Individual and Contextual Correlates of Latent Bystander Profiles toward Racist Hate Speech: A Multilevel Person-centered Approach

Prior research into bystander responses to hate speech has utilized variable-centered analyses - such approaches risk simplifying the complex nature of bystander behaviors. Hence, the present study used a person-centered analysis to investigate latent hate speech bystander profiles. In addition, individual and classroom-level correlates associated with the various profiles were studied. The sample included 3225 students in grades 7-9 (51.7% self-identified as female; 37.2% with immigrant background) from 215 classrooms in Germany and Switzerland. The latent profile analysis revealed that four distinct profiles could be distinguished: Passive Bystanders (34.2%), Defenders (47.3%), Revengers (9.8%), and Contributors (8.6%). Multilevel logistic regression models showed common and distinct correlates. For example, students who believed that certain social groups are superior were more likely to be Revengers and Contributors than Passive Bystanders, students who felt more connected with teachers were more likely to be Defenders, and students who were more open to diversity were less likely to be Contributors than Passive Bystanders. Students were less likely Defenders and more likely Revengers and Contributors than Passive Bystanders in classrooms with high rates of hate speech perpetration. Further, in classrooms with high hate speech intervention, students were more likely to be Defenders and less likely to be Contributors than Passive Bystanders. In classrooms with stronger cohesion, students were more likely to be Defenders and less likely to be Contributors than Passive Bystanders. In conclusion, the findings add to our understanding of bystander profiles concerning racist hate speech and the relevance of individual and classroom-level factors in explaining various profiles of bystander behavior.

Multilevel determinants of physical violence among ever-partnered women in South Africa

BACKGROUND

Violence against women continues to be a challenge in many countries. Many women suffer physical violence at the hands of their intimate partners and sometimes this leads to their deaths. This study aimed to examine the multilevel determinants of physical violence among ever-partnered women in South Africa.

METHODS

We used data from the 2016 South Africa Demographic and Health Survey. The study has a weighted sample size of 4169 ever-partnered women aged 18-49 years, based on the domestic violence module. We included univariate, bivariate and multilevel logistic regression analysis. We included a two-level model to measure the relationship between the selected background characteristics and physical violence.

RESULTS

The prevalence of physical violence among ever-partnered women was 20.6%. The bivariate findings showed that educational status, employment status, witness to inter-parental violence, partner's drinking habits, household wealth, educational difference, and province were statistically associated with physical violence. The multilevel analysis showed some evidence of between-cluster variation in physical violence. We found that age, education, employment status, witness to inter-parental violence, partner's drinking habits, household wealth, education difference, place of residence, and province were key predictors of physical violence. The odds of physical violence were more than two-fold in the Eastern Cape and Mpumalanga compared to Gauteng.

CONCLUSION

The study highlighted various key factors explaining physical violence. The findings suggest the need for targeted interventions aimed at specific communities of women, such as those from the Eastern Cape and Mpumalanga, as well as interventions that will empower women and address gender inequalities.

A quantitative approach to the intersectional study of mental health inequalities during the COVID-19 pandemic in UK young adults

PURPOSE

Mental health inequalities across social identities/positions during the COVID-19 pandemic have been mostly reported independently from each other or in a limited way (e.g., at the intersection between age and sex or gender). We aim to provide an inclusive socio-demographic mapping of different mental health measures in the population using quantitative methods that are consistent with an intersectional perspective.

METHODS

Data included 8,588 participants from two British cohorts (born in 1990 and 2000-2002, respectively), collected in February/March 2021 (during the third UK nationwide lockdown). Measures of anxiety and depressive symptomatology, loneliness, and life satisfaction were analysed using Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) models.

RESULTS

We found evidence of large mental health inequalities across intersectional strata. Large proportions of those inequalities were accounted for by the additive effects of the variables used to define the intersections, with some of the largest gaps associated with sexual orientation (with sexual minority groups showing substantially worse outcomes). Additional inequalities were found by cohort/generation, birth sex, racial/ethnic groups, and socioeconomic position. Intersectional effects were observed mostly in intersections defined by combinations of privileged and marginalised social identities/positions (e.g., lower-than-expected life satisfaction in South Asian men in their thirties from a sexual minority and a disadvantaged childhood social class).

CONCLUSION

We found substantial inequalities largely cutting across intersectional strata defined by multiple co-constituting social identities/positions. The large gaps found by sexual orientation extend the existing evidence that sexual minority groups were disproportionately affected by the pandemic. Study implications and limitations are discussed.

What does the MAIHDA method explain?

Multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) is a new approach to quantitative intersectional modelling. Along with an outcome of interest, MAIHDA entails the use of two sets of independent variables. These include group demographics such as race, gender, and poverty status as well as strata which are constructs such as Black female poor, Black female wealthy, and White female poor. These constructs represent the combination of the demographic variables. To operationalize the approach, an initial random intercepts model with strata as a level 2 context is specified. Then, another model is specified that includes the strata as well as the demographic variables as level 1 fixed effects. As such, it is argued that MAIHDA uniquely identifies the additive and intersectional effects for any given outcome. In this paper we show that MAIHDA falls short of this promise: the strata are an individual-level composite variable not a level 2 context. Rather than being analogous to neighborhoods as contexts, strata are analogous to socio-economic status which is a combination of individual-level demographic variables, albeit often presented as a group-level characteristic. The result is that the demographic variables are inserted in both level 2 and 1. This duplication across the levels in MAIHDA means that there is a built-in collinearity across the levels and that the models are mis-specified and, therefore, redundant. We conclude that single-level models with the demographic variables and interactions or with the strata as fixed effects are still the more accurate models for quantitative intersectional analyses.

The impact of different data handling strategies in exploratory and confirmatory factor analysis of diary measures: an evaluation using simulated and real-world asthma nighttime symptoms diary data

BACKGROUND

Daily diaries are an important modality for patient-reported outcome assessment. They typically comprise multiple questions, so understanding their underlying structure is key to appropriate analysis and interpretation. Structural evaluation of such measures poses challenges due to the high volume of repeated measurements. Potential strategies include selecting a single day, averaging item-level observations over time, or using all data while accounting for its multilevel structure.

METHOD

The above strategies were evaluated in a simulated dataset via exploratory and confirmatory factor modelling by comparing their impact on various estimates (i.e., inter-item correlations, factor loadings, model fit). Each strategy was additionally explored using real-world data from an observational study (the Asthma Nighttime Symptoms Diary).

RESULTS

Both single day and item average strategies resulted in biased factor loadings. The former displayed lower overall bias (single day: 0.064; item average: 0.121) and mean square error (single day: 0.007; item average: 0.016) but greater frequency of incorrect factor number identification compared with the latter (single day: 46.4%; item average: 0%). Increased estimated inter-item correlations were apparent in the item-average method. Non-trivial between- and within-person variance highlighted the utility of a multilevel approach. However, convergence issues and Heywood cases were more common under the multilevel approach (90.2% and 100.0%, respectively).

CONCLUSIONS

Our findings suggest that a multilevel approach can enhance our insight when evaluating the structural properties of daily diary data; however, implementation challenges still remain. Our work offers guidance on the impact of data handling decisions in diary assessment.

Co-occurrence of dental caries and periodontitis: multilevel modelling approach

BACKGROUND

Previous studies reported varyingly positive, negative, or no relationships between caries and periodontitis. Therefore, the aim was to assess the potential co-occurrence of caries experience and periodontal inflammation on the same teeth.

METHODS

This cross-sectional study used data from the Lithuanian National Oral Health Survey. The study included a stratified random sample of 1405 individuals aged 34-78, recruited from 5 Lithuanian cities and 10 peri-urban/rural areas (response rate 52%). Information about sociodemographic (age, sex, education, residence), behavioral (sugar-containing diet, tooth brushing frequency, use of interdental care products, last dental visit, smoking) and biological (systemic disease, use of medication and xerostomia) determinants was collected using the World Health Organization (WHO) Oral Health Questionnaire for Adults supplemented with additional questions. Clinical data were recorded using the WHO criteria and collected by one trained and calibrated examiner. Dental caries status was recorded as sound, decayed, missing, filled surfaces. Subsequently for the analyses, status was recorded at a tooth-level as decayed- and filled-teeth (DT and FT) including proximal, buccal, and oral surfaces. Two measures were used for periodontal status. The probing pocket depth (PPD) was measured at six sites and recorded at a tooth level into the absence of PPD or presence of PPD ≥ 4 mm. Bleeding on probing (BOP) was measured at the same six sites and was recorded as either present or absent at a tooth-level. Univariable and multivariable 2-level random intercept binary logistic regression analyses were utilized.

RESULTS

Positive associations were found between DT and BOP (OR 1.42, 95% CI 1.20-1.67), FT and BOP (OR 2.07, 95% CI 1.82-2.23), DT and PPD (OR 1.38, 95% CI 1.15-1.67) and FT and PPD (OR 2.01, 95% CI 1.83-2.20).

