 slope, and disc height. Clinical outcomes showed significant improvement from the preoperative visit to the final postoperative follow-up.

CONCLUSIONS

High rates of fusion (97.0%) were observed in this challenging patient cohort, which compares favorably with previously published rates of fusion in ACDF at 3 or more levels.

CLINICAL RELEVANCE

The optimal management of cervical spinal pathology regarding approach, technique, and implants used is an active area of ongoing investigation. The high levels of radiographic and clinical success utilizing a relatively novel implant material in a high-risk surgical cohort reported here may influence surgical decision making.

LEVEL OF EVIDENCE: 3

Predictors of Community-Based Health Insurance in Ethiopia via Multilevel Mixed-Effects Modelling: Evidence from the 2019 Ethiopia Mini Demography and Health Survey

Background

The World Health Organization has endorsed a community-based health insurance scheme (CBHIS) as a shared financing plan to improve access to health services and ensure universal coverage of the healthcare delivery system. Such a contributory scheme is the most likely option to provide health insurance coverage when governments cannot offer direct health care support. Despite improvements in access to current healthcare services, Ethiopia’s healthcare delivery remained low, owing to the country’s underdeveloped healthcare finance system. As a result, the present study assessed CBHIS coverage and its predictors in Ethiopia at the individual and community level.

Methods

The availability of CBHIS was checked via a criterion: at least one of the cluster respondents had to be enrolled in CBHIS. This study was based on secondary data from the Ethiopia Mini Demography and Health Survey (EMDHS) 2019 and included 7724 respondents. The study population was described using percentage and frequency. Four multilevel mixed-effects logistic regression modelling stages were performed to control for variations due to heterogeneity across clusters, and determinant predictors of CBHIS enrollment were outplayed.

Results

The prevalence of CBHIS enrollment in Ethiopia was 33.13%. Rural residents were 3.218 times (AOR = 3.218; 95% CI: 1.521, 6.809), male household heads were 1.574 times (AOR = 1.574, 95% CI: 1.105, 2.241), getting funds from the safety net program were times 2.062 (AOR = 2.062, 95% CI: 1.297, 3.279), attending the primary educational level was 1.686 times (AOR = 1.686, 95% CI: 1.007, 2.821), bank accounts were 1.373 times (AOR = 1.373, 95% CI: 1.052, 1.792), and wealth index was 1.356 times (AOR = 1.356, 95% CI: 1.001, 1.838) more likely associated with CBHIS coverage, whereas the regions, the other religions, and women aged 20–24 had lower odds of CBHIS coverage.

Conclusion

In Ethiopia, regional healthcare expenditure per capital, religious affiliation, women age range, residents, sex of household head, funds from the safety net program, formal educational level, and having bank accounts were associated with community-based health insurance scheme coverage.

Room-Temperature Fabricated Multilevel Nonvolatile Lead-Free Cesium Halide Memristors for Reconfigurable In-Memory Computing

Recently, conductive-bridging memristors based on metal halides, such as halide perovskites, have been demonstrated as promising components for brain-inspired hardware-based neuromorphic computing. However, realizing devices that simultaneously fulfill all of the key merits (low operating voltage, high dynamic range, multilevel nonvolatile storage capability, and good endurance) remains a great challenge. Herein, we describe lead-free cesium halide memristors incorporating a MoO_X interfacial layer as a type of conductive-bridging memristor. With this design, we obtained highly uniform and reproducible memristors that exhibited all-around resistive switching characteristics: ultralow operating voltages (<0.18 V), low variations (<30 mV), long retention times (>10⁶ s), high endurance (>10⁵, full on/off cycles), record-high on/off ratios (>10¹⁰, smaller devices having areas <5 × 10^-4 mm²), fast switching (<200 ns), and multilevel programming abilities (>64 states). With these memristors, we successfully implemented stateful logic functions in a reconfigurable architecture and accomplished a high classification accuracy (ca. 90%) in the simulated hand-written-digits classification task, suggesting their versatility in future in-memory computing applications. In addition, we exploited the room-temperature fabrication of the devices to construct a fully functional three-dimensional stack of memristors, which demonstrates their potential of high-density integration desired for data-intensive neuromorphic computing. High-performance, environmentally friendly cesium halide memristors provide opportunities toward next-generation electronics beyond von Neumann architectures.

