Search

Abstract Background Early marriage and motherhood have long been prevalent in India, with 44.5% of women aged 20–24 reporting marriage before 18 in NFHS 3 (2005–2006), dropping to 26.8% in NFHS 4 (2015–2016). Early motherhood has also seen a significant decline, with first births by age 18 decreasing from 34.3% in NFHS I to 8.2% in NFHS V. Despite these improvements, significant regional disparities persist due to social, normative, and legal factors. This study investigates the spatial heterogeneity of early marriage and motherhood across Indian districts, offering a multilevel analysis that reveals critical local variations often obscured at broader levels. Understanding these patterns is crucial for targeted policy interventions and addressing the root causes of early marriage and motherhood. Methods Utilizing data from the fifth round of National Family Health Survey, this study employs multilevel logistic regression and geospatial analysis to assess the determinants and spatial distribution of early marriage and early motherhood among ever-married women in India. The analysis incorporates individual, household, and community-level variables, complemented by spatial analysis techniques, including Empirical Bayes Bivariate Moran’s I values and LISA cluster maps, to identify regional patterns and hotspots. Results This study revealed that educational attainment emerged as a critical determinant, with uneducated women significantly more likely to marry early. Socioeconomic factors, such as poverty and limited mass media exposure, also heightened the risk of early marriage and motherhood. Caste and religion were significantly associated with these events, with marginalized groups facing higher prevalence. Spatial analysis revealed significant geographic disparities, with central and eastern regions showing higher concentrations of early marriage and motherhood. District-level characteristics and the influence of neighboring districts were also significant, highlighting the importance of localized interventions. Conclusions The findings underscore the critical role of education, economic empowerment, and media literacy in mitigating early marriage and motherhood risks. The study calls for multi-sectoral interventions in geographical hotspots to break the cycle of early family formation and promote reproductive health. Policies enhancing educational opportunities, addressing economic disadvantages, and considering district-specific factors are essential. Comprehensive strategies are necessary to empower women, foster reproductive health, and address the multifaceted nature of early marriage and motherhood in India.

Abstract Background Regional variations in SARS-CoV-2 infection were observed in Canada and other countries. Studies have used multilevel analyses to examine how a context, such as a neighbourhood, can affect the SARS-CoV-2 infection rates of the people within it. However, few multilevel studies have quantified the magnitude of the general contextual effect (GCE) in SARS-CoV-2 infection rates and assessed how it may be associated with individual- and area-level characteristics. To address this gap, we will illustrate the application of the median rate ratio (MRR) in a multilevel Poisson analysis for quantifying the GCE in SARS-CoV-2 infection rates in Ontario, Canada. Methods We conducted a population-based, two-level multilevel observational study where individuals were nested into regions (i.e., forward sortation areas [FSAs]). The study population included community-dwelling adults in Ontario, Canada, between March 1, 2020, and May 1, 2021. The model included seven individual-level variables (age, sex, asthma, diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease) and four FSA census-based variables (household size, household income, employment, and driving to work). The MRR is a median value of the rate ratios comparing two patients with identical characteristics randomly selected from two different regions ordered by rate. We examined the attenuation of the MRR after including individual-level and FSA census-based variables to assess their role in explaining the variation in rates between regions. Results Of the 11 789 128 Ontario adult community-dwelling residents, 343 787 had at least one SARS-CoV-2 infection during the study period. After adjusting for individual-level and FSA census-based variables, the MRR was attenuated to 1.67 (39% reduction from unadjusted MRR). The strongest FSA census-based associations were household size (RR = 1.88, 95% CI: 1.71–1.97) and driving to work (RR = 0.68, 95% CI: 0.65–0.71). Conclusions The individual- and area-level characteristics in our study accounted for approximately 40% of the between-region variation in SARS-CoV-2 infection rates measured by MRR in Ontario, Canada. These findings suggest that population-based policies to address social determinants of health that attenuate the MRR may reduce the observed between-region heterogeneity in SARS-CoV-2 infection rates.

Purpose : The authors aimed to identify the factors affecting interhospital transfer (“transfer”) of severe pediatric patients who visited to an emergency department (ED). Methods : Using the Korean National ED Information System, we analyzed high-acuity patients aged 18 years or younger who visited EDs of local or regional emergency centers nationwide. The high acuity was defined as a Korean Triage and Acuity Scale 1-2. To investigate the factors associated with transfer, a multilevel modeling was selected, examining independent variables at both individual- and hospital-levels with transfer as a dependent variable. Results : A model consisting of variables at individual- and hospital-levels showed the factors as follows: mode of arrival(self-transport: odds ratio, 0.48 [95% confidence interval, 0.38-0.61]; other ambulances: 0.41 [0.24-0.71]; compared with firehouse ambulance), visit at 18:00-07:59 (0.75 [0.64-0.88]), intentional injury (1.59 [1.03-2.47]; compared with non-injury), decreased level of consciousness (drowsy: 1.94 [1.33-2.84]; stupor: 4.08 [2.99-5.57]; coma: 1.81 [1.26-2.60]; compared with alert), severe illness diagnosis (1.49 [1.12-1.98]), the number of all beds in EDs (1.02 [1.01-1.04]), and acceptance for treatment (0.92 [0.87-0.98]; with increment of 1%). Conclusion : This study confirms that both individual-level and hospital-level factors affect the transfer risk of severe pediatric patients in EDs. The study suggests the needs for direct transportation to specialized pediatric treatment facilities, and concentrated support for the pediatric emergency medical centers and pediatric trauma centers.

Abstract Background Sexual violence is a violation of women’s rights, resulting in significant physical and psychological challenges and adverse reproductive health outcomes. Addressing these issues demands urgent public health interventions and support systems to mitigate the profound impact on individuals and societies. Thus, this study aimed to assess sexual violence against ever-married reproductive-age women in East Africa. Methods Data retrieved from the recent Demographic and Health Survey (DHS) of East African countries was used, and a weighted sample of 40,740 ever-married reproductive-age women was included. To identify factors associated with sexual violence, multilevel mixed-effects models utilizing robust Poisson regression were applied. Akaike’s and Bayesian information criteria, as well as deviance, were utilized to compare the models. In the multivariable regression model, adjusted prevalence ratios (APR) with 95% confidence intervals (CI) were used to estimate the strength of association, with statistical significance set at a p-value

Abstract Background One of the reasons for the high rates of maternal and child morbidity and mortality in Sub-Saharan Africa is the rising proportion of teenage pregnancy. Preventing teenage pregnancy is critical to meeting sustainable development goal number three which aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. To support the achievement of this goal, this study aimed to assess the spatial variation and factors associated with teenage pregnancy in Ethiopia using the recent nationally representative data. Methods A secondary data analysis of the 2019 Ethiopian mini Demographic and Health Survey was conducted with a total weighted sample of 2211 (unweighted 2100) teenagers. The Bernoulli model was fitted using SaTScan version 9.6 to identify hotspot areas and the geospatial pattern and prediction of teenage pregnancy were mapped using ArcGIS version 10.7. A multilevel logistic regression model was fitted to identify factors associated with teenage pregnancy among teenagers. Adjusted OR with 95% CI was calculated and variables having a p-value less than 0.05 were statistically significant factors of teenage pregnancy. Result The prevalence of teenage pregnancy among adolescents aged 15–19 years in Ethiopia was 12.89% (95% CI: 11.56%, 14.36%). The SaTScan analysis identified a primary cluster in the Gambella region of Ethiopia (log-likelihood ratio = 14.02, p