CONCLUSIONS

Our findings add evidence for the co-occurrence of periodontal inflammation and caries on the same teeth. This suggests the need for increased emphasis on a transdisciplinary approach in designing oral health interventions that target dental caries and periodontal disease simultaneously. In addition, longitudinal studies exploring the co-occurrence of caries and periodontal disease at the same sites, taking into consideration the levels of both conditions and genetic variation, are warranted.

The complexities of suicide: a multilevel survival analysis examining individual, familial and neighbourhood determinants of suicide risk using Danish register-based data

BACKGROUND

Suicide risk is complex and nuanced, and how place impacts suicide risk when considered alongside detailed individual risk factors remains uncertain. We aimed to examine suicide risk in Denmark with both individual and neighbourhood level risk factors.

METHODS

We used Danish register-based data to identify individuals born in Denmark from 1972, with full parental information and psychiatric diagnosis history. We fitted a two-level survival model to estimate individual and neighbourhood determinants on suicide risk.

RESULTS

We identified 1723 cases of suicide in Denmark during the follow-up period from 1982 to 2015. Suicide risk was explained mainly by individual determinants. Parental comorbidities, particularly maternal schizophrenia [incidence rate ratio (IRR): 2.29, 95% CI 1.56-3.16] and paternal death (2.29, 95% CI 1.31-3.72) partly explained suicide risk when adjusted for all other determinants. The general contextual effect of suicide risk across neighbourhoods showed a median incidence rate ratio (MRR) of 1.13 (1.01-1.28), which was further reduced with full adjustment. Suicide risk increased in neighbourhoods with a higher proportion of manual workers (IRR: 1.08; 1.03-1.14), and decreased with a higher population density (IRR: 0.89; 0.83-0.96).

CONCLUSION

Suicide risk varies mainly between individuals, with parental comorbidities having the largest effect on suicide risk. Suicide risk was less impacted by neighbourhood, though, albeit to a lesser extent than individual determinants, some characteristics were associated with suicide risk. Suicide prevention policies might consider targeting interventions towards individuals more vulnerable due to particular parental comorbidities, whilst taking into account that some neighbourhood characteristics might exacerbate this risk further.

Family, Community, and the Rural Social Mobility Advantage

Children born into poverty in rural America achieve higher average income levels as adults than their urban peers. As economic opportunity tends to be more abundant in cities, this "rural advantage" in income mobility seems paradoxical. This article resolves this puzzle by applying multilevel analysis to new spatial measures of rurality and place-level data on intergenerational income mobility. We show that the high level of rural income mobility is principally driven by boys of rural-origin, who are more likely than their urban peers to grow up in communities with a predominance of two-parent households. The rural advantage is most pronounced among Whites and Hispanics, as well as those who were raised in the middle of the country. However, these dynamics are more nuanced for girls. In fact, girls from lower-income rural households exhibit a disadvantage in their personal income attainment, partly due to the persistence of traditional gender norms. These findings underscore the importance of communities with strong household and community supports in facilitating later-life income mobility, particularly for boys. They also challenge the emerging consensus that attributes the rural income mobility advantage to migration from poorer rural areas to wealthier towns and cities.

Multilevel modelling of neonatal mortality in Ghana: Does household and community levels matter?

Background

Neonatal mortality accounts for an increasing share of under-five deaths, and they are declining at a slower rate than postnatal deaths. Apparently, neonatal mortality is increasingly becoming a major public health problem in Ghana and the world over. The current study sought to analyze neonatal mortality as a function of predictor variables and to estimate and understand unobserved household and community-level residual effects on neonatal mortality to provide data driven evidence to shape informed policies and interventions aimed at reducing the neonatal mortality burden.

Methods

The current study extracted three-level complex data on 5884 children born in the five years preceding the 2014 Ghana Demographic and Health Survey. A two-level and three-level multilevel logistic models were applied to estimate unobserved household and community-level variations in neonatal mortality in the presence of set of predictor variables. Sampling weights were incorporated in both the descriptive and inferential analysis since the data used emanated from a complex survey. Model fit statistics such as AIC scores for a weighted two-level and three-level random intercept logistic models were compared. The model with the lowest AIC score was considered the most preferred model.

Results

The household-level random intercept model suggested that the odds of neonatal mortality was higher among multiple births [OR = 3.15 (95% CI: 1.17, 8.50)], babies born to mothers who received prenatal care from non-skilled worker [OR = 5.88 (95% CI: 2.90, 11.91)], babies delivered through caesarian section [OR = 2.47 (95% CI: 1.06, 5.79)], a household with 1-4 members [OR = 10.23 (95% CI: 4.17, 25.50)], a short preceding birth interval (<24 months) [OR = 3.05 (95% CI: 1.18, 7.88)], and preceding birth interval between 24 and 47 months [OR = 2.88 (95% CI: 1.41, 5.91)]. Substantial unobserved household-level residual variations in neonatal mortality were observed.

Conclusion

The findings of the current study provide an actionable information to be used by government and other stakeholders in the health sector to renew commitment to reduce neonatal mortality to an acceptable level. There is the need to intensify maternal health education by health providers to encourage pregnant women to visit antenatal clinics at least four times so they could benefit substantially from ANC services.

Alcohol and marijuana use predicting next-day absenteeism and engagement at school and work: A daily study of young adults

This study examined effects of alcohol and marijuana use on next-day absenteeism and engagement at work and school among young adults (18-25 years old) who reported past-month alcohol use and simultaneous alcohol and marijuana use. Participants completed twice daily surveys for five, 14-day bursts. The analytic sample was 409 [64 % were enrolled in university (N = 263) and 95 % were employed (N = 387) in at least one burst]. Daily measures included: any alcohol or marijuana use, quantity of alcohol or marijuana use (i.e., number of drinks, number of hours high), attendance at work or school, and engagement (i.e., attentiveness, productivity) at school or work. Multilevel models examined between- and within-person associations between alcohol and marijuana use and next-day absenteeism and engagement at school or work. Between-persons, the proportion of days of alcohol use days was positively associated with next-day absence from school, consuming more drinks was positively associated with next-day absence from work, and the proportion of days of marijuana use was positively associated with next-day engagement at work. At the daily-level, when individuals consumed any alcohol and when they consumed more drinks than average, they reported lower next-day engagement during school and work. When individuals used marijuana and when they were high for more hours than average, they reported lower next-day engagement during school. Findings suggest alcohol and marijuana use consequences include next-day absence and decrements in next-day engagement at school and work, which could be included in interventions aimed at ameliorating harmful impacts of substance use among young adults.

Examining the risk factors for overweight and obesity among women in Ghana: A multilevel perspective

Overweight/obesity prevalence is on the increase in epidemic proportions across Low- and Middle-Income countries (LMICs). The public health burden associated with obesity/overweight cannot be underestimated due to its association with chronic health outcomes. This study investigated the individual- and community level risk factors for obesity/overweight among reproductive women. The data used consist of 4393 reproductive women and form part of the 2014 Ghana Demographic and Health Survey (GDHS). Information on these women are clustered within 427 communities. A 2-tier random intercept multilevel logistic model was used to assess the effect of individual- and community level factors on the likelihood of a woman to be obese/overweight. The obesity/overweight prevalence among reproductive women was estimated to be 35.5% (95% CI: 34.04, 36.90%), which significantly differed across clusters. Most at risk were women from middle-income households (aOR = 2.85; 95% CI: 2.28, 3.56), upper-income households (aOR = 5.019, 95% CI: 3.85, 6.55), attaining secondary education (aOR = 1.74; 95% CI: 1.41, 2.16), and higher (aOR = 1.63; 95% CI: 1.14, 2.33), old age (20-29 years (aOR = 4.26; 95% CI: 3.142,5.78); 30-39 years (aOR = 8.59; 95% CI: 6.15, 12.00); 40-49 years (aOR = 12.81; 95% CI: 9.10, 18.16)). Significant differences in the probability of being overweight/obese between different communities were observed (MOR = 1.39). The high prevalence of overweight/obesity requires urgent public health interventions to prevent future public health crises. Efforts to strengthen the healthcare system, encourage lifestyle modification, and public health education are needed to solidify the gains of ensuring a healthy population by 2030 (SDG 3).

Exploring the spatiotemporal factors affecting bicycle-sharing demand during the COVID-19 pandemic

This study investigates the roles of the socio-economic, land use, built environment, and weather factors in shaping up the demand for bicycle-sharing trips during the COVID-19 pandemic in Toronto. It uses "Bike Share Toronto" ridership data of 2019 and 2020 and a two-stage methodology. First, multilevel modelling is used to analyze how the factors affect monthly station-level trip generation during the pandemic compared to pre-pandemic period. Then, a geographically weighted regression analysis is performed to better understand how the relationships vary by communities and regions. The study results indicate that the demand of the service for commuting decreased, and the demand for recreational and maintenance trips increased significantly during the pandemic. In addition, higher-income neighborhoods are found to generate fewer weekday trips, whereas neighbourhoods with more immigrants experienced an increase in bike-share ridership during the pandemic. Moreover, the pandemic trip generation rates are more sensitive to the availability of bicycle facilities within station buffers than pre-pandemic rates. The results also suggest significant spatial heterogeneity in terms of the level of influence of the explanatory factors on the demand for bicycle-sharing during the pandemic. Based on the findings, some neighbourhood-specific policy recommendations are made, which inform decisions regarding the locations and capacity of new stations and the management of existing stations so that equity concerns about the usage of the system are adequately accounted for.