Church Contextual Factors Associated With Latinx Physical Activity and Park Use

Churches can be important settings for promoting physical activity (PA) among Latinx populations. Little is known about what factors across the church context-social, organizational, and physical (outdoor spaces)-are associated with Latinx PA to inform faith-based PA interventions. This study investigated associations of church contextual factors with Latinx PA. We used cross-sectional data from a Latinx adult sample recruited from 6 churches that each had a nearby park in Los Angeles, California (n = 373). Linear or logistic regression models examined associations of church PA social support, PA social norms, perceived quality and concerns about the park near one's church, and church PA programming with 4 outcomes: accelerometer-based moderate-to-vigorous PA (MVPA) and self-reported adherence to PA recommendations, use of the park near one's church, and park-based PA. Park quality and concerns were positively associated with using the park near one's church. Church PA programming was positively associated with park-based PA. None of the factors were related to accelerometer-based MVPA or meeting PA recommendations. Findings suggest targeting church PA programming and nearby parks may be key to improving Latinx park use. Church and local parks department partnerships may help enhance park conditions to support churchgoing Latinx PA and health.

The Utility of Mixed Models in Sport Science: A Call for Further Adoption in Longitudinal Data Sets

PURPOSE

Sport-science research consistently contains repeated measures and imbalanced data sets. This study calls for further adoption of mixed models when analyzing longitudinal sport-science data sets. Mixed models were used to understand whether the level of competition affected the intensity of women's rugby league match play.

METHODS

A total of 472 observations were used to compare the mean speed of female rugby league athletes recorded during club-, state-, and international-level competition. As athletes featured in all 3 levels of competition and there were multiple matches within each competition (ie, repeated measures), the authors demonstrated that mixed models are the appropriate statistical approach for these data.

RESULTS

The authors determined that if a repeated-measures analysis of variance (ANOVA) were used for the statistical analysis in the present study, at least 48.7% of the data would have been omitted to meet ANOVA assumptions. Using a mixed model, the authors determined that mean speed recorded during Trans-Tasman Test matches was 73.4 m·min-1, while the mean speeds for National Rugby League Women and State of Origin matches were 77.6 and 81.6 m·min-1, respectively. Random effects of team, athlete, and match all accounted for variations in mean speed, which otherwise could have concealed the main effects of position and level of competition had less flexible ANOVAs been used.

CONCLUSION

These data clearly demonstrate the appropriateness of applying mixed models to typical data sets acquired in the professional sport setting. Mixed models should be more readily used within sport science, especially in observational, longitudinal data sets such as movement pattern analyses.

Determinants of Inadequate Minimum Dietary Diversity Intake Among Children Aged 6-23 Months in Sub-Saharan Africa: Pooled Prevalence and Multilevel Analysis of Demographic and Health Survey in 33 Sub-Saharan African Countries

Background

Inappropriate feeding practices result in significant threats to child health by impaired cognitive development, compromised educational achievement, and low economic productivity, which becomes difficult to reverse later in life. There is minimal evidence that shows the burden and determining factors of inadequate dietary intake among children aged under 2 years in sub-Saharan African (SSA) countries. Therefore, this study aimed to assess the pooled magnitude, wealth-related inequalities, and other determinants of inadequate minimum dietary diversity (MDD) intake among children aged 6-23 months in the SSA countries using the recent 2010-2020 DHS data.

Methods

A total of 77,887 weighted samples from Demographic and Health Survey datasets of the SSA countries were used for this study. The Microsoft Excel and STATA version 16 software were used to clean, extract, and analyze the data. A multilevel binary logistic regression model was fitted. The concentration index and curve were applied to examine wealth-related inequalities in the outcomes. P-value < 0.05 with 95% CI was taken to declare statistical significance.

Results

The pooled magnitude of inadequate MDD intake among children aged 6-23 months in SSA was 76.53% (95% CI: 73.37, 79.70), ranging from 50.5% in South Africa to 94.40% in Burkina Faso. Individual-level factors such as women having secondary and above education (AOR = 0.66; 95% CI; 0.62, 0.70), being employed (AOR = 0.76; 95% CI; 0.72, 0.79), having household media exposure (AOR = 0.69; 95% CI; 0.66, 0.72), richest wealth (AOR = 0.46; 95% CI; 0.43, 0.50), having health institution delivery (AOR = 0.87;95% CI; 0.83, 0.91), and community-level factor such as living in upper middle-income country (AOR = 0.42; 95% CI; 0.38, 0.46) had a significant protective association, whereas rural residence (AOR = 1.29; 95% CI; 1.23, 1.36) has a significant positive association with inadequate MDD intake among children aged 6-23 months. Inadequate MDD intake among children aged 6-23 months in SSA was disproportionately concentrated on the poor households (pro-poor) (C = -0.24; 95% CI: -0.22, -0.0.26).