Abstract Background Worldwide, sexual and reproductive health remains a prominent public health concern for women of reproductive age. Modern contraceptive methods play a crucial role in enabling individuals and families to regulate fertility, thereby reducing unintended pregnancies, abortions, pregnancy-related complications, and mortality. Due to the scarcity of reliable and current data regarding the factors affecting the adoption of modern contraceptives among women of reproductive age at the national level in Ghana, this research aimed to explore the determinants of modern contraceptive usage among reproductive age women. Methods The study analyzed data from the 2022 Ghana Demographic and Health Survey, including a weighted sample of 6,839 reproductive-age women. By employing a multilevel logistic regression model, the study sought to determine factors associated with the utilization of modern contraceptives. Associations between explanatory variables and the outcome were evaluated using adjusted odds ratios (AORs) along with 95% confidence intervals (CIs). Statistical significance was established using a p-value threshold of less than 0.05. All statistical analyses were conducted using STATA version 17 software. Results The study found that 26.36% (95% CI: 25.33-27.34%) of women of reproductive age in Ghana used modern contraceptives. Secondary education (AOR = 1.26, 95% CI = 1.03–1.53), poorer household (AOR = 1.30, 95% CI = 1.05–1.61), women’s marital status, i.e. married (AOR = 1.46, 95% CI = 1.16–1.83), living with a partner (AOR = 1.65, 95% CI = 1.32–2.06), divorced (AOR = 2.53, 95% CI = 1.48–4.31), and separated (AOR = 1.70, 95% CI = 1.21–2.37), multipara (AOR = 1.39, 95% CI = 1.04–1.87), were the factors that promote modern contraceptive utilization. Women’s age in years, i.e. 35–39 (AOR = 0.71, 95% CI = 0.52–0.97), 40–44 (AOR = 0.63, 95% CI = 0.44–0.90), and 45–49 (AOR = 0.45, 95% CI = 0.25–0.79), history of pregnancy loss (AOR = 0.86, 95% CI = 0.76–0.98), region, i.e. Greater Accra (95% CI = 0.42–0.92), Bono East (95% CI = 0.32–0.81), Northern (95% CI = 0.28–0.67), Savannah (95% CI = 0.28–0.81), and North East (95% CI = 0.20–0.63), were all associated with a lower use of modern contraceptives. Conclusions Modern contraceptive utilization was low in this study. Factors such as women’s education, socioeconomic status, and marital status were associated with increased modern contraceptive utilization, whereas women’s age and regional disparities were linked to lower usage rates. These findings emphasize the need for targeted interventions to address socioeconomic barriers and regional disparities in access to family planning services across Ghana.

Abstract Background Contraceptive usage in Ethiopia is significantly influenced by the decision-maker at the household level. Joint decision-making involving both women and their husbands/partners is considered ideal for improving contraceptive uptake among women and for managing health outcomes related to contraceptive side effects. However, there is a lack of substantial evidence regarding the prevalence and impact of joint decision-making on contraceptive use in Ethiopia. Therefore, the current study aimed to assess the magnitude of joint decision-making on contraceptive use and its determinant factors among married, contraceptive-using, reproductive-age women in Ethiopia. Methods This study was conducted based on the Ethiopian Demographic and Health Survey (EDHS) 2016 data. A total weighted sample of 3,669 married, contraceptive-using, reproductive-age women were included in the study. Multilevel logistic regression was employed due to the hierarchical nature of the data. Variables with a p-value of ≤ 0.2 in the bivariate multilevel analysis were included in the multivariable multilevel analysis. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to determine the direction and strength of associations. Variables with a p-value of

Abstract Background Despite the intended 50% reduction in anemia in women of reproductive age, this tendency has only worsened. Even though iron deficiency is the most prevalent cause of anemia, anemia and chronic illnesses like HIV are closely associated; in fact, 48.6% of people living with HIV who were 15 years of age or older had anemia. However, the burden of anemia among HIV-positive women in sub-Saharan African (SSA) countries is not well documented. Therefore, the goal of our research was to investigate anemia and the factors that are linked to it in SSA women who had HIV infections. Methods A cross-sectional study was conducted using demographic and health survey datasets from 18 SSA countries. A total of 7823 weighted samples were included. STATA version 16 software was used for analysis. A multilevel logistic regression model was fitted. An adjusted odds ratio with a 95% CI and a p-value

Abstract Background Many married women of reproductive age with husbands or partners are less cooperative in using contraceptives, often resulting in unintended pregnancies or secret contraceptive use. This private use of contraceptives causes women to suffer from side effects without proper support, and many women in Ethiopia die due to unintended pregnancies. However, the involvement of husbands or partners in the contraceptive decision-making process in Ethiopia is often neglected. There is also a lack of evidence regarding the determinants of husbands’ or partners’ decision-making power on contraceptive use in Ethiopia. Objective This study aimed to assess the determinants of low involvement of husbands/partners in women’s contraceptive use decision-making processes in Ethiopia. Methods This study was based on Ethiopian Demographic and Health Survey data, collected from January 18 to June 27, 2016. Weighted samples of 3,669 reproductive-age women were included. Husbands’/partners’ independent decision-making was measured by whether the husband/partner decided independently or alone about contraceptive use, categorized as “Yes” or “No”. A multilevel logistic regression model was fitted, and ICC (Intra-class Correlation Coefficient), MOR (Median Odds Ratio), PCV (Proportion Change in Variance), and deviance were used to assess model fitness and comparison. Variables with a p-value of ≤ 0.2 in the bivariate analysis were considered candidates for multivariable multilevel analysis. An adjusted odds ratio with a 95% confidence interval was used to determine both the direction and strength of the association, and a p-value of

Abstract Background Underweight is a prevalent health issue in children. This study aimed to identify factors associated with underweight in children aged 1–2 years in Hamadan city. Unlike the studies conducted in this field, which are cross-sectional and do not provide information on the effect of age changes on underweight, our longitudinal approach provides insights into weight changes over time. On the other hand, this study focuses on the high-risk age group of 1 to 2 years, which has only been addressed in a few studies. Methods In this longitudinal study, 414 mothers with 1 to 2 year-old children referred to the health centers of Hamadan city, whose information is in the SIB system, a comprehensive electronic system, were examined to identify factors related to underweight. The response variable was weight-for-age criteria classified into three categories: underweight, normal weight, and overweight. A two-level longitudinal ordinal model was used to determine the factors associated with underweight. Results Of the children studied, 201 (48.6%) were girls and 213 (51.4%) were boys. Significant risk factors for underweight included low maternal education (AOR = 3.56, 95% CI: 1.10–11.47), maternal unemployment (AOR = 3.38, 95% CI: 1.05–10.91), maternal height (AOR = 0.85, 95% CI: 0.79–0.92), lack of health insurance (AOR = 2.85, 95% CI: 1.04–7.84), gestational age less than 24 years (AOR = 3.17, 95% CI: 16.28–0.97), child age 12–15 months (AOR = 2.27, 95% CI: 1.37–3.74), and child's birth weight (AOR = 0.63, 95% CI: 0.70–0.58). Conclusion Based on the results of the present study, it seems that the possibility of being underweight among children is more related to the characteristics of mothers; therefore, taking care of mothers can control some of the weight loss of children.

Abstract Background We aimed to measure the variance due to examination conditions during the first sessions of objective structured clinical examinations (OSCEs) performed at a French medical school and identify factors associated with student success. Methods We conducted a retrospective, observational study using data from the first three OSCEs sessions performed at Paris-Saclay medical school in 2021 and 2022. For all sessions (each organized in 5 parallel circuits), we tested a circuit effect using a linear mixed-effects model adjusted for sex and the average academic level of students (according to written tests). Then, we studied the factors associated with student success at one station using a multivariate linear mixed-effects model, including the characteristics of students, assessors, and standardized patients. Results The study included three OSCEs sessions, with 122, 175, and 197 students and a mean (± SD) session score of 13.7(± 1.5)/20, 12.7(± 1.7)/20 and 12.7(± 1.9)/20, respectively. The percentage of variance due to the circuit was 6.5%, 18.2% (statistically significant), and 3.8%, respectively. For all sessions, the student’s average level and station scenario were significantly associated with the score obtained in a station. Still, specific characteristics of assessors or standardized patients were only associated with the student’s score in April 2021 (first session). Conclusion The percentage of the variance of students’ performance due to the examination conditions was significant in one out of three of the first OSCE sessions performed at Paris-Saclay medical school. This result seems more related to individual behaviors rather than specific characteristics of assessors or standardized patients, highlighting the need to continue training teaching teams. National clinical trial number Not applicable.

Abstract Background Poor infant and child feeding practices, in combination with increased rates of infectious diseases, are the main immediate causes of malnutrition during the first two years of life. Non-breastfed children require milk and other dairy products, as they are rich sources of calcium and other nutrients. As far as our search is concerned, there is no evidence on the pooled magnitude and determinants of minimum milk feeding frequency among non-breastfed children in sub-Saharan Africa conducted using the most recent indicators for assessing infant and young child feeding practices published in 2021. Therefore, this study is intended to determine the magnitude and associated factors of minimum milk feeding frequency among non-breastfed children aged 6–23 months in sub-Saharan Africa using the most recent guideline and demographic and health survey dataset. Methods Data from the most recent health and demographic surveys, which were carried out between 2015 and 2022 in 20 sub-Saharan African countries, were used. The study comprised a weighted sample consisting of 13,315 non-breastfed children between the ages of 6 and 23 months. STATA/SE version 14.0 statistical software was used to clean, recode, and analyze data that had been taken from DHS data sets. Utilizing multilevel mixed-effects logistic regression, the factors associated with the outcome variable were identified. Model comparison and fitness were assessed using deviance (-2LLR), likelihood ratio test, median odds ratio, and intra-class correlation coefficient. Finally, variables with a p-value

Abstract Objective In view of the increasing number of people with (multiple) chronic conditions, the Organisation for Economic Co-operation and Development (OECD) initiated the International Survey of People Living with Chronic Conditions (PaRIS survey), which aims to provide insight in patient-reported outcomes and experiences of chronic care provided by primary care practices to support policy development. The objective of this research note is to describe the structure of the data, collected in the PaRIS survey and how the data will be analysed in a multilevel approach for cross-country comparison. Analysis plan The data structure of the PaRIS survey represents three levels: countries/health systems, primary care practices and patients. Multilevel analysis is used because of its accuracy in estimating country-level outcomes, its flexibility in modelling relationships, and its opportunities in connecting to relevant policy questions. Country-level outcomes will be estimated to facilitate cross-country comparison and (future) within-country comparison over time. Characteristics of patients that potentially explain variation in patient-reported outcomes and experiences can be linked to primary care practice and country/health system characteristics. This makes it possible to address policy-relevant questions relating, e.g., to the impact of chronic care management on patients with a specific chronic condition.