Assessing the contribution of migration related policies to equity in access to healthcare in European countries. A multilevel analysis

Access to good healthcare and the conditions for good health is one of the central dimensions of immigrant integration. National health policies play a major role in equipping residents with the necessary entitlements to accessible and acceptable healthcare services. Rarely analysed so far is the contribution of migration-related health policies to equity in access to healthcare between immigrants and the general population. To address this gap, this study analysed whether the extent to which migration is considered within national health policies moderates the association between immigration status and subjectively perceived unmet medical need in Europe. Using data from the 2019 European Union Statistics on Income and Living Conditions (EU-SILC) survey in combination with the Migration Integration Policy Index (MIPEX) a multilevel analysis was carried out assessing the cross-level interaction between immigration status and MIPEX scores controlling for individual-level factors such as age, gender, education and employment status. While our results showed that immigrants are more likely to report unmet medical need than the general population (adjusted Odds Ratio (aOR) = 1.32; 95% confidence interval (CI) 1.22-1.43), the cross-level interaction indicated increased relative inequality in unmet medical need between immigrants and the general population in countries with high MIPEX scores compared to countries with low MIPEX scores (aOR = 1.39, 95% CI: 1.18-1.63). The main reason for this increase of inequality on the relative scale was the overall lower prevalence of unmet medical need in countries with high MIPEX scores. In conclusion, our findings indicate that even in countries with relatively migration-friendly health policies inequalities in access to healthcare between immigrants and the general population persist.

Telephone treatments in Improving Access to Psychological Therapies services: an analysis of use and impact on treatment uptake

BACKGROUND

There is debate about how best to increase access to psychological therapy and deliver mental healthcare effectively and efficiently at a national level. One trend is the increased use of the telephone to deliver therapy. However, there is the potential to disadvantage certain patient groups and/or impact on uptake of help. This study aims to answer three questions: (i) Which factors are associated with being offered an assessment by telephone? (ii) Which factors are associated with attendance at assessment? and (iii) What is the impact of an assessment by telephone on subsequent treatment appointment?

METHODS

Routine outcome data was provided by seven UK Improving Access to Psychological Therapy services. The analysis sample comprised 49,923 patients who referred to 615 general practices in 2017. Multilevel modelling, including service and GP practice as random factors, was used to answer the three research questions.

RESULTS

The offer of an initial assessment by telephone was strongly associated with local service configuration. Patient self-referral, a shorter wait, greater age and lower deprivation were associated with attendance at assessment and subsequent treatment session. Telephone mode assessment had no impact on the uptake of the assessment but may influence the uptake of further treatment if this was also by telephone. The practitioner carrying out the assessment had a significant effect on subsequent treatment uptake.

CONCLUSION

Offering telephone assessments does not have a negative impact on uptake of assessment and services may benefit by facilitating and integrating telephone assessments into their systems. The COVID-19 pandemic has accelerated the use of telephone and other remote means of delivery, and results from this study can inform services to consider how best to re-configure post-pandemic.

The paradox of declining fertility and declining contraceptive use in India: An artefact of survey design?

•Ensuring data quality in large scale surveys is challenging.•The trend and pattern of declining fertility and declining contraceptive use in India is puzzling.•Interview privacy setting and interviewer effect can partially explain the anomaly.•Large scale surveys impose severe demands on survey supervision and ability to ensure privacy.•Innovative ways of data collection for sensitive issues can be explored for proper reporting.

Sexual Intercourse Frequency During Pregnancy: Weekly Surveys Among 237 Young Women From A Random Population-Based Sample

BACKGROUND

Significant differences in sexual frequency during pregnancy have been documented in cross-sectional and once-per-trimester longitudinal studies, with the highest sexual frequency in the first trimester and the lowest in the third trimester. However, changes in sexual frequency may be more complex than these comparisons suggest; patterns of sexual frequency have not been assessed using frequent (e.g., weekly) assessments throughout a woman's pregnancy.

AIM

To assess changes in the frequency of sexual intercourse across all weeks of pregnancy.

METHODS

We used data from 237 women (54% White; 43% Black) who reported a pregnancy during the Relationship Dynamics and Social Life (RDSL) study. RDSL was based on a random population-based sample of 992 women in the United States, aged 18 or 19, who completed a baseline interview and brief weekly follow-up surveys for 2.5 years. We used generalized multilevel modeling to fit and compare linear, quadratic, and piecewise (via b-splines) models.

OUTCOME

Weekly probability of sexual intercourse.

RESULTS

Sexual intercourse frequency clearly declined across pregnancy, yet the pattern followed the course of common pregnancy symptomology (i.e., nausea, fatigue) more closely than trimester cutoffs. The best fitting model demonstrated that the probability of sexual intercourse declined sharply (∼18% each week) between conception and 11 weeks, subsequently increased by ∼3% each week between weeks 11 and 21, and then declined steadily (∼6% each week) through the end of pregnancy.

CLINICAL TRANSLATION

Documenting more precise patterns of change in sexual frequency during pregnancy provides important information to many who wish to maintain sexual intimacy while pregnant, or to those who would otherwise find the sexual disruptions particularly challenging.

STRENGTHS & LIMITATIONS

This study is the first to document changes in sexual intercourse frequency throughout all weeks of pregnancy as they naturally occurred among a representative sample of young women. The focus on sexual intercourse limits the findings to only one aspect of human sexuality. The narrow age range of the sample precludes generalization to all pregnant women.

CONCLUSION

Changes in sexual frequency are more complex than the general declines suggested by other studies; within-trimester patterns reveal the shortcomings in understanding sexual behavior changes when aggregated by trimester, such as severely underestimating the degree of fluctuation in the first trimester. Pregnancy symptomology may be most favorable to intercourse towards the end of the first and beginning of second trimesters, and least favorable near the end of the pregnancy. Shari M. Blumenstock, Jennifer S. Barber. Sexual Intercourse Frequency During Pregnancy: Weekly Surveys Among 237 Young Women From A Random Population-Based Sample. J Sex Med 2022;19:1524-1535.

(I can't get no) satisfaction: A comparative study of healthcare recommodification in Europe, 2010-18

European health reforms during the last decades have strengthened patient rights and introduced choice, competition and financial incentives in a sector that has typically been state-directed and centrally controlled. The marketisation of health care has also drawn out profit and introduced private provision. The main argument behind this trend is that market competition will improve service quality and deliver health services more efficiently. Such reforms often fall under the umbrella of New Public Management (NPM), and there is a lack of empirical research on their effects. The purpose of this paper is to investigate the association between healthcare marketisation and health system outcomes across European nations. In order to measure a country's degree of healthcare marketisation we employed indicators of healthcare decommodification. The concept refers to the extent to which an individual's access to healthcare is dependent upon their market position and the extent to which a country's provision of health is independent from the market. These indicators are three measures that assess the financing, provision and coverage of the private sector, and thus reflects the varied role of the market in a health care system: private health care expenditure as amount of GDP, private hospital beds as amount of total hospital bed stock, and public healthcare coverage. As indicator of health system outcome, we employed a measure that has not previously been investigated in the context of healthcare marketisation: satisfaction with health care system. We used multilevel analyses on five waves (2009-2017) of the biannual European Social Survey (ESS), with our final models including more than 120,000 individuals from 21 countries. Our methodological approach allowed us to study both cross-sectional and longitudinal relationships. The strongest substantial associations were between coverage and satisfaction, with high public healthcare coverage being associated with higher satisfaction.

Age heterogeneities in child growth and its associated socio-demographic factors: a cross-sectional study in India

Background

The impacts of socio-demographic and environmental risk factors on child growth have been widely documented. However, it remains unclear whether the impacts of such risk factors on child growth have remained static or changed with child’s age. The present study aims to assess the underlying age heterogeneities in child growth and its potential determinants over age in under-five children.

Methods

Cross-sectional data on child height (measured as height-for-age z-score, i.e., HAZ) and weight (measured as weight-for-age z-score, i.e., WAZ) and potential confounding factors from India’s 2015–16 National Family Health Survey (NFHS) were used to construct anthropometric age-profiles by a number of bio-demographic and socioeconomic characteristics. Further, age-interacted multilevel regression analyses were performed to examine differential effects of such/those risk factors on child height and weight by age.

Results

Faltered height and weight growth during first two years of life was noticed in children of all socioeconomic groups studied, albeit with varying magnitude. In case of child’s height, factors such as short birth interval, higher birth order, maternal education, household wealth, district level mortality rate have shown strong interaction with child’s age during the first 23 months, signifying their age-varying role in different developmental stages of child growth. These factors explain the observed upward and downward shifts in height curve during first two years. Some of these variables (e.g., household wealth) have shown even stronger age interactions after the second birthday of children. For child’s weight, interactive effects of most socio-demographic risk factors attenuated parabolically with child’s age.

Conclusions

The impacts of several risk factors, measured at the child, mother, community, and district levels, on child growth indicators varied significantly with the child’s age. Nutritional interventions aimed at preventing poor linear growth in children in India should consider these underlying age heterogeneities for growth determinants into account.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03415-x.