Conclusion and Recommendations

There is a high magnitude of inadequate minimum dietary diversity intake among children aged 6-23 months in SSA. Variables such as secondary and above maternal education, having an employed mother, having exposure to media, richest wealth, having health institution delivery, and living in the upper middle-income country have a significant negative association, whereas living in rural residence has a significant positive association with inadequate MDD intake. These findings highlight that to increase the MDD intake in the region, policy makers and other stakeholders need to give prior attention to enhancing household wealth status, empowering women, and media exposure.

Teacher victimization and teachers' subjective well-being: Does school climate matter?

Guided by the job demands-resources model, we examined the multilevel associations between victimization experience with student violence directed against teachers, school climate, and teachers' subjective well-being (i.e., school connectedness and teaching efficacy) among 1711 teachers (7th-12th grade) from 58 middle and high schools in China. Hierarchical linear modeling analyses revealed that teachers who reported more frequent teacher victimization perceived a lower level of teaching efficacy; however, teachers in schools with a higher level of teacher victimization scores at the school level perceived a higher level of teaching efficacy. Although school climate was positively related to teacher well-being at both teacher and school levels, the negative association between teacher victimization and teachers' subjective well-being at the teacher level was exacerbated in schools with a more positive school climate at the school level. The significant cross-level moderating effect of school-level school climate in the association between teacher-level victimization and subjective well-being was consistent with the "healthy context paradox" but contradicted with the "emotion contagion hypothesis." Our findings support the risk influence of teacher victimization and the promotive role of positive school climate on teachers' subjective well-being. Our results also indicate that teachers in schools with a more positive and collective perception of school climate tend to be more attuned to the negative influences of teacher victimization on their subjective well-being than teachers in schools with a less positive and collective perception of school climate.

Prevalence and Definition of Multilevel Lumbar Developmental Spinal Stenosis

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To define multilevel lumbar developmental spinal stenosis (DSS) using a composite score model and to determine its prevalence.

METHODS

This was a cohort study of 2385 openly recruited subjects with lumbosacral (L1-S1) MRIs. All subjects with previous spinal surgery or spinal deformities were excluded. The anteroposterior (AP) vertebral canal diameter was measured by two independent observers. Any associations between level-specific vertebral canal diameter and subject body habitus were analysed with non-parametric tests. Three or more stenotic levels, equivalent to a composite score of 3 or more, were considered as multilevel DSS. The median values of these subjects' AP canal diameters were used to construct the multilevel DSS values. Receiver operating characteristic analysis was utilized to determine the ability of these cut-off values to screen for DSS by presenting their area under curve, sensitivity and specificity.

RESULTS

Subject body habitus was poorly correlated with AP vertebral canal diameter. Multilevel DSS was identified as L1<19 mm, L2<19 mm, L3<18 mm, L4<18 mm, L5<18 mm, S1<16 mm with 81%-96% sensitivity and 72%-91% specificity. The prevalence of multilevel DSS in this cohort was 7.3%.

CONCLUSIONS

Utilizing a large homogeneous cohort, the prevalence of multilevel DSS is determined. Our cut-offs provide high diagnostic accuracy. Patients with multiple levels that fulfil these criteria may be at-risk of spinal canal compressions at multiple sites.

LEVEL OF EVIDENCE

III.

Spine Stereotactic Body Radiotherapy to Three or More Contiguous Vertebral Levels

Background

With survival improving in many metastatic malignancies, spine metastases have increasingly become a source of significant morbidity; achieving durable local control (LC) is critical. Stereotactic body radiotherapy (SBRT) may offer improved LC and/or symptom palliation. However, due to setup concerns, SBRT is infrequently offered to patients with ≥3 contiguous involved levels. Because data are limited, we sought to evaluate the feasibility, toxicity, and cancer control outcomes of spine SBRT delivered to ≥3 contiguous levels.

Methods

We retrospectively identified all SBRT courses delivered between 2013 and 2019 at a tertiary care institution for postoperative or intact spine metastases. Radiotherapy was delivered to 14-35 Gy in 1-5 fractions. Patients were stratified by whether they received SBRT to 1-2 or ≥3 contiguous levels. The primary endpoint was 1-year LC and was compared between groups. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity was assessed. In-depth dosimetric data were collected.