Abstract Background Patients who receive invasive mechanical ventilation (IMV) in the intensive care unit (ICU) have exhibited lower in-hospital mortality rates than those who are treated outside. However, the patient-, hospital-, and regional factors influencing the ICU admission of patients with IMV have not been quantitatively examined. Methods This retrospective cohort study used data from the nationwide Japanese inpatient administrative database and medical facility statistics. We included patients aged ≥ 15 years who underwent IMV between April 2018 and March 2019. The primary outcome was ICU admission on the day of IMV initiation. Multilevel logistic regression analyses incorporating patient-, hospital-, or regional-level variables were used to assess cluster effects by calculating the intraclass correlation coefficient (ICC), median odds ratio (MOR), and proportional change in variance (PCV). Results Among 83,346 eligible patients from 546 hospitals across 140 areas, 40.4% were treated in ICUs on their IMV start day. ICU admission rates varied widely between hospitals (median 0.7%, interquartile range 0–44.5%) and regions (median 28.7%, interquartile range 0.9–46.2%). Multilevel analyses revealed significant effects of hospital cluster (ICC 82.2% and MOR 41.4) and regional cluster (ICC 67.3% and MOR 12.0). Including patient-level variables did not change these ICCs and MORs, with a PCV of 2.3% and − 1.0%, respectively. Further adjustment for hospital- and regional-level variables decreased the ICC and MOR, with a PCV of 95.2% and 85.6%, respectively. Among the hospital- and regional-level variables, hospitals with ICU beds and regions with ICU beds had a statistically significant and strong association with ICU admission. Conclusions Our results revealed that primarily hospital and regional factors, rather than patient-related ones, opposed ICU admissions for patients with IMV. This has important implications for healthcare policymakers planning interventions for optimal ICU resource allocation.

Abstract Hazardous drinking, defined as the consumption of homemade, unofficially made alcohol and non-beverages, is prevalent and accounts for a high proportion of alcohol-related deaths in Russia. Individual-level characteristics are important explanations of hazardous drinking, but they are unlikely to explain spatial variation in this type of alcohol consumption. Areas that attracted insufficient attention in the research of hazardous drinking are the legacy of industrialization and the speed of economic reforms, mainly through the privatization policy of major enterprises in the 1990s. Applying mixed-effects logistic regressions to a unique dataset from 30 industrial towns in the European part of Russia, we find that in addition to individual-level characteristics such as gender, age, marital status, education, social isolation, labor market status, and material deprivation, the types of towns where informants’ relatives resided such as industrial structure and speed of privatization also accounted for the variance in hazardous alcohol consumption among both male and female populations of the analyzed towns.

Abstract Background Knowledge of the fertility period aids women in refraining and engaging in sexual intercourse to avoid and to get pregnant, respectively. The effect of community-level factors on knowledge of the fertility period was not yet known in Kenya. Therefore, we aimed to investigate the community- and individual-level determinants of knowledge of fertility period among women of childbearing age in Kenya. Methods The 2022 Kenyan Demography and Health Survey data was used for the current study. This study included 16,901 women of reproductive age. To account for the clustering effects of DHS data and the binary nature of the outcome variable, a multilevel binary logistic regression model was applied. An adjusted odds ratio with a 95% confidence interval was reported to declare the statistical significance. In addition, the model that had the lowest deviance was the one that best fit the data. Results The overall prevalence of knowledge of the fertility period among Kenyan women was 38.1% (95%CI = 37.3, 38.9). Women’s age, women’s education status, heard FP, contraceptive use, media exposure, and distance from health facility significant individual factors while place of residence, and community-level education, were all of factors were found to be strongly associated with knowledge of fertility period. Conclusion As per the findings of our study, Knowledge of the fertility period among reproductive women was low in Kenya. In the era of increasing refusal of hormone-based family planning, fertility-awareness-based family planning methods may be an option. Promoting the correct fertility period through education and media outreach may be helpful strategies for enhancing fertility decision-making.

Abstract Background Teenage pregnancy is becoming one of the most common social and public health problems worldwide, with the highest prevalence in sub-Saharan Africa. Health risks and adverse outcomes of pregnancy and childbirth among adolescent girls are the commonest cause of the global burden of maternal morbidity and mortality. This study is intended to determine the pooled prevalence and determinants of teenage pregnancy in sub-Saharan Africa using the most recent demographic and health survey data (2019–2022). Methods A cross-sectional study was conducted using data from the most recent demographic and health surveys of four countries (Kenya, Tanzania, Gabon, and Cameroon) in sub-Saharan Africa conducted between 2019 and 2022. A total weighted sample of 12,829 teenagers aged 15 to 19 years was included in the study. Data extracted from demographic and health survey data sets were cleaned, recorded, and analyzed using STATA/SE version 14.0 statistical software. Multilevel mixed-effects logistic regression was used to determine the factors associated with the dependent variable. Finally, variables with a p-value ≤ 0.05 and an adjusted odds ratio with a 95% confidence interval were declared statistically significant. Results The pooled prevalence of teenage pregnancy among women aged 15 to 19 years was 18.15% (95% CI: 17.49, 18.83). Teenage pregnancy was positively associated with the respondent’s age [AOR = 2.97; 95% CI (2.55, 3.46)], educational status [AOR = 2.21; 95% CI (1.62, 3.03)] and [AOR = 1.80; 95% CI (1.54, 2.12)], wealth status [AOR = 2.61; 95% CI (2.12, 3.22)] and [AOR = 1.65; 95% CI (1.33, 2.05)], relation to the household head [AOR = 2.09; 95% CI (1.60, 2.72)], and unmet need for contraception [AOR = 14.3; 95% CI (11.5, 17.8)]. On the other hand, it was negatively associated with marital status [AOR = 0.08; 95% (0.07, 0.10)], working status [AOR = 0.75; 95% CI (0.64, 0.88)], age at first sex [AOR = 0.68; 95% CI (0.58, 0.80)], contraceptive use [AOR = 0.25; 95% CI (0.20, 0.30)], contraceptive knowledge [AOR = 0.27; 95% CI (0.19, 0.40)], and community contraceptive utilization [AOR = 0.85; 95% CI (0.73, 0.99)]. Conclusion In the current study, one out of six young women aged 15 to 19 experienced teenage pregnancy. Therefore, addressing unmet needs for family planning, improving women’s educational status, and giving special attention to teenagers with low educational and economic status are recommended.

Abstract Introduction Even though childhood diarrhea is treated with a simple treatment solution, it continues to be one of the leading causes of under-five child mortality and malnutrition globally. In resource-limited settings such as Sub-Saharan Africa (SSA), the combination of oral rehydration salts (ORS) and zinc is regarded as an effective treatment for diarrhea; however, its utilization is very low. The purpose of this study was to determine the proportion and associated factors of co-utilization of ORS and zinc among under-five children with diarrhea in SSA. Methods The proportion and associated factors of co-utilization of ORS and zinc among under-five children with diarrhea in SSA were determined using secondary data analysis of recent Demographic and Health Surveys (DHS) of 35 SSA countries. The study included a total of 44,341 under-five children with diarrhea in weighted samples. A generalized linear mixed-effects model with robust error variance was used. For the variables included in the final model, adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) were estimated. A model with the lowest deviance value were considered as the best-fitted model. Result The pooled proportion of co-utilization of ORS and zinc for the treatment of diarrhea among under five children in SSA countries was 43.58% with a 95% CI (43.15%, 44.01%). Sex of the child, maternal age, residence, maternal educational and employment status, wealth index, media exposure, perceived distance to health facility and insurance coverage were statistically significant determinants of ORS and Zinc co-utilization for treating diarrhea among under five children in SSA. Conclusion Only less than half of under-five children with diarrhea in SSA were treated with a combination of ORS and zinc. Thus, strengthening information dissemination through mass media, and community-level health education programs are important to scale up the utilization of the recommended combination treatment. Furthermore, increasing health insurance coverage, and establishing strategies to address the community with difficulty in accessing health facilities is also crucial in improving the use of the treatment.