Rumen fluke infections (Paramphistomidae) in diarrhoeal cattle in western France and association with production parameters

This study was conducted to assess the impact of rumen flukes (RFs) (Paramphistomatidae) on various production parameters of cattle in Normandy. Faecal and blood samples were taken between 1 January 2010 and 31 December 2019 as part of the routine diagnostic activity for diarrhoea in weaned cattle, including a quantitative parasitological analysis coupled with a search for Johne's disease (paratuberculosis). Information on slaughter and carcass weight, inter-farm movements and mortality was obtained from the French national registration database (BDNI). The study was conducted at two levels using adapted categorical RF variables: 1) at the cattle level (>12 months), an estimation of presence of adult parasites using egg count in faecal samples (negative vs. positive) and 2) at the herd level, an estimation of 6-24 months of the dairy heifers exposure to larval forms on the basis of the proportion of dairy cattle shedding eggs in the herd (three classes). At the cattle level, the outcome variables were carcass weight (model 1), case-control status for mortality within 30 days of diagnosis (model 2) and case-control status for slaughter within 365 days of diagnosis (model 3). At the herd level, the outcome variable was the mortality ratio for dairy heifers aged 6-24 months (Model 4). Other important covariates were used to improve model fit. Multivariate analyses were performed using a linear mixed model (model 1), generalised estimating equations (GEE) (models 2 and 3) and a multinomial logistic model (model 4). Overall, 1291 out of 4315 cattle (29.9%) were found to excrete RF eggs and 19.6% of the positives had an excretion score of >200 eggs/g. The prevalence increased steadily with age class and was higher in beef cattle than dairy cattle (42.7% vs. 26.9%) in the years 2015-2019 compared to 2010-2014 (33.3% vs. 26.5%) and in November-February (33.2%) compared to March-June (28.9%) and July-October (27.3%). Rumen fluke variables were not found to be explanatory factors of outcome variables at both animal and herd levels. In contrast, significant negative associations were observed between outcome variables and other health covariates, such as Johne's disease, GI nematode, bovine viral diarrhoea and coccidia statuses. In conclusion, RFs are prevalent in cattle reared in Normandy but this does not result in significant production losses. Therefore, the value to farmers of oxyclozanide treatment at an effective dose for paramphistomosis after simple identification of RF eggs in the faeces seems limited.

Trends in material and non-material inequalities in adolescent health and health behaviours: A 12-year study in 23 European countries

Information on trends in adolescent health inequalities is scarce but the available evidence suggests that inequalities are increasing. Prior studies describe associations between material resources of socioeconomic status (SES) and health, while information on non-material SES resources and inequalities in health behaviours is lacking. To improve current understandings of evolutions in adolescent health inequalities, we examined how material and non-material SES resources were associated with changes in selected health outcomes (life satisfaction, physical and psychological symptoms) and health behaviours (physical activity, screen time, breakfast, fruit, vegetables, sweets and soft drinks consumption and alcohol and tobacco use) over a 12-year period. Repeated cross-sectional data came from the 2002, 2006, 2010 and 2014 waves of the Health Behaviour in School-aged Children (HBSC) survey from 23 European countries (n = 480,386). Measures of family affluence and occupational social class were used as indicators of material and non-material SES resources respectively. Regression-based slope indices of inequality indicated that absolute material and non-material inequalities remained stable from 2002 to 2014 in all health outcomes, except for life satisfaction for which a decrease in material inequalities was found between the highest and lowest affluence group (0.81 to 0.68 difference; p < 0.001). In terms of health behaviours, material inequalities decreased in screen time between highest and lowest affluence groups (0.53 to 0.34 h/day difference; p < 0.001), fruit (odds ratio [OR] 1.89 to 1.72 lower odds; p = 0.0088) and soft drinks consumption (OR 1.36 to 1.13 lower odds; p < 0.001) and remained stable in all others. Non-material inequalities increased in all health behaviours (except for sweets consumption) between highest and lowest occupational social class groups: physical activity (0.16 to 0.24 h/day difference; p = 0.0071), screen time (-0.41 to -0.58 h/day difference; p < 0.001), breakfast (0.21 to 0.51 day/week difference; p < 0.001), fruit (OR 1.23 to 1.48 higher odds; p < 0.001), vegetables (OR 1.39 to 1.74 higher odds; p < 0.001) and soft drinks consumption (OR 0.59 to 0.43 lower odds; p < 0.001) and alcohol (OR 0.99 to 0.85 lower odds; p = 0.0420) and tobacco use (OR 0.71 to 0.59 lower odds; p = 0.0183). In summary, non-material inequalities in most health behaviours increased, whereas material inequalities in adolescent health and health behaviours remain stable or decreased. Policies and interventions may consider non-material SES components as these can help in reducing future health inequalities.

Effect of individual, household and regional socioeconomic factors and PM2.5 on anaemia: A cross-sectional study of sub-Saharan African countries

There is limited knowledge on the effect of contextual and environmental factors on the risk of anaemia, as well as the spatial distribution of anaemia in the Sub-Saharan Africa region. In this study, we used multi-country data from the Demographic & Health survey (DHS) with 270,011 observations and PM_2.5 data from NASA, applied to the spatial risk pattern of anaemia in the SSA region. The prevalence of anaemia amongst women (41%) was almost twice that of men (22%). A Bayesian hierarchical model showed that individual household, neighbourhood and regional socioeconomic factors were significantly associated with the likelihood of being anaemic. 1 μg/m³ increase in cumulative lifetime PM_2.5 exposure accounted for 1% (β = 0.011, CI = 0.008 - 0.015) increase in the likelihood of being anaemic. The results suggest the need for a multidimensional approach to tackle anaemia in the Sub-Saharan African region and identify high-risk areas for target intervention policies or programs.

Sibling Resemblances in Physical Fitness in Three Distinct Regions in Peru: The Peruvian Sibling Study on Growth and Health

We estimated sibling resemblance in health-related physical fitness (PF) and examined how individual characteristics and shared natural environment accounted for sibling similarities. The sample comprised 656 sibling pairs and 102 triplets (6-15 years of age), from three geographical areas of Peru. PF components included morphological (waist circumference, sum of skinfolds), muscular (handgrip strength, standing long jump), and motor (shuttle-run). Body mass index (BMI) and somatic maturation were also assessed. In general, sibling intraclass correlations differed significantly across sib-ship types for waist circumference and handgrip strength but were the same for sum of skinfolds, standing long jump, and shuttle-run. Further, in general, both individual characteristics and geographical area of residence significantly influenced the magnitude of sibling resemblance as well as the mean levels of PF. In conclusion, individual characteristics and shared natural environment jointly influenced the expression of PF in Peruvian siblings, revealing the importance of these features when designing individualized programs promoting fitness.

How do policy levers shape the quality of a national health system?

Poor quality of care may have a detrimental effect on access and take-up and can become a serious barrier to the universality of health services. This consideration is of particular interest in view of the fact that health systems in many countries must address a growing public-sector deficit and respond to increasing pressures due to COVID-19 and aging population, among other factors. In line with a rapidly emerging literature, we focus on patient satisfaction as a proxy for quality of health care. Drawing on rich longitudinal and cross-sectional data for Spain and multilevel estimation techniques, we show that in addition to individual level differences, policy levers (such as public health spending and the patient-doctor ratio, in particular) exert a considerable influence on the quality of a health care system. Our results suggest that policymakers seeking to enhance the quality of care should be cautious when compromising the level of health resources, and in particular, health personnel, as a response to economic downturns in a sector that traditionally had insufficient human resources in many countries, which have become even more evident in the light of the current health crisis. Additionally, we provide evidence that the increasing reliance on the private health sector may be indicative of inefficiencies in the public system and/or the existence of features of private insurance which are deemed important by patients.

Heterogeneity in the association between weather and pain severity among patients with chronic pain: a Bayesian multilevel regression analysis

INTRODUCTION

Previous studies on the association between weather and pain severity among patients with chronic pain have produced mixed results. In part, this inconsistency may be due to differences in individual pain responses to the weather.

METHODS

To test the hypothesis that there might be subgroups of participants with different pain responses to different weather conditions, we examined data from a longitudinal smartphone-based study, Cloudy with a Chance of Pain, conducted between January 2016 and April 2017. The study recruited more than 13,000 participants and recorded daily pain severity on a 5-point scale (range: no pain to very severe pain) along with hourly local weather data for up to 15 months. We used a Bayesian multilevel model to examine the weather-pain association.

RESULTS

We found 1 in 10 patients with chronic pain were sensitive to the temperature, 1 in 25 to relative humidity, 1 in 50 to pressure, and 3 in 100 to wind speed, after adjusting for age, sex, belief in the weather-pain association, mood, and activity level. The direction of the weather-pain association differed between people. Although participants seem to be differentially sensitive to weather conditions, there is no definite indication that participants' underlying pain conditions play a role in weather sensitivity.

CONCLUSION

This study demonstrated that weather sensitivity among patients with chronic pain is more apparent in some subgroups of participants. In addition, among those sensitive to the weather, the direction of the weather-pain association can differ.