Results

Overall, 165 patients with 194 SBRT courses were identified [54% were men, median age was 61 years, 93% had Karnofsky Performance Status (KPS) ≥70, and median follow-up was 15 months]. One hundred thirteen patients (68%) received treatment to 1-2 and 52 to 3-7 (32%) levels. The 1-year LC was 88% (89% for 1-2 levels vs. 84% for ≥3 levels, p = 0.747). On multivariate analysis, uncontrolled systemic disease was associated with inferior LC for patients with ≥3 treated levels. No other demographic, disease, treatment, or dosimetric variables achieved significance. Rates of new/progressive fracture were equivalent (8% vs. 9.5%, p = 0.839). There were no radiation-induced myelopathy or grade 3+ acute or late toxicities in either group. Coverage of ≥95% of the planning target volume with ≥95% prescription dose was similar between groups (96% 1-2 levels vs. 89% ≥3 levels, p = 0.078).

Conclusions

For patients with ≥3 contiguous involved levels, spine SBRT is feasible and may offer excellent LC without significant toxicity. Prospective evaluation is warranted.

The relationship between responsibility attribution and session outcomes: Two-dimension attribution and two-person perspective

OBJECTIVE

Blame attribution (who is to blame for problem causes) and solution attribution (who is to control problem solving) are two critical dimensions of responsibility attribution in psychotherapy. The present study aimed to (1) investigate the impacts of blame attribution and solution attribution on session outcomes from both client and therapist perspectives and (2) clarify the relationship between the therapist-client congruence of responsibility attribution and session outcomes.

METHOD

A total of 69 clients were recruited at a university counselling centre. Client-rated responsibility attribution (to what extent they were responsible for the causes and solution of their current concerns), therapist-rated responsibility attribution (to what extent they thought their clients should be responsible for the causes and solution of clients' current concerns), client-rated session quality and symptom level for each session were collected across 387 sessions. Multilevel regression was used to explore the relationship between responsibility attribution and session outcomes. Truth and bias model and response surface analysis were utilized to analyse the within-client and between-client client-therapist congruence effects.

RESULTS

The main results included that (1) the clients with higher solution responsibility had more symptom improvement and higher evaluation of session quality (between-client level). A client's perceived solution responsibility predicted better session quality and fewer next session symptom levels (within-client level). (2) If a therapist attributed more solution responsibility to his/her client, the session quality was higher (within-client level). (3) Neither clients' nor therapists' perspectives on blame attribution directly affected session outcomes. But the higher the client's blame for his/her problem causes, the stronger the association between solution responsibility and symptom reduction (within-client level). (4) Higher within-client client-therapist congruence on blame responsibility led to better session outcomes.

CONCLUSION

The clients' solution responsibility and client-therapist congruence on blame for problem causes contribute to session outcomes in psychotherapy.

The Sampling Ratio in Multilevel Structural Equation Models: Considerations to Inform Study Design

Multilevel structural equation modeling (MSEM) allows researchers to model latent factor structures at multiple levels simultaneously by decomposing within- and between-group variation. Yet the extent to which the sampling ratio (i.e., proportion of cases sampled from each group) influences the results of MSEM models remains unknown. This article explores how variation in the sampling ratio in MSEM affects the measurement of Level 2 (L2) latent constructs. Specifically, we investigated whether the sampling ratio is related to bias and variability in aggregated L2 construct measurement and estimation in the context of doubly latent MSEM models utilizing a two-step Monte Carlo simulation study. Findings suggest that while lower sampling ratios were related to increased bias, standard errors, and root mean square error, the overall size of these errors was negligible, making the doubly latent model an appealing choice for researchers. An applied example using empirical survey data is further provided to illustrate the application and interpretation of the model. We conclude by considering the implications of various sampling ratios on the design of MSEM studies, with a particular focus on educational research.

A Systematic Review and Meta-Analysis on the Association and Differences between Aerobic Threshold and Point of Optimal Fat Oxidation

Over the past two decades, scientists have attempted to evaluate whether the point of maximal fat oxidation (FATmax) and the aerobic threshold (AerT) are connected. The existence of such a relationship would allow a more tailored training approach for athletes while improving the efficacy of individualized exercise prescriptions when treating numerous health-related issues. However, studies have reported conflicting results, and this issue remains unresolved. This systematic review and meta-analysis aimed: (i) to examine the strength of the association between FATmax and AerT by using the effect size (ES) of correlation coefficient (r) and standardized mean difference (SMD); (ii) to identify potential moderators and their influence on ES variability. This study was registered with PROSPERO (CRD42021239351) and ClinicalTrials (NCT03789045). PubMed and Google Scholar were searched and fourteen articles, consisting of overall 35 ES for r and 26 ES for SMD were included. Obtained ESs were analyzed using a multilevel random-effects meta-analysis. Our results support the presence of a significant association between FATmax and AerT exercise intensities. In conclusion, due to the large ES variance caused by clinical and methodological differences among the studies, we recommend that future studies follow strict standardization of data collection and analysis of FATmax and AerT-related outcomes.