BackgroundTeenage women's fertility health faces significant challenges from unintended pregnancies and unsafe abortions. Using an emergency contraception within a defined time period could prevent unintended pregnancy and its damaging consequences, like unintended childbirth and unsafe abortion. Despite it being an appropriate contraception, the knowledge of teenage women about emergency contraception is lower among women in developing countries. Therefore, this study aimed to examine the magnitude of emergency contraception knowledge and its associated factors among teenage women in Ethiopia.MethodsData for this study was obtained from the recent Demographic and Health Surveys. A total weighted sample of 3,381 teenage reproductive women were included. The significant associated factors with emergency contraception knowledge among teenage reproductive women were determined by fitting a multilevel mixed-effect binary logistic regression model. Finally, Adjusted Odds Ratio (AOR) with a 95% confidence interval and a P value of less than 0.05 was used to declare statistical significance.ResultsIn Ethiopia, the magnitude of teenage women who knew about emergency contraception was 19.47% (95%CI: 18.17, 20.84). Age 17 years (AOR = 1.76, 95%CI, 1.24, 2.48) and age 19 years (AOR = 2.18, 95%CI, 1.47, 3.22), primary education level (AOR = 2.76, 95%CI, 1.60, 4.76), secondary and above educational level (AOR = 4.70, 95%CI, 2.62, 8.44), being protestant followers (AOR = 0.63, 95%CI, 0.45, 0.87), being muslim followers (AOR = 0.68, 95%CI, 0.49, 0.93), media exposure (AOR = 3.36, 95%CI, 2.59, 4.34), rural residence (AOR = 0.45; 95%CI: 0.22, 0.86), and high community level education (AOR = 140, 95%CI: 1.32, 2.00) were factors significantly associated with knowledge of emergency contraception among teenage women.ConclusionsThis finding concluded that less than one in five teenage women knew about emergency contraception in Ethiopia. The knowledge of emergency contraception among teenage women in Ethiopia was substantially associated with women's age, education level, religion, media exposure, residency and community-level education. Hence, there is a need to implement comprehensive awareness programs and promotion of emergency contraception as a way of curbing cases of unintended pregnancies among teenage women. Government and non-governmental organizations should design targeted educational initiatives and media campaigns to improve emergency contraception knowledge among young teenagers, women with lower educational backgrounds, and rural teenagers.

IntroductionHuman rights violations and violence against women are serious public health issues that have numerous detrimental repercussions on one’s physical, emotional, sexual, and reproductive health. According to studies, women’s perceptions and traits of violence are highly predictive of their likelihood of seeking help against violence. Even though intimate partner violence is a huge challenge nowadays in Africa, there is a low level of help-seeking behavior. Conducting this study at the East African level on help-seeking behavior can provide a clue for policy-makers. Therefore, this study aimed to reveal the prevalence of help-seeking behavior against intimate partner violence and determinant factors among women in East Africa.MethodMultilevel logistic regression analysis was carried out among East Africans using recent demographic and health survey data. A total of 7,387 participants aged 15 to 49 years were included in this study from East African countries. Individual- and community-level variables were considered to determine the associated factors with help-seeking behaviors against intimate partner violence with 95% CI and AOR.ResultsThe prevalence of help-seeking behavior against intimate partner violence among women was 38.07% with 95% CI (36.96%, 39.18%). Husbands drink alcohol [AOR = 1.46: 95% CI (1.33, 1.61)], women who have work [AOR = 1.33: 95% CI (1.19, 1.50)], and women with higher educational status [AOR = 1.36: 95% CI (1.16, 1.59)] were factors associated with help-seeking behavior against intimate partner violence.ConclusionApproximately four out of 10 women were seeking help for intimate partner violence in East Africa. Husbands drinking alcohol, women’s high educational status, and women having occupations were the factors that were associated with help-seeking behaviors against intimate partner violence.

Abstract This study aimed to investigate the association between bullying at school and tooth loss in southern Brazilian adolescents. This population-based cross-sectional study included a representative sample of 15–19-year-old students attending high schools in Santa Maria, southern Brazil. Data on sociodemographic and behavioral variables were collected through questionnaires. Contextual data on bullying at school was provided by educational institutions (bullying episodes in the previous year: ‘no,’ ‘sometimes,’ or ‘often’). Tooth loss was clinically assessed by the M component of the DMFT index, modeled as a discrete variable. Multilevel Poisson regression was used, and rate ratios (RR) and 95% confidence intervals (CI) were estimated. The prevalence of tooth loss was 9.2% (95%CI = 7.5–10.8). Adolescents who attended the schools where bullying events often occurred had 0.39 (95%CI = 0.33–0.45) missing teeth, on average, in contrast to an average of 0.14 (95%CI = 0.08–0.19) among those whose schools did not experience bullying in the previous year. After adjusting for important cofactors, the contextual variable of bullying at school remained significantly associated with the study outcome. Adolescents who attended schools where bullying frequently occurred were 2.49-fold more likely to have an additional missing tooth than those whose school did not experience bullying in the previous year (RR = 2.49, 95%CI = 1.37–4.51, p = 0.003). In conclusion, the frequent bullying episodes at school were associated with more permanent teeth lost due to caries in this population. Hence, improving the school environment may improve the oral health of adolescents.

Cities in Malawi have long been outside the focus of disaster risk reduction. As a result, urban risks remain poorly understood, and urban governments and disaster risk reduction (DRR) practitioners working in cities struggle to adequately support vulnerable urban populations. This is evidenced by recent disasters such as Cyclone Freddy, which devastated the city of Blantyre in 2023, and increasingly common small-scale events in urban areas. This article analyses the Malawian city as a distinct riskscape, shaped by national-level policies of neglect that create an institutional void that DRR practitioners working at the city level struggle to fill. This process is complicated by a multitude of challenges at different levels of governance, especially leaving small-scale events prevalent in urban areas largely unaddressed. This process of risk accumulation is increasingly affecting urban residents. Methodologically, we demonstrate this through a comprehensive policy analysis and by drawing on expert and civil society interviews and questionnaires conducted in Lilongwe City. Contribution: By outlining the interlocking challenges at multiple levels and grounding them in empirical data, we highlight the specificities of urban DRR efforts in Malawi and provide opportunities to improve them.

BackgroundThe majority of maternal deaths were associated with a lack of access to skilled birth attendance. Because childbirth accounts for most maternal deaths, skilled birth attendance is crucial for reducing maternal mortality. The use of skilled birth attendance in Ethiopia is low, and it is crucial to identify factors that determine the use of skilled birth attendance. Hence, this study aimed to assess the spatial distribution, wealth-related inequality, and determinants for skilled birth attendance in Ethiopia.MethodsSecondary data analysis was done with a total weighted sample of 5,251 reproductive-aged women using the 2019 mini EDHS. The concentration index and graph were used to assess wealth-related inequalities. Spatial analysis was done to identify the spatial distribution and multilevel logistic regression analysis was used to identify predictors of skilled birth attendance in Ethiopia. Analysis was done using STATA version 14, ArcGIS, and SaTscan software.ResultsThe prevalence of skilled birth attendance was 50.04% (95% CI: 48.69%, 51.40%) in Ethiopia. Old age, being married, being educated, having television and radio, having ANC visits, being multiparous, having large household sizes, having a rich wealth index, living in rural residence, and living in a high level of community poverty and women's education were significant predictors of skilled birth attendance. Skilled birth attendance was disproportionately concentrated in rich households [C = 0.482; 95% CI: 0.436, 0.528]. High prevalence of unskilled birth attendance was found in Somalia, SNNP, Afar, and southern parts of the Amhara regions. Primary clusters of unskilled birth attendance Somalia and some parts of Oromia region of Ethiopia.ConclusionHalf of the women in Ethiopia did not utilize skilled birth attendants with significant spatial clustering. Age, marital status, educational status, ANC Visit, having television and radio, parity, household size, wealth index, residence, community level poverty, and community level of women's education were significant predictors of skilled birth attendance. Skilled birth attendance was unevenly concentrated in rich households. The regions of Somalia, SNNP, Afar, and southern Amhara were identified as having a high prevalence of using unskilled birth attendance. Public health interventions should target those women at high risk of using unskilled birth attendants.