The impacts of ignoring individual mobility across clusters in estimating a piecewise growth model

A three-level piecewise growth model (3L-PGM) can be used to break up nonlinear growth into multiple components, providing the opportunity to examine potential sources of variation in individual and contextual growth within different segments of the model. The conventional 3L-PGM assumes that the data are strictly hierarchical in nature, where measurement occasions (level 1) are nested within individuals (level 2) who are members of a single cluster (level 3). However, in longitudinal research, it is sometimes difficult for data structures to remain purely clustered during a study, such as when some students change classrooms or schools over time. One resulting data structure in this situation is known as a multiple membership structure, where some lower-level units are members of more than one higher-level unit. The new multiple membership PGM (MM-PGM) extends the 3L-PGM to handle multiple membership data structures frequently found in the social sciences. This study sought to examine the consequences of ignoring individual mobility across clusters when estimating a 3L-PGM in comparison to estimating a MM-PGM. MM-PGM estimates were less biased (especially in the cluster-level coefficient estimates), although we found substantial bias in cluster-level variance components across some conditions for both models.

Changes in regional variation in mortality over five decades - The contribution of age and socioeconomic population composition

Existing evidence suggests that within-country area variation in mortality has increased in several high-income countries. Little is known about the role of changes in the population composition of areas in these trends. In this study, we look at mortality variation across Finnish municipalities over five decades. We examine trends by sex, age categories and two broad cause of death groups and assess the role of individual-level compositional factors. Analyses rely on individual-level register data on the total Finnish population aged 30 years and over. We estimated two-level Weibull survival-models with individuals nested in areas for 10 periods between 1972 and 2018 to assess municipal-level variation in mortality. Median hazard ratio (MHR) was used as our summary measure and analyses were adjusted for age and socioeconomic characteristics. The results show a clear overall growth in area variation in mortality with MHR increasing from 1.14 (95% CI 1.12-1.15) to 1.28 (CI 1.26-1.30) among men and 1.17 (CI 1.15-1.18) to 1.30 (CI 1.27-1.32) among women. This growth, however, was fully attenuated by adjustment for age. Area differentials were largest and increased most among men at ages 30-49, and particularly for external causes. This increase was largely due to increasing differentiation in the socioeconomic composition of municipalities. In conclusion, our study shows increases in mortality differentials across municipalities that are mostly attributable to increasing differentiation between municipalities in terms of individual compositional factors.

Trends in smoking prevalence over time and space: A comparison between sexual minority and heterosexual populations

Research has suggested that lesbian, gay and bisexual (LGB) individuals are more likely to smoke tobacco than heterosexual individuals, but specific geographic patterns have not been examined frequently. We analysed change in smoking prevalence over time across Great Britain for LGB and heterosexual populations, comparing models for men and women. Smoking prevalence remained greater for sexual minority (SM) women over time than for other groups. Across Great Britain, decreases in smoking prevalence in urban areas were more pronounced for SM men compared with SM women. Future anti-smoking policies should consider sexuality and its association with place to eradicate smoking inequalities.

Multilevel regression and poststratification for estimating population quantities from large health studies: a simulation study based on US population structure

INTRODUCTION

Recruiting a representative sample of participants is becoming increasingly difficult in large-scale health surveys. Multilevel regression and poststratification (MRP) has been shown to be effective in estimating population descriptive quantities in non-representative samples. We performed a simulation study, previously applied to an Australian population, this time to a US population, to assess MRP performance.

METHODS

Data were extracted from the 2017 Current Population Survey representing a population of US adult males aged 18-55 years. Simulated datasets of non-representative samples were generated. State-level prevalence estimates for a dichotomous outcome using MRP were compared with the use of sampling weights (with and without raking adjustment). We also investigated the impact on MRP performance of sample size, model misspecification, interactions and the addition of a geographic-level covariate.

RESULTS

MRP was found to achieve generally superior performance, with large gains in precision vastly outweighing the increased accuracy observed for sampling weights with raking adjustment. MRP estimates were generally robust to model misspecification. We found a tendency of MRP to over-pool between-state variation in the outcome, particularly for the least populous states and small sample sizes. The inclusion of a state-level covariate appeared to mitigate this and further improve MRP performance.

DISCUSSION

MRP has been shown to be effective in estimating population descriptive quantities in two different populations. This provides promising evidence for the general applicability of MRP to populations with different geographic structures. MRP appears to be a valuable analytic strategy for addressing potential participation bias from large-scale health surveys.

Number of lung resections performed and long-term mortality rates of patients after lung cancer surgery: evidence from an Italian investigation

OBJECTIVES

Although it has been postulated that patients might benefit from the centralization of high-volume specialized centres, conflicting results have been reported on the relationship between the number of lung resections performed and the long-term, all-cause mortality rates among patients who underwent surgery for lung cancer. A population-based observational study was performed to contribute to the ongoing debate.

METHODS

The 2613 patients, all residents of the Lombardy region (Italy), who underwent lung resection for lung cancer from 2012 to 2014 were entered into the cohort and were followed until 2018. The hospitals were classified according to the annual number of pulmonary resections performed. Three categories of lung resection cases were identified: low (≤30), intermediate (31-95) and high (>95). The outcome of interest was all-cause death. A frailty model was used to estimate the death risk associated with the categories of numbers of lung resections performed, taking into account the multilevel structure of the data. A set of sensitivity analyses was performed to account for sources of systematic uncertainty.

RESULTS

The 1-year and 5-year survival rates of cohort members were 90% and 63%. Patients operated on in high-volume centres were on average younger and more often women. Compared to patients operated on in a low-volume centre, the mortality risk exhibited a significant, progressive reduction as the numbers of lung resections performed increased to intermediate (-13%; 95% confidence interval +10% to -31%) and high (-26%; 0% to -45%). Sensitivity analyses revealed that the association was consistent.

CONCLUSIONS

Further evidence that the volume of lung resection cases performed strongly affects the long-term survival of lung cancer patients has been supplied.

How Do Undiagnosed Symptoms of Maternal Psychological Distress During the Postnatal Period Affect Child Developmental Outcomes?

Objectives

Evidence suggests that maternal psychological distress is an under-diagnosed condition that can have lasting impacts on child outcomes. Models based solely on maternal outcomes have not found screening to be cost-effective. This research explores the effects of self-reported maternal psychological distress on children’s language and behavioural development up to the age of 7.

Methods

Using longitudinal survey data from 10,893 families in the UK Millennium Cohort Study, multilevel models are used to explore the differential effects of maternal diagnosed and treated depression versus untreated maternal psychological distress during the postnatal year on longer-term child outcomes.

Results

Both diagnosed and treated depression and self-reported maternal psychological distress have detrimental effects on child behavioural development. Behavioural outcomes up to age 5 were better for children of women who received treatment for depression, compared with children those whose mothers’ psychological distress was untreated, but this was not maintained to age 7. Little or no evidence of a difference was found between maternal psychological distress and child language development.

Conclusions for Practice

This research highlights the lack of effectiveness of existing treatment for maternal psychological distress both to benefit child development and to provide long-term symptom remediation for women. Future research could aim to identify more effective treatments for both women and children.

School and individual factors on game addiction: A multilevel analysis

This study investigated the protective or risk factors of game addiction at individual and school-level using multilevel modelling. Data from Korea Children and Youth Panel Survey was used for the analyses. The findings revealed that individual-level variables, including gender, delinquency, family intimacy, stress, self-esteem and self-control, were significant predictors of game addiction. Furthermore, protective school climate contributed to decreasing the level of game addiction and risky school climates positively predicted game addiction. The effect of individual-level variables on game addiction was different depending on the type or level of school-level variables. Based on the findings, implications and suggestions for future studies were discussed.

Multilevel modelling of factors associated with caesarean section in Ethiopia: community based cross sectional study

OBJECTIVE

The aim of this study was to identify socio-demographic and health related factors associated with caesarean section in Ethiopia.

RESULTS

A total of 256 mothers undergoing to CS among 7193 delivery. Average maternal age of a participant was 29.26 years and 80% of mothers having two and more children. A woman delivered in private institution was 30% (AOR = 1.29; 95% CI 1.25, 1.32) more likely undergoing CS as compared to home delivery. Factors associated with CS were higher education level (AOR = 1.09, 95% CI 1.07, 1.12), preceding birth interval (AOR = 1.01; 95% CI 1.00. 1.03), multiple pregnancy (AOR = 1.11; 95% CI 1.08, 1.15), multiple parity (AOR = 0.98; 95% CI 0.97, 0.99), large size the child (AOR = 1.01; 95% CI 1.001, 1.02), richest households (AOR = 0.98; 95% CI 0.97, 0.99), rural residence (AOR = 0.98 95% CI 0.96, 0.99) and Addis Ababa (AOR = 1.06; 95% CI 1.04,1.09). As a conclusion and recommendation, the prevalence of CS higher in private institutions and Addis Ababa, so professionals should apply CS alone medical indication.

Small area deprivation and stigmatising attitudes towards mental illness: a multilevel analysis of Health Survey for England (2014) data

PURPOSE

The aim of this study was to explore how small area deprivation is associated with attitudes towards mental illness in a large sample of individuals living in private households in England.

METHOD

Cross-sectional data from Health Survey for England (2014) were analysed using multilevel models. The exposure of interest was the deprivation level of the small area in which an individual resides as measured by Index of Multiple Deprivation (IMD) score. The primary outcome was an individual's overall attitude towards mental illness, measured using a 12 item version of the Community Attitudes toward the Mentally Ill (CAMI) scale. Further outcomes were the two subscales of the CAMI, reflecting attitudes of (1) prejudice and exclusion and (2) tolerance and support. Individuals were nested within household and small geographical area.

RESULTS

5820 participants were included. Results from unadjusted models found strong evidence that individuals residing in the most deprived areas of England have worse attitudes towards mental illness compared to individuals living in the least deprived areas (estimated difference = - 3.5 points; 95% CI - 4.8 to - 2.2; P < 0.001). After adjusting for age, sex, education level, ethnicity and weekly income there was no longer evidence for this association (adjusted difference = - 0.1 points, 95% CI - 1.3 to 1.2; P = 0.931). Similar patterns of results were found for the CAMI subscales.

CONCLUSIONS

The relationship between small area-level deprivation and attitudes towards mental illness is no longer observed when controlling for certain individual-level characteristics.

Comparisons of the discrepancy between loneliness and social isolation across Ireland and Sweden: findings from TILDA and SNAC-K

PURPOSE

Loneliness may have different cultural meanings in different countries. This may manifest as differing levels of Social Asymmetry-the discrepancy between loneliness and social isolation. Since loneliness is thought to be low in Sweden relative to more southerly countries, we hypothesised that more number of individuals would also fall into the "discordant robust" category of Social Asymmetry, i.e. that more individuals in Sweden would have lower loneliness levels relative to social isolation than in Ireland. We also explored the clinical relevance of Social Asymmetry in both countries, by examining its association with cognitive functioning.

METHODS

We derived Social Asymmetry metrics in two representative cohort studies: the Irish Longitudinal Study on Ageing (TILDA) and the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K). Data pertaining to a dementia-free sample of 4565 Irish participants and 3042 Swedish participants, all aged over 60 years, were analysed using a multilevel modelling approach, with country as a higher-order variable.

RESULTS

Contrary to the expected, more individuals in Ireland were "discordant robust" than in Sweden. We also found evidence for superior performance in global cognitive functioning among those in the "discordant robust" category relative to those in the discordant susceptible (i.e. those with higher levels of loneliness than social isolation) category, β = 0.61, p < .001, across both countries.

CONCLUSIONS

Irish older adults may be more robust to the impact of social isolation on loneliness than those in the Swedish cohort. Social Asymmetry was related to cognitive functioning in both countries, suggesting that Social Asymmetry is a clinically relevant construct.

Math versus meaning in MAIHDA: A commentary on multilevel statistical models for quantitative intersectionality

RATIONALE

Intersectionality has been increasingly adopted as a theoretical framework within quantitative research, raising questions about the congruence between theory and statistical methodology. Which methods best map onto intersectionality theory, with regard to their assumptions and the results they produce? Which methods are best positioned to provide information on health inequalities and direction for their remediation? One method, multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA), has been argued to provide statistical efficiency for high-dimensional intersectional analysis along with valid intersection-specific predictions and tests of interactions. However, the method has not been thoroughly tested in scenarios where ground truth is known.

METHOD

We perform a simulation analysis using plausible data generating scenarios where intersectional effects are present. We apply variants of MAIHDA and ordinary least squares regression to each, and we observe how the effects are reflected in the estimates that the methods produce.

RESULTS

The first-order fixed effects estimated by MAIHDA can be interpreted neither as effects on mean outcome when interacting variables are set to zero (as in a correctly-specified linear regression model), nor as effects on mean outcome averaged over the individuals in the population (as in a misspecified linear regression model), but rather as effects on mean outcome averaged over an artificial population where all intersections are of equal size. Furthermore, the values of the random effects do not reflect advantage or disadvantage of different intersectional groups.

CONCLUSIONS

Because first-order fixed effects estimates are the reference point for interpreting random effects as intersectional effects in MAIHDA analyses, the random effects alone do not provide meaningful estimates of intersectional advantage or disadvantage. Rather, the fixed and random parts of the model must be combined for their estimates to be meaningful. We therefore advise caution when interpreting the results of MAIHDA in quantitative intersectional analyses.

Development of 11- to 16-year-olds' short-term power output determined using both treadmill running and cycle ergometry

PURPOSE

To investigate the development of peak power output (PP) and mean power output (MP) during two different modes of exercise in relation to sex and concurrent changes in age, body mass, fat-free mass (FFM), maturity status and, in the case of MP, peak oxygen uptake ([Formula: see text]).

METHODS

PP and MP were determined cycling against a fixed braking force (Wingate anaerobic test) and running on a non-motorized treadmill. Peak [Formula: see text] was determined using cycle ergometry and treadmill running. 135 (63 girls) students initially aged 11-14 years were tested over 2 days on three annual occasions. The data were analysed using multiplicative allometric modelling which enables the effects of variables to be partitioned concurrently within an allometric framework. Multiplicative models were founded on 301 (138 from girls) determinations of PP and MP on each ergometer.

RESULTS

With body mass controlled for, both PP and MP increased with age but maturity status did not independently contribute to any of the multiplicative allometric models. Boys' PP and MP were significantly (p < 0.05) higher than girls' values on both ergometers. On both ergometers in both sexes, the most powerful morphological influence on PP and MP was FFM. Ergometer-specific peak [Formula: see text] had a significant (p < 0.05), additional effect in explaining the development of MP.

CONCLUSIONS

The development of short-term power output is sex specific but within sex multiplicative allometric models of running- and cycling-determined PP and MP were similar, suggesting that either mode of exercise can be used in future studies of short-term power output in youth.

Effects of urbanization on metabolic syndrome via dietary intake and physical activity in Chinese adults: Multilevel mediation analysis with latent centering

RATIONALE

China has undergone rapid urbanization in the past decades. Metabolic syndrome refers to a cluster of cardiometabolic risk factors such as abdominal obesity, raised blood pressure, and elevated glucose. Existing studies have not explicitly examined the urbanization effect on metabolic syndrome.

OBJECTIVE

The present study aims to examine the temporal effects of urbanization on metabolic syndrome in the Chinese context and evaluate dietary intake and physical activity as potential mediating factors.

METHOD

The study sample comprised 6,217 Chinese adults aged between 30 and 65 recruited in 218 communities from 2000 to 2009 waves of the China Health and Nutrition Survey. Growth in urbanization of the communities was derived using latent growth modeling on continuous urbanization index from 2000 to 2009. The participants reported their physical activity and dietary intake. Body mass index and biomarkers were measured at 2009 for diagnosis of metabolic syndrome. Multilevel mediation analysis with novel latent centering approach was conducted across gender to evaluate direct and indirect effects of urbanization on metabolic syndrome via changes in dietary intake and physical activity.

RESULTS

The sample displayed linear increasing trends in urbanization, intakes of red meat, dairy products and fast food and declining cereal intake and physical activity with significant inter-individual variations. Controlling for individual-level and community-level covariates, urbanization showed a positive but non-significant direct effect on metabolic syndrome across gender. There were significant and positive indirect effects from urbanization to metabolic syndrome via changes in physical activity in males and via changes in fast food intake in females.

CONCLUSIONS

The present results highlight the health impact of urbanization as a dynamic process at the community level on metabolic syndrome via different indirect pathways of lifestyle factors across gender. Methodological and practical implications are discussed in relation to these modifiable lifestyle factors in the urbanizing Chinese society.

Assessing system-based trainings for primary care teams and quality-of-life of patients with multimorbidity in Thailand: patient and provider surveys

Background

Strengthening primary care is considered a global strategy to address non-communicable diseases and their comorbidity. However, empirical evidence of the longer-term benefits of capacity building programmes for primary care teams contextualised for low- and middle-income countries is scanty. In Thailand, a series of system-based capacity building programmes for primary care teams have been implemented for a decade. An analysis of the relationship between these systems-based trainings in diverse settings of primary care and quantified patient outcomes was needed.

Methods

Facility-based and community-based cross-sectional surveys were used to obtain data on exposure of primary care team members to 11 existing training programmes in Thailand, and health profiles and health-related quality of life of their patients measured in EuroQol-5 Dimension (EQ-5D) scale. Using a multilevel modelling, the associations between primary care provider’s training and patient’s EQ-5D score were estimated by a generalized linear mixed model (GLMM).

Results

While exposure to training programmes varied among primary care teams nationwide, District Health Management Learning (DHML) and Contracting Unit of Primary Care (CUP) Leadership Training Programmes, which put more emphasis on bundling of competencies and contextualising of applying such competencies, were positively associated with better health-related quality of life of their multimorbid patients.

Conclusions

Our report provides systematic feedback to a decade-long investment on system-based capacity building for primary care teams in Thailand, and can be considered as new evidence on the value of human resource development in primary care systems in low- and middle-income countries. Building multiple competencies helps members of primary care teams collaboratively manage district health systems and address complex health problems in different local contexts. Coupling contextualised training with ongoing programme implementation could be a key entity to the sustainable development of primary care teams in low and middle income countries which can then be a leverage for improving patients outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0951-6) contains supplementary material, which is available to authorized users.