Abstract Background Worldwide, recommendations for fruit and vegetable consumption are not met, which can cause chronic diseases. Especially adolescence is an important phase for the development of health behaviours. Therefore, in the Netherlands, the Healthy School program was established to aid schools in promoting healthy lifestyles among their students. We examined to what extent the variation between secondary schools regarding students’ fruit and vegetable consumption could be explained by differences between schools regarding Healthy School certification, general school characteristics, and the school population. Additionally, we examined whether Healthy School certification was related to the outcomes, and whether the association differed for subgroups. Methods We performed a repeated cross-sectional multilevel study. We used data from multiple school years from the national Youth Health Monitor on secondary schools (grades 2 and 4, age ranged from approximately 12 to 18 years) of seven Public Health Services, and added data with regard to Healthy School certification, general school characteristics and school population characteristics. We included two outcomes: the number of days a student consumed fruit and vegetables per week. In total, we analysed data on 168,127 students from 256 secondary schools in the Netherlands. Results Results indicated that 2.87% of the variation in fruit consumption and 5.57% of the variation in vegetable consumption could be attributed to differences at the school-level. Characteristics related to high parental educational attainment, household income, and educational track of the students explained most of the variance between schools. Additionally, we found a small favourable association between Healthy School certification and the number of days secondary school students consumed fruit and vegetables. Conclusions School population characteristics explained more variation between schools than Healthy School certification and general school characteristics, especially indicators of parental socioeconomic status. Nevertheless, Healthy School certification seemed to be slightly related to fruit and vegetable consumption, and might contribute to healthier dietary intake. We found small differences for some subgroups, but future research should focus on the impact in different school contexts, since we were restricted in the characteristics that could be included in this study.

This study tested the effect of variance in service quality ratings on overall scores of users in reviews (7,210 sites, 576,449 reviews) on the well-known hotel accommodation reservation site “Rakuten Travel.” The results revealed that the overall score was lower for a hotel with higher variance in service quality ratings for most functions. This trend was clearer for leisure travelers than for business travelers. An additional survey of general managers of the hotels in the first analysis suggested that practicing total quality management (TQM) in a hotel may reduce the variance in service quality ratings of users.

Abstract Background The prevalence of teenage pregnancy in Colombia is higher than the worldwide average. The identification of socio-geographical disparities might help to prioritize public health interventions. Aim To describe variation in the probability of teenage maternity across geopolitical departments and socio-geographical intersectional strata in Colombia. Methods A cross-sectional study based on live birth certificates in Colombia. Teenage maternity was defined as a woman giving birth aged 19 or younger. Multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was applied using multilevel Poisson and logistic regression. Two different approaches were used: (1) intersectional: using strata defined by the combination of health insurance, region, area of residency, and ethnicity as the second level (2) geographical: using geopolitical departments as the second level. Null, partial, and full models were obtained. General contextual effect (GCE) based on the variance partition coefficient (VPC) was considered as the measure of disparity. Proportional change in variance (PCV) was used to identify the contribution of each variable to the between-strata variation and to identify whether this variation, if any, was due to additive or interaction effects. Residuals were used to identify strata with potential higher-order interactions. Results The prevalence of teenage mothers in Colombia was 18.30% (95% CI 18.20–18.40). The highest prevalence was observed in Vichada, 25.65% (95% CI: 23.71–27.78), and in the stratum containing mothers with Subsidized/Unaffiliated healthcare insurance, Mestizo, Rural area in the Caribbean region, 29.08% (95% CI 28.55–29.61). The VPC from the null model was 1.70% and 9.16% using the geographical and socio-geographical intersectional approaches, respectively. The higher PCV for the intersectional model was attributed to health insurance. Positive and negative interactions of effects were observed. Conclusion Disparities were observed between intersectional socio-geographical strata but not between geo-political departments. Our results indicate that if resources for prevention are limited, using an intersectional socio-geographical approach would be more effective than focusing on geopolitical departments especially when focusing resources on those groups which show the highest prevalence. MAIHDA could potentially be applied to many other health outcomes where resource decisions must be made.

Abstract Consuming foods high in iron benefits metabolic processes as well as the development of the neonatal and fetal brain. Despite the significance of eating foods high in iron for public health, Ethiopian practices are still limited when compared to the World Health Organization's (WHO) assessment of its consumption of such foods. This study used the Ethiopia Demographic and Health Survey (EDHS) to evaluate the consumption of iron-rich foods, regional clustering, and related characteristics among children aged 6–23 months. The information was taken from the typical EDHS 2019 dataset, which included a weighted sample of 1572 young children aged 6–23 months old in total. Utilizing Kuldorff's SaTScan version 9.6 software, spatial scan statistics were produced. Software from ArcGIS 10.8 was used to display the regional distribution of inadequate consumption of foods high in iron. Utilizing multilevel or mixed effects logistic regression analysis, the associated determinants for a healthy diet rich in foods containing iron were found. In the final model, a P-value of

Abstract Purpose According to the 4th and 5th rounds of National Family Health Survey (NFHS), there is high prevalence of hysterectomies in the three states of Andhra Pradesh Telangana and Bihar. The three said states have more than double the number of hysterectomies taking place than the national average. Our purpose is to analyse whether these rates are increasing, decreasing or have stabilized and their reasons thereof. Such an analyses will help the policy makers in recommending good clinical practices within their states. Material and methods We used data from NFHS-4 (2015-16) and NFHS-5 (2019-2021) rounds. We calculated the differences in predicted probabilities for various factors, performed a Fairlie Decomposition analyses to quantify the positive and negative contributors in the prevalence of hysterectomy across the three states over two time points, and assessed the association of various socio-demographic characteristics to hysterectomy through a multilevel logistic regression model. Results and conclusion The results show that out of a total of 80,976 eligible respondents from the states under study, 5826 respondents self-reported that they had a hysterectomy done. It was found that older age, living in rural areas, belonging to other backward classes and higher wealth quintile, and higher parity positively contributed to the increased prevalence of hysterectomies in the three states. Higher educational attainment and previous use of family planning methods acted as protective factors. Characteristics at the household level had the highest intra-class correlation value in the prevalence of hysterectomy among women, followed by the Primary Sampling Unit and District levels, indicating high clustering in the prevalence of hysterectomy at the household level in all three states. Heavy menstrual bleeding/pain was the leading cause of hysterectomies in all three states, followed by fibroids/cysts in Andhra Pradesh and Telangana and Uterine disorder/ prolapse in Bihar. Over 80% of hysterectomies took place in the private hospitals. Recommendations The study recommends better, more efficient and accountable hysterectomy surveillance to ensure more sustainable woman’s reproductive health services in India. Government should adopt and implement standard regulatory guidelines to prevent provider-driven avoidable hysterectomies. Moreover, we recommend informing primary care professionals about the long-term health effects of hysterectomy and promoting alternate therapies for treating uterine fibroids and heavy bleeding.

Abstract Background Despite the World Health Organization’s firm recommendation to start breastfeeding during the first hour after delivery, nearly 54% of children in low- and middle-income countries are unable to initiate breastfeeding within the recommended time frame. Understanding the initiation of breastfeeding is essential for optimal child health and maternal well-being. Methods This study was conducted using the recent Ethiopian Demographic and Health Survey (EDHS) data (2019) on a weighted sample of 1982 Ethiopian mothers of children aged under 24 months. The data extraction was conducted between August 1 and 30, 2023. Delayed’ initiation of breastfeeding is defined as failure to initiate breastfeeding within one hour after birth. STATA version 17 was used for non-spatial analysis. ArcGIS Pro and Sat Scan version 9.6 were used to map the visual presentation of delayed breastfeeding initiation. Global Moran’s I was computed to determine whether delayed breastfeeding initiation is randomly distributed, clustered, or dispersed. Getis-Ord Gi* Spatial Statistics was done to identify significant spatial clusters of cold and hot spot areas. Multilevel mixed-effect logistic regression analysis was computed to identify determinants of delayed breastfeeding initiation. Results The prevalence of delayed breastfeeding initiation is 26.4% (95% CI 24.4, 28.3). Significant clustering of delayed initiation of breastfeeding practice was found in the Somali region. Less clustering was identified in Northern Amhara, Addis Ababa and Dire Dawa. Being a young mother (15–24 years) (AOR 1.66; 95% CI 1.06, 2.62), no antenatal care (AOR 1.45; 95% CI 1.04, 2.02), cesarean section (AOR 4.79; 95% CI 3.19, 7.21) and home birth (AOR 1.53; 95% CI 1.14, 2.06) were found to be determinants of delayed initiation of breastfeeding. Conclusions In Ethiopia, delayed breastfeeding initiation is distributed non-randomly. Significant hotspot areas were identified in the eastern part of Ethiopia. Thus, deploying additional resources in high hotspot regions is recommended. Programs should focus on promoting health facility birth and increasing antenatal care visits. Further emphasis should be considered on supporting young mothers and those giving birth via cesarean section to improve timely breastfeeding initiation.