A multilevel study of neighborhood disadvantage, individual socioeconomic position, and body mass index: Exploring cross-level interaction effects

This study examined associations between neighborhood disadvantage and body mass index (BMI), and tested whether this differed by level of individual socioeconomic position (SEP). Data were from 9953 residents living in 200 neighborhoods in Brisbane, Australia in 2007. Multilevel linear regression analyses were undertaken by gender to determine associations between neighborhood disadvantage, individual SEP (education, occupation and household income) and BMI (from self-reported height and weight); with cross-level interactions testing whether the relationship between neighborhood disadvantage and BMI differed by level of individual SEP. Both men (Quintile 4, where Quintile 5 is the most disadvantaged β = 0.66 95%CI 0.20, 1.12) and women (Quintile 5 β = 1.32 95%CI 0.76, 1.87) from more disadvantaged neighborhoods had a higher BMI. BMI was significantly higher for those with lower educational attainment (men β = 0.71 95%CI 0.36, 1.07 and women β = 1.66 95%CI 0.78, 1.54), and significantly lower for those in blue collar occupations (men β = -0.67 95%CI -1.09, -0.25 and women β = -0.71 95%CI -1.40, -0.01). Among men, those with a lower income had a significantly lower BMI, while the opposite was found among women. None of the interaction models had a significantly better fit than the random intercept models. The relationship between neighborhood disadvantage and BMI did not differ by level of education, occupation, or household income. This suggests that individual SEP is unlikely to be an effector modifier of the relationship between neighborhood disadvantage and BMI. Further research is required to assist policy-makers to make more informed decisions about where to intervene to counteract BMI-inequalities.

Association between school-level attributes and weight status of Ghanaian primary school children

Background

Little is known about the impact of the school environmental context on the emerging trend of childhood obesity in Africa. We examined the association of the schools’ contextual factors with body mass index (BMI), abdominal obesity and overweight (including obesity) in urban Ghana.

Method

Using cross-sectional data from 543 school children aged 8–11 years attending 14 primary schools, we applied multilevel logistic regressions and linear regression models to investigate the association of child- and school level attributes with overweight, abdominal obesity, and BMI.

Results

We observed significant variance of the random effects of schools in BMI (2.65, p <  0.05), abdominal obesity (0.85, p <  0.05), and overweight (1.41, p < 0.05), with school contextual levels accounting for 19.7, 20.6, and 30.0% of the total variability observed in BMI, abdominal obesity and overweight respectively. Attending high socioeconomic (SES) level school, private school and school with increased after-school recreational facilities were associated with higher BMI. Children were more likely to be overweight if they attended a high SES level school, had access to healthful foods at school, and after-school recreational facilities. With regards to abdominal obesity, attending a school with increased physical activity facilities decreased the odds of abdominal obesity; however the odds increased if they attended a school with access to after-school recreational facilities.

Conclusion

A number of school-level factors were associated with BMI, overweight and abdominal obesity of children in the present study. Our results provide support for improved school environment to reduce overweight.

Bayesian analysis of herd-level risk factors for bovine digital dermatitis in New Zealand dairy herds

Background

Bovine digital dermatitis (BDD) is considered the most important infectious cause of lameness in dairy cattle worldwide, but has only recently been observed in New Zealand. Although many studies have investigated the risk factors for BDD in confined dairy systems, information on risk factors in pasture-based system is limited. Therefore a cross-sectional study including 59,849 animals from 127 dairy herds in four regions of New Zealand was conducted to identify the herd-level factors associated with the probability of a herd being BDD-lesion positive and with within-herd BDD prevalence.

Results

Purchasing heifers was associated with increased odds of a herd being BDD-lesion positive (odds ratio [OR]: 2.33, 95% probability interval [PI]: 1.26–4.42) and a cow being BDD affected (OR: 3.76, 95%PI: 1.73–8.38), respectively. Higher odds of a herd being BDD-lesion positive (OR: 2.06, 95%PI: 1.17–3.62) and a cow being BDD affected (OR: 2.87, 95%PI: 1.43–5.94) were also seen in herds where heifers co-grazed with cattle from other properties. In addition, using outside staff to treat lameness was associated with higher odds of a cow being BDD affected (OR: 2.18, 95%PI: 0.96–4.98).

Conclusion

This study highlighted that movements of heifers are significantly associated with the spread of BDD within and between dairy herds in New Zealand. To minimise the risk of disease introductions in herds where moving heifers cannot be avoided, it is best to purchase heifers only from herds where BDD-freedom has been confirmed and, if heifers have to graze-off a farm, they should be reared as a single biosecure management group, especially since animals may be BDD-infected without having clinically obvious lesions.

Electronic supplementary material

The online version of this article (10.1186/s12917-019-1871-3) contains supplementary material, which is available to authorized users.

Factors influencing unmet need for family planning among Ghanaian married/union women: a multinomial mixed effects logistic regression modelling approach

BACKGROUND

Unmet need for family planning is high (30%) in Ghana. Reducing unmet need for family planning will reduce the high levels of unintended pregnancies, unsafe abortions, maternal and neonatal morbidity and mortality. The purpose of this study was to examine factors that are associated with unmet need for family planning to help scale up the uptake of family planning services in Ghana.

METHODS

This cross sectional descriptive and inferential study involved secondary data analysis of women in the reproductive age (15-49 years) from the Ghana Demographic and Health Survey 2014 data. The outcome variable was unmet need for family planning which was categorized into three as no unmet need, unmet need for limiting and unmet need for spacing. Chi-squared test statistic and bivariate multilevel multinomial mixed effects logistic regression model were used to determine significant variables which were included for the multivariable multilevel multinomial mixed effects logistic regression model. All significant variables (p < 0.05) based on the bivariate analysis were included in the multinomial mixed effects logistic regression model via model building approach.

RESULTS

Women who fear contraceptive side effects were about 2.94 (95% CI, 2.28, 3.80) and 2.58 (95% CI, 2.05, 3.24) times more likely to have an unmet need for limiting and spacing respectively compared to those who do not fear side effects. Respondents' age was a very significant predictor of unmet need for family planning. There was very high predictive probability among 45-49 year group (0.86) compared to the 15-19 year group (0.02) for limiting. The marginal predictive probability for spacing changed significantly from 0.74 to 0.04 as age changed from 15 to 19 to 45-49 years. Infrequent sexual intercourse, opposition from partners, socio-economic (wealth index, respondents educational level, respondents and partner's occupation) and cultural (religion and ethnicity) were all significant determinants of both unmet need for limiting and spacing.

CONCLUSIONS

This study reveals that fear of side effect, infrequent sex, age, ethnicity, partner's education and region were the most highly significant predictors of both limiting and spacing. These factors must be considered in trying to meet the unmet need for family planning.

Development of peak oxygen uptake from 11-16 years determined using both treadmill and cycle ergometry

PURPOSES

To investigate the development of peak oxygen uptake ([Formula: see text]) assessed on both a treadmill and a cycle ergometer in relation with sex and concurrent changes in age, body mass, fat-free mass (FFM), and maturity status and to evaluate currently proposed 'clinical red flags' or health-related cut-points for peak [Formula: see text].

METHODS

Multiplicative multilevel modelling, which enables the effects of variables to be partitioned concurrently within an allometric framework, was used to analyze the peak [Formula: see text]s of 138 (72 boys) students initially aged 11-14 years and tested on three annual occasions. Models were founded on 640 (340 from boys) determinations of peak [Formula: see text], supported by anthropometric measures and maturity status.

RESULTS

Mean peak [Formula: see text]s were 11-14% higher on a treadmill. The data did not meet the statistical assumptions underpinning ratio scaling of peak [Formula: see text] with body mass. With body mass appropriately controlled for boys' peak [Formula: see text]s were higher than girls' values and the difference increased with age. The development of peak [Formula: see text] was sex-specific, but within sex models were similar on both ergometers with FFM the dominant anthropometric factor.

CONCLUSIONS

Data should not be pooled for analysis but data from either ergometer can be used independently to interpret the development of peak [Formula: see text] in youth. On both ergometers and in both sexes, FFM is the most powerful morphological influence on the development of peak [Formula: see text]. 'Clinical red flags' or health-related cut-points proposed without consideration of exercise mode and founded on peak [Formula: see text] in ratio with body mass are fallacious.

The impact of rural-urban community settings on cognitive decline: results from a nationally-representative sample of seniors in China

BACKGROUND

Aging and rural-urban disparities are two major social problems in today's ever-developing China. Much of the existing literature has supported a negative association between adverse community setting with the cognitive functioning of seniors, but very few studies have empirically investigated the impact of rural-urban community settings on cognitive decline in the late life course of the population in developing countries.

METHODS

Data of seniors aged 65 or above (n = 1709) within CHARLS (The China Health and Retirement Longitudinal Study, a sister study of HRS), a nationally representative longitudinal cohort (2011-2015) in China, were analyzed using a multilevel modeling (MLM) of time within individuals, and individual within communities. Cognitive impairment was assessed with an adapted Chinese version of Mini-Mental State Examination.

RESULTS

Urban community setting showed a significant protective effect (β = - 1.978, p < .000) on cognitive impairment in simple linear regression, and the MLM results showed it also had a significant lower cognitive impairment baseline (β = - 2.278, p < .000). However, the curvature rate of cognitive decline was faster in urban community setting indicated by a positive interaction between the quadratic time term and urban community setting on cognitive impairment (β = 0.320, p < .05). A full model adjusting other individual SES factors was built after model fitness comparison, and the education factor accounted for most of the within and between community setting variance.

CONCLUSIONS

The findings suggest that urban community setting in one's late-life course has a better initial cognitive status but a potentially faster decline rate in China, and this particular pattern of senior cognitive decline emphasize the importance of more specific preventive measures. Meanwhile, a more holistic perspective should be adopted while construct a risk factor model of community environment on cognitive function, and the influence at society level needs to be further explored in future research.

Associations between lifestyle, physical and social environments and frailty among Chinese older people: a multilevel analysis

BACKGROUND

Frailty represents a public health priority and an increasingly prevalent condition in the ageing population. It is seen as reflecting an interaction among individual factors and a range of environmental elements. This study aims to examine the association between frailty and individual factors, physical and social environments among Chinese older people.

METHODS

The data were from the Shanghai Healthy City Survey in 2017, which sampled 2559 older people aged ≥60 years from 67 neighbourhoods. The FRAIL scale was used to assess frailty, and social and physical environments were assessed using validated and psychometrically tested instruments. Individual factors included age, gender, education, employment, marital status, smoking, drinking, physical exercise, organization participation, self-rated health and psychological well-being. A multilevel analysis was conducted to examine whether physical and social environments were associated with frailty.

RESULTS

The prevalence of pre-frailty and frailty were 39.5 and 16.9%, respectively. The prevalence of frailty increased with age from 14.6% (60-64 years) to 26.5% (≥75 years). After adjusting for age and/or gender, older age, women, and those with low education, alcohol dependence, physical inactivity, poor self-rated health, or psychological disorders had a higher prevalence of frailty. The multilevel analysis indicated that after controlling for individual covariates, compared to the 1st quartile of aesthetic quality, the odds ratio (OR) of frailty for the 4th quartile was 0.65 (0.47-0.89); compared to the 1st quartile of walking environment, the OR of frailty for the 4th quartile was 0.43 (0.19-0.95); compared to the 1st quartile of social cohesion, the OR of frailty for the 4th quartile was 0.73 (0.54-0.99); compared to the 1st quartile of social participation, the ORs of frailty for the 2nd, 3rd and 4th quartiles were 0.76 (0.59-0.97), 0.59 (0.45-0.77) and 0.59 (0.45-0.77), respectively.

CONCLUSIONS

Frailty is a highly prevalent health condition among the aged population in China. Healthcare should focus on frail elderly who are older age, women, those with low education, and those with mental health problems. It may decrease frailty among Chinese older people to encourage social participation and healthy behaviours and to build aesthetic, walkable and cohesive neighbourhoods.

Community-level social capital, parental psychological distress, and child physical abuse: a multilevel mediation analysis

PURPOSE

The purpose of this study was to investigate the association between community-level social capital and physical abuse towards children, and the mediating effect of parental psychological distress by multilevel mediation analyses.

METHODS

We analyzed data from a population-based study of first-grade elementary school children (6-7 years old) in Adachi City, Tokyo, Japan. The caregivers of first-grade students from all elementary schools in Adachi City (N = 5355) were asked to respond to a questionnaire assessing parents' self-reported physical abuse (beating and hitting) and neighborhood social capital. Among them, 4291 parents returned valid responses (response rate 80.1%). We performed multilevel analyses to determine the relationships between community-level parental social capital and physical abuse, and further multilevel mediation analyses were performed to determine whether parental psychological distress mediated the association.

RESULTS

Low community-level social capital was positively associated with physical abuse (both beating and hitting) after adjustment for other individual covariates (beating: middle, OR = 1.54, 95% CI 1.11-2.13; low, OR = 1.33, 95% CI 0.94-1.88; and hitting: middle, OR = 1.35, 95% CI 1.02-1.80; low, OR = 1.16, 95% CI 0.86-1.57). Multilevel mediation analyses revealed that community-level parental psychological distress did not mediate the association (indirect effect ß = 0.10, 95% CI - 0.10 to 0.29, p = 0.34 for beating; ß = 0.03, 95% CI - 0.16 to 0.23, p = 0.74 for hitting).

CONCLUSIONS

Fostering community-level social capital might be important for developing a strategy to prevent child maltreatment, which may have a direct impact on abusive behavior towards children.

Multilevel linear modelling of the response-contingent learning of young children with significant developmental delays

AIM

The purpose of the study was to isolate the sources of variations in the rates of response-contingent learning among young children with multiple disabilities and significant developmental delays randomly assigned to contrasting types of early childhood intervention.

METHOD

Multilevel, hierarchical linear growth curve modelling was used to analyze four different measures of child response-contingent learning where repeated child learning measures were nested within individual children (Level-1), children were nested within practitioners (Level-2), and practitioners were nested within the contrasting types of intervention (Level-3).

RESULTS

Findings showed that sources of variations in rates of child response-contingent learning were associated almost entirely with type of intervention after the variance associated with differences in practitioners nested within groups were accounted for. Rates of child learning were greater among children whose existing behaviour were used as the building blocks for promoting child competence (asset-based practices) compared to children for whom the focus of intervention was promoting child acquisition of missing skills (needs-based practices).

IMPLICATIONS

The methods of analysis illustrate a practical approach to clustered data analysis and the presentation of results in ways that highlight sources of variations in the rates of response-contingent learning among young children with multiple developmental disabilities and significant developmental delays.

The utility of geodemographic indicators in small area estimates of limiting long-term illness

Small area health data are not always available on a consistent and robust routine basis across nations, necessitating the employment of small area estimation methods to generate local-scale data or the use of proxy measures. Geodemographic indicators are widely marketed as a potential proxy for many health indicators. This paper tests the extent to which the inclusion of geodemographic indicators in small area estimation methodology can enhance small area estimates of limiting long-term illness (LLTI). The paper contributes to international debates on small area estimation methodologies in health research and the relevance of geodemographic indicators to the identification of health care needs. We employ a multilevel methodology to estimate small area LLTI prevalence in England, Scotland and Wales. The estimates were created with a standard geographically-based model and with a cross-classified model of individuals nested separately in both spatial groupings and non-spatial geodemographic clusters. LLTI prevalence was estimated as a function of age, sex and deprivation. Estimates from the cross-classified model additionally incorporated residuals relating to the geodemographic classification. Both sets of estimates were compared against direct estimates from the 2011 Census. Geodemographic clusters remain relevant to understanding LLTI even after controlling for age, sex and deprivation. Incorporating a geodemographic indicator significantly improves concordance between the small area estimates and the Census. Small area estimates are however consistently below the equivalent Census measures, with the LLTI prevalence in urban areas characterised as 'blue collar' and 'struggling families' being markedly lower. We conclude that the inclusion of a geodemographic indicator in small area estimation can improve estimate quality and enhance understanding of health inequalities. We recommend the inclusion of geodemographic indicators in public releases of survey data to facilitate better small area estimation but caution against assumptions that geodemographic indicators can, on their own, provide a proxy measure of health status.

Place and preference effects on the association between mental health and internal migration within Great Britain

Individuals with mental health needs are more likely to migrate than the general population, but the effects of migration preference and place of residence are often overlooked. These issues are addressed through the application of a novel origin and destination multilevel model to survey data. In comparison to those with good mental health, individuals with poor mental health are more likely to make undesired moves and this is moderated, but not explained by place of residence. Implications for understanding the mental health and migration relationship, and its impact on service provision are then proposed.

Are multiple-trial experiments appropriate for eyewitness identification studies? Accuracy, choosing, and confidence across trials

Eyewitness identification experiments typically involve a single trial: A participant views an event and subsequently makes a lineup decision. As compared to this single-trial paradigm, multiple-trial designs are more efficient, but significantly reduce ecological validity and may affect the strategies that participants use to make lineup decisions. We examined the effects of a number of forensically relevant variables (i.e., memory strength, type of disguise, degree of disguise, and lineup type) on eyewitness accuracy, choosing, and confidence across 12 target-present and 12 target-absent lineup trials (N = 349; 8,376 lineup decisions). The rates of correct rejections and choosing (across both target-present and target-absent lineups) did not vary across the 24 trials, as reflected by main effects or interactions with trial number. Trial number had a significant but trivial quadratic effect on correct identifications (OR = 0.99) and interacted significantly, but again trivially, with disguise type (OR = 1.00). Trial number did not significantly influence participants' confidence in correct identifications, confidence in correct rejections, or confidence in target-absent selections. Thus, multiple-trial designs appear to have minimal effects on eyewitness accuracy, choosing, and confidence. Researchers should thus consider using multiple-trial designs for conducting eyewitness identification experiments.