Teenage pregnancy remains a critical public health issue in developing countries, significantly impacting maternal health. In Kenya, despite an expected decrease in teenage pregnancy rates from 18% in 2014 to 15% in 2022, evidence on its prevalence and associated factors is still limited. This study utilized data from the latest Kenya Demographic and Health Survey, analysing 6,390 participants through multilevel binary logistic regression. The findings revealed a 15.3% prevalence (95%CI: 14.4, 16.2%) and identified key factors linked to teenage pregnancy, including being aged 18–19, higher education, contraceptive use, unemployment, wealth status, media exposure, and a higher proportion of uneducated individuals. The study underscores the urgent need for strategic investment in policy development and evaluation to enhance adolescent sexual and reproductive health. Targeted interventions should prioritize economically disadvantaged households, focusing on maternal education and empowerment to reduce teenage pregnancies by 2030.

Previous research on customer loyalty primarily viewed it within the framework of constructs at the individual level of analysis. Consequently, prior research has ignored service recovery performance and customer loyalty nested within the branch-level studies of retail banks. However, this multilevel analysis examined how the service recovery system influences customer-level outcomes. Multilevel analysis determined the relationship between the Level 2 and Level 1 constructs. A sample of 1514 responses was drawn from Indian branch heads, frontline employees, and customers of retail banks. This study used a multilevel approach to understand the macro- and micro-level dynamics of service recovery in retail banking. These findings emphasize the importance of effective service recovery systems, standardized definitions, and standardized measurements. This approach allows for a comprehensive examination of the impact of the service recovery system on service recovery performance, recovery satisfaction, and customer service loyalty by considering the nested structure of the data and the influence of higher-level variables on lower-level variables. This study calls for retail banks to invest in well-managed service recovery, recognize and reward employees for exceptional performance, and continuously monitor customer complaints to identify areas for improvement.

Objective: To investigate if individual and contextual socioeconomic factors are associated with contraceptive use in Brazilian women from 18 to 49 years old, stratified by parity. Methods: Cross-sectional, population-based study that analyzed data from 16,879 women from 18 to 49 years old, respondents of the 2013 National Health Survey. Individual factors such as reproductive history, access to health services, and sociodemographic characteristics were considered; and as contextual factors, Human Development Index (HDI), Sociodemographic Index (SDI) Primary Health Care Coverage (PHC coverage) and Average Monthly Income were included. Multilevel logistic regression models were estimated, stratified by parity, with women being level 1 and States and Federal District of level 2 units. Results: Nulliparous women had lower prevalence of contraceptive use (77.9 %) when compared with primiparous and multiparous (88.7 %), as well as greater variability in the chance of using contraception (ICC = 2.1 vs. ICC = 1.1, respectively). Women who lived in States with higher levels of HDI, average monthly income and SDI were more likely to use contraception. The greater PHC coverage was positively associated with the use of contraceptives for primiparous/multiparous women and negatively for the nulliparous. Furthermore, higher education increased the chances of using contraception, both for nulliparous and primiparous/multiparous women. Conclusions: The high contraceptive coverage in Brazil hides important inequities in access, highlighting contextual characteristics associated with the use of contraceptives, in addition to individual factors. The lower prevalence and chance of using contraceptives for nulliparous women with greater social vulnerability reveal inequity and priority in public policies. Implications for practice: The need to improve access to contraception is highlighted, considering both the individual and contextual vulnerabilities of women, which implies ensuring timely and qualified access to contraceptive methods, especially for young and nulliparous women who are more socially vulnerable.

IntroductionThis study delves into individual and community-level factors influencing the availability of water, soap, and cleansing agents for handwashing in Ethiopia. Its comprehensive exploration offers nuanced insights, informing targeted interventions and policies to effectively enhance handwashing resources across Ethiopia. Therefore, this study aimed to assess individual and community-level factors of availability of observed water, soap, and other cleansing agents for hand washing practices in Ethiopia.MethodsData from the 2021 PMA-ET, encompassing 24,747 household participants, informed this study. Employing STATA version 17.0, a multi-level mixed-effect logistic regression analysis was performed to identify individual and community-level factors. Adjusted odds ratios with a 95% confidence interval conveyed the strength and direction of associations, with significance determined at p

BackgroundThere is a global struggle with food insecurity and undernutrition among women, and Ethiopia has been particularly impacted by these issues. To address this challenge, Ethiopia has implemented a cash and food safety net program over many years. However, there is limited information available regarding the program’s factors and spatial distributions, with no recent national evidence from Ethiopia. Consequently, the objective of this study is to investigate the spatial clustering and determinants of the Productive Safety Net Program (PSNP) in Ethiopia.MethodThis study utilized data from the Ethiopian Demographic and Health Survey. The sample included 8,570 weighted households. Given the hierarchical nature of the data, a multilevel logistic regression model was employed to identify factors influencing the outcome variable. Geographical clusters of individuals receiving assistance from the PSNP were examined using SaTScan software and the Bernoulli model, along with the Kulldorff methods. The nationwide distribution of the program beneficiaries was visualized using ArcGIS version 10.8. Variables were considered statistically significant if their p-value was

IntroductionAdolescents face unique challenges related to their sexual and reproductive health (SRH), with access to timely services being critical for positive outcomes. However, SRH service utilization among adolescents remains low. This study aimed to identify factors influencing SRH service use among adolescents in Gamo Zone, Ethiopia.MethodsA community-based cross-sectional study involved 1172 adolescents selected through stratified sampling. Structured face-to-face interviews were employed for data collection. Multilevel mixed logistic regression was fitted to identify factors and latent class analysis was conducted to understand population heterogeneity.ResultsThe findings of this study reveal that 198 (16.89%) adolescents (95% CI: 14.8%-19.2%) utilized SRH services within the past 12 months. Factors significantly associated with SRH service utilization included good knowledge about SRH rights (AOR = 4.65; 95% CI: 2.68, 8.07), belonging to one-parent families (AOR = 4.13; 95% CI: 2.39, 7.12), engaging in parental discussions regarding SRH issues (AOR = 3.17; 95% CI: 1.89, 5.29), high family support (AOR = 1.96; 95% CI: 1.09, 3.51), and enrolling in school (AOR = 0.19; 95% CI: 0.11, 0.33). Additionally, access to social media was associated with increased SRH service utilization among adolescents (AOR = 1.98; 95% CI: 1.25, 3.15). Latent class analysis identified four groups: rural school-enrolled adolescents living with parents, urban school-enrolled adolescents with both parents, urban disadvantaged female adolescents, and early adolescents with limited social media access.ConclusionsIn conclusion, our study sheds light on the utilization of SRH services among adolescents, revealing that 16.89% of the participants accessed these services within the past year. Significant factors associated with SRH service utilization included good knowledge about SRH rights, belonging to one-parent families, engaging in parental discussions regarding SRH issues, high family support, and enrollment in school. Interestingly, access to social media was also linked to increased utilization of SRH services among adolescents. Furthermore, our latent class analysis identified four distinct classes of adolescents based on socio-demographic indicators, highlighting the heterogeneity within this population. These findings underscore the importance of tailored interventions and targeted approaches to address the diverse needs of adolescents in accessing and utilizing SRH services.

IntroductionThe World Health Organization recommends that children aged 6–23 months should consume a diversified diet, including fruits and vegetables, during each meal. However, low consumption of fruits and vegetables contributes to 2.8% of child deaths globally. The literature review indicates limited research on factors that affect zero vegetable or fruit consumption among children aged 6–23 months in East Africa. Therefore, this study aimed to investigate the household- and community-level factors determining zero vegetable or fruit consumption among children aged 6–23 months in East Africa.MethodThe study analyzed cross-sectional secondary data from the recent rounds of demographic and health surveys conducted in East Africa from 2015 to 2023. The weighted sample comprised 113,279 children aged 6–23 months. A multilevel mixed-effect analysis was used, measuring the random variation between the clusters based on the intra-cluster correction coefficient, median odds ratio, and proportional change variance. Adjusted odds ratio with a 95% confidence interval was reported while considering variables having a p < 0.05 as statistically significant.ResultsThe overall prevalence of zero vegetable or fruit consumption among children aged 6–23 months in East Africa was 52.3%, with Ethiopia showing the highest prevalence (85.9%). The factors associated with zero vegetable or fruit consumption were maternal educational level, number of household members, short birth interval, multiple births, sex of the household head, household wealth index, community-level maternal literacy, community-level wealth index, and countries.ConclusionConsidering the high overall prevalence of zero vegetable or fruit consumption among children aged 6–23 months in East Africa, overlooking this nutritional gap among children is a serious oversight. Therefore, efforts should be geared toward improving individual- and community-level maternal literacy. In particular, nutrition and public health organizations should support low-income communities to achieve vegetable or fruit consumption for infants and young children.

Vaccination has played a major role in overcoming the COVID-19 pandemic. However, vaccination status can be influenced by demographic and socio-economic factors at individual and area level.In the context of the LINK-VACC project, the Belgian vaccine register for the COVID-19 vaccination campaign was linked at individual level with other registers, notably the COVID-19 laboratory test results and demographic and socio-economic variables from the DEMOBEL database. The present article aims at investigating to which extent COVID-19 vaccination status is associated with area level and/or individual level demographic and socio-economic factors. From a sample of all individuals tested for SARS-CoV-2 (LINK-VACC sample) demographic and socio-economic indicators are derived and their impact on vaccination coverages at an aggregated geographical level (municipality) is quantified. The same indicators are calculated for the full Belgian population, allowing to assess the representativeness of the LINK-VACC sample with respect to the impact of demographic and socio-economic disparities on vaccination uptake.In a second step, hierarchical models are fitted to the individual level LINK-VACC data to disentangle the individual and municipality effects allowing to evaluate the added value of the availability of individual level data in this context.The most important effects observed at the individual level are reflected in the aggregated data at the municipality level. Multilevel analyses show that most of the demographic and socio-economic impacts on vaccination are captured at the individual level, although accounting for area level in individual level analyses improve the overall description.

Abstract Background Acute respiratory infections (ARIs) remain a major public health concern which become the leading cause of mortality and morbidity in children under the age of five. A large percentage of childhood deaths and complications can be avoided by seeking proper medical care. Therefore, this study aimed to assess the magnitude, and individual and community-level determinants of mothers’ healthcare-seeking behavior for their children under the age of five who had ARI symptoms in Ethiopia. Method A secondary data analysis was conducted using the 2016 Ethiopian Demographic and Health Surveys(EDHS) with a total weighted sample of 643 under-five children who had ARI symptoms within two weeks of the survey. Due to the hierarchical nature of the EDHS data, a multi-level logistic regression model was used to identify the individual and community-level factors influencing mothers’ health care-seeking behavior for their children with ARI symptoms. In the multivariable multilevel analysis, those variables with a p-value 24 months [AOR = 0.35; 0.19–0.63], having primary education [AOR = 3.25; 1.27–8.32], being media exposed [AOR = 2.49; 1.15, 5.38], female household head[AOR = 3.90; 1.35, 11.24], and delivery at health institution[AOR = 2.24; 1.00, 5.01] were significant predictors of health care seeking behavior of mother for their children with ARI symptoms. Conclusion There is poor treatment-seeking behavior for children with symptoms of ARI in Ethiopia with significant community level variations. The multilevel logistic regression analysis showed that improving mothers’ education, women’s empowerment, facilitating institutional delivery and media accessibility are critical to promoting health-seeking behaviors among mothers or caregivers of under-five children with ARI symptoms. Hence, concerned bodies should design targeted interventions that increase mothers’ or caregivers’ treatment-seeking behavior for childhood ARI to reduce child morbidity and mortality.

Abstract Background Consistent reports from health professionals suggest that heroin is commonly used by patients undergoing opioid maintenance treatment (OMT) in France, potentially jeopardizing their recovery process. However, there has been no formal epidemiological assessment on the matter. Methods We use a yearly updated compendium retrieving information on patients admitted in treatment centres in France between 2010 and 2020. Given the hierarchical nature of the data collection, we conduct 2-level modified Poisson regressions to estimate the risks of past month heroin use among patients on OMT. Results Despite an overall decreasing trend over time, heroin use among patients on OMT is indeed common, with half of patients declaring concurrent use. Our study unveils differentiated risks of heroin use vary according to the type of OMT, with patients on methadone more likely to use heroin compared to those on buprenorphine. The use of multilevel-related measures also uncovers high heterogeneity among patients’ profiles, reflecting different stages in the treatment process, as well as differentiated practices across treatment centres. Conclusion Opioid maintenance treatment is associated with heroin use, in particular when methadone is involved. The heterogeneity among patients on OMT should be given particular attention, as it underscores the need for tailored interventions.

Abstract Background Unhealthy food consumption that begins early in life is associated with a higher risk of nutrient inadequacy and related chronic diseases later in life. Healthy eating and consumption of important nutrients help to maintain a healthy body weight and reduce the risk of developing chronic conditions. Research from sub-Saharan Africa regarding consumption of unhealthy foods remains limited, with no studies quantifying the pooled prevalence among young children. Therefore, this study is intended to assess the pooled prevalence and determinants of unhealthy food consumption among children aged 6 to 23 months. Methods Data from the most recent demographic and health surveys of five countries in sub-Saharan Africa conducted between 2015 and 2022 were used. A total weighted sample of 16,226 children aged 6 to 23 months was included in the study. Data extracted from DHS data sets were cleaned, recorded, and analyzed using STATA/SE version 14.0 statistical software. Multilevel mixed-effects logistic regression was used to determine the factors associated with the dependent variable. Intra-class correlation coefficient, likelihood ratio test, median odds ratio, and deviance (-2LLR) values were used for model comparison and fitness. Finally, variables with a p-value

Abstract Background As global aging intensifies, older adults with chronic diseases are of increasing concern. Home and community-based services (HCBSs) have been proven to promote self-rated health (SRH) in older adults, but no research explored the associations between the use of overall HCBSs, three different types of HCBSs (health care, daily care, and social support services) and SRH among older adults with chronic diseases. Consequently, this study applies a national publicly available database to examine these associations among older adults with chronic diseases. Methods 8,623 older adults with chronic diseases (≥ 60 years old) were included in this study. SRH was evaluated applying a concise question with a 1 − 5 scale. HCBSs utilization was assessed through the question, “What kind of HCBSs were used in the community?”. Univariate general linear regression models aimed to compare the mean values of SRH in terms of HCBSs utilization in each group. This study is a cross-sectional study design and the relationship between HCBSs utilization and SRH was assessed by multilevel linear regression. Results The mean score for SRH among the respondents was 3.19, of whom 20.55% used one or more HCBSs, 19.47% utilized health care services, 2.44% utilized social support services, and only 0.55% utilized daily care services. The use of HCBSs was found to be linked to SRH among older adults with chronic diseases (β = 0.085, SE = 0.025, p

Abstract Background Case-mix adjustment of patient reported experiences (PREMs) and outcomes (PROMs) of care are meant to enable fair comparison between units (e.g. care providers or countries) and to show where improvement is possible. It is important to distinguish between fair comparison and improvement potential, as case-mix adjustment may mask improvement potential. Case-mix adjustment takes into account the effect of patient characteristics that are related to the PREMs and PROMs studied, but are outside the sphere of influence of the units being compared. We developed an approach to assess which patient characteristics would qualify as case-mix adjusters, using data from an international primary care study. Results We used multilevel analysis, with patients nested in general practices nested in countries. Case-mix adjustment is indicated under the following conditions: there is a main effect of the potential case-mix adjuster on the PREM/PROM; this effect does not vary between units; and the distribution of the potential case-mix adjuster differs between units. Random slope models were used to assess whether the impact of a potential case-mix adjuster varied between units. To assess whether a slope variance is big enough to decide that case-mix adjustment is not indicated, we compared the variances in the categories of a potential case-mix adjuster. Significance of the slope variance is not enough, because small variances may be significantly different from zero when numbers are large. We therefore need an additional criterion to consider a slope variance as important. Borrowing from the idea of a minimum clinically important difference (MCID) we proposed a difference between the variances of 0.25*variance (equivalent to a medium effect size). We applied this approach to data from the QUALICOPC (Quality and costs of primary care in Europe) study. Conclusions Our approach provides guidance to decide whether or not patient characteristics should be considered as case-mix adjusters. The criterion of a difference between variances of 0.25*variance works well for continuous PREMs and PROMs, but seems to be too strict for binary PREMs and PROMs. Without additional information, it is not possible to decide whether important slope variation is the result of either differences in performance between general practices or countries, or cultural differences.

Abstract Background Knowledge of the ovulatory period enables women in avoiding and engaging in sexual intercourse either to avoid and to have pregnancy as desired. It has been reported that young people have less knowledge of the ovulatory period. There is limited evidence about the spatial variability of knowledge of the ovulatory period among young women in Ethiopia. Hence, this study aimed to assess the spatial variation and factors sociated with knowledge of the ovulatory period among youths in Ethiopia for providing geographically targeted interventions. Method A secondary data analysis was carried out using the 2016 Ethiopian Demographic and Health Surveys with a total weighted sample of 6143 youths. Multilevel logistic regression analysis was utilized to identify factors influencing knowledge of the ovulatory period. ArcGIS version 10.7 software and Kuldorff’s SaTScan version 9.6 was used for the spatial analysis. Results Being older youth [AOR = 1.98; 1.46, 2.70], youths having primary education [AOR = 1.70; 1.23, 2.35], youths having secondary & higher education [AOR = 2.30; 1.41, 3.74], youths whose husbands have primary education [AOR = 1.39; 1.02, 1.91], and youths who use contraception [AOR = 1.66; 1.24, 2.22] were significant predictors of knowledge of ovulatory period. Knowledge of the ovulatory period among youth had non random spatial distribution across Ethiopia, and the primary clusters of incorrect knowledge of the ovulatory period were observed in Somalia, SNNPR, Benishangul gumuz, and Gambella regions of Ethiopia. Conclusion There was a non-random spatial pattern in the distribution of knowledge of the ovulation period among young women in Ethiopia. Age of youth, educational status, education of husband, and contraceptive use were significant predictors of knowledge of the ovulatory period among young women in Ethiopia. Hence, interventions should prioritize at-risk youths residing in regions with limited knowledge of the ovulatory period to enhance their awareness of the fertility window.

The research examined how different profiles of emotional intelligence (attention, clarity, and emotional regulation) act as protective or risk factors against cyber-victimization, taking into account individual and behavioral variables such as gender, sexual orientation, self-esteem, social anxiety, Internet risk, and parental control among high school students (11–18 years). A simulated sample was used, which was derived from an experimental sample of 1908 subjects (50.7% girls). Statistical equivalence was ensured between the two samples, and a multilevel analysis was conducted using the emotional intelligence profiles as the grouping variable. The results showed that the variability in emotional intelligence profiles predicted 96.7% of the variability of cyber-victimization. Factors that increase this likelihood include excessive interpersonal attention and low emotional regulation, higher social anxiety, offline victimization, older age, high parental supervision, and low self-esteem. In addition, being male and heterosexual is associated with a lower risk of cyber-victimization than being female and non-heterosexual. In general, it is suggested that protective measures against cyber-victimization should warn about the risk of Internet use, avoid paternalistic behavior by adults, and reduce rumination or excessive attention to the opinions of others.

BackgroundAnemia is a severe public health problem affecting 54% of pregnant women in SSA Yet, only a limited number of studies have provided a partial assessment of the pooled prevalence and related determinants of the severity levels of anemia in pregnant women in SSA. Therefore, this study provides the most recent estimates of anemia severity levels and related determinants.MethodsThe most recent Demographic Health Survey (DHS) dataset of 21 Sub-Saharan African countries which were collected between 2015 and 2022 were used. A total of 14,098 pregnant women were included. Multilevel ordinal logistic regression was used.ResultsThe pooled prevalence of anemia was 51.26%. Pregnant women who were in the old age groups, and who have attended secondary and higher education were less likely to be at higher levels of anemia. Those women who have given birth to >1 children in the last 5 years, pregnant women in second and third trimester and living in poorest households had greater odds of being at higher levels of anemia.ConclusionIn Sub-Saharan Africa, anemia is a severe public health concern for pregnant mothers. When developing and implementing strategies for the prevention and control of anemia, it is imperative to take into account the individual and community circumstances. Programs for the prevention and control of anemia should incorporate the economic and educational empowerment of women.

Objectives: Many urban-dwelling older Nigerians are multidimensionally deprived and are unable to meet their daily financial, nutritional, and healthcare needs. This has implications for their health outcomes, yet it has been under-researched. This study assessed the multidimensional deprivation index (MDI) of urban-dwelling older Nigerians and the associated factors.Methods: The study analysed a weighted sample of 5,225 older persons aged ≥60 years from Nigeria’s Demographic and Health Survey, 2018. MDI was estimated, and associations were examined using a multilevel multinomial logistic regression model.Results: Nationally, 75% of the older persons were multidimensionally deprived, with 27% severely deprived. Women (36%) were more severely deprived than men (20%). Those in the Northern regions (38%–40%) were the most deprived. Higher MD risk was associated with female gender and older ages ≥70–79 years. Conversely, lower risk was associated with households headed by family and residence in educated communities. Community variation accounts for 10.4% and 35.9% of the MD and severe MD risks, respectively.Conclusion: This study suggests socioeconomic interventions that address gender disparities and target highly deprived regions, with consideration for individual and community characteristics.

Abstract The aim of this study was to assess the factors associated with oral health-related quality of life in adolescents (OHRQoL). Individual data on adolescents were collected from a secondary database. OHRQoL was measured using the oral impact on daily performance (OIDP) scale. Individual- and city-level variables were selected to represent the structural and intermediate determinants of health. The individual covariates analyzed were sex, age, skin color, maternal education, household income, number of people per room in the housing unit, dental attendance, self-perception of dental needs, untreated dental caries, and gingival bleeding. The contextual variables included the allocation factor, the Human Development Index (HDI), Gini coefficient, illiteracy, unemployment, income, average number of emergency dental visits per inhabitant, access to a sanitary sewer system, garbage collection, primary health care coverage, oral health team coverage, and number of tooth extractions between selected dental procedures and supervised toothbrushing. Unadjusted and adjusted multilevel Poisson regression analyses were used to evaluate the relationship between contextual and individual variables with overall OIDP scores (STATA version 16.0) - rate ratio (RR) and 95%CI. The mean OIDP score was 0.72 and the prevalence was 31.8%. There was an association between supervised toothbrushing average and the outcome (RR 0.95; 95%CI 0.91–0.99). Moreover, adolescents who lived in municipalities with the highest average number of emergency dental visits per inhabitant showed a higher OIDP. Sex, maternal education, untreated dental caries, and gingival bleeding were associated with OIDP. In addition, intersectoral public policies focusing on the reduction of social inequalities should be on the agenda of policymakers and stakeholders.

IntroductionThe situation generated by the recent pandemic has had several effects on education, one of them being the necessary but hasty efforts of teachers and students to adapt to the demands of a virtual classroom environment. Thus, it is essential to promote the development of digital competencies in future teachers, enabling them to create effective learning situations in the digital medium. Moreover, the European university curriculum includes a set of specific competencies (specific to each degree) and a series of generic competencies, many of which are related to emotional intelligence. Our work emerges from these specific premises and the more general need to develop emotional skills and learning abilities in virtual environments for future educators.MethodsThe sample comprised 240 students in higher education, pursuing a bachelor’s degree in education at the University of Alicante, Spain (68.3% were female and average age of the participants was 19.43 years SD = 4.127). Using a quasi-experimental design with pretests, posttests, and a control group, we present the effects of an online program aimed at improving the emotional skills and academic achievement of future teachers in higher education. In this study, a 30-h emotional intelligence training program was implemented. Since the student sample was grouped into different classes, we analyzed, using a generalized linear mixed-effects model, whether students who took the program showed a significant improvement in their academic achievement at the end of their studies, compared to those who did not take it.ResultsThe findings show a significant improvement in the academic achievement at the end of the bachelor’s degree studies of the students in the experimental group.DiscussionThese results open up a field of possibilities for the implementation of this type of training using virtual environments, enabling interventions to enhance the emotional development of the teaching staff (and, subsequently, in their students), develop their teaching careers adequately, and employ the ideal strategies to address educational programs. Looking ahead, the integration of emotional development programs that incorporate emerging technology into university curricula could enhance the preparation of educators profoundly and create adaptable learning environments for contemporary students.

This paper analyses teaching strategies in relation to the science achievement of 4th-grade students using TIMSS 2019 data. It focuses on seven Arabic-speaking countries, which share similar cultures and distinct features of their societies and school systems. It applies multilevel modeling with student- and classroom-level information to decompose variance and understand relationships at these two levels. Overall, the results show the importance of analysis at the classroom level, as half of the science achievement variance is associated with differences between classrooms. Our results indicate that in the Arabic-speaking countries, emphasis on academic success and more active instruction are positively related to student achievement. On the other hand, science investigation methods such as planning and running experiments are negatively related to achievement, although the effects are small in magnitude. Moreover, the results from multilevel models with random coefficients for home resources suggest that higher emphasis on academic success increases differences in student achievement depending on their socioeconomic background.

With the integration of information and communication technologies (ICT) into curricula, teachers are responsible for promoting ICT literacy among secondary school students, which requires in-depth technological knowledge (TK) and technological-pedagogical knowledge (TPK) on the part of teachers. This study uses a multilevel analysis to examine how teachers’ professional knowledge at TK and TPK influences secondary school students’ ICT literacy. Using data from n = 1,566 students from a larger sample taught in N = 134 classes by N = 220 teachers in N = 39 schools, our results show contrary to our hypotheses, no significant relationship between teachers’ professional knowledge regarding TK and TPK and students’ cross-curricula ICT literacy. Furthermore, we did not find any significant relationship in our model between students’ study-related ICT use and ICT literacy. By analyzing the relationship between teachers’ TK and TPK and students’ ICT literacy, our study provides new insights into the relationship between teachers’ cross-curricular knowledge and students’ cross-curricular achievements. It discusses further possible explanations and directions for future research.