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The bidirectional relationship between physical health (PH) and depressive symptoms (DS) remains unclear. Data were extracted from the Health and Retirement Study in the United States. PH was measured with a composite of chronic diseases, functional limitations and difficulties in basic and instrumental activities of daily living, and DS with a modified Center for Epidemiological Studies of Depression. Latent growth curve models (LGCM) were employed to examine how the change in PH or DS affected their mutual trajectories in later life. In addition, multilevel models were utilized. There were 6144 participants included, with an average age of 69.82 ± 6.85 years at baseline, of whom 3686 (59.99 %) were women. PH scores increased from 5.65 in 2010 to 7.72 in 2018, while depression scores increased from 1.14 to 1.31. LGCM results showed that the initial levels of PH and DS were associated (β = 0.558, P <.001), and the initial level of PH could predict the trajectory of DS (β = 0.089, P <.001). Likewise, the initial level of DS was also related to initial PH (β = −0.563, P <.001) but couldn't predict the trajectory of PH. Furthermore, the slopes of PH and DS were predicted bidirectionally by each other. Two-level logistic models further demonstrated the bidirectional association between PH and DS. There was a bidirectional association between physical health and depressive symptoms, which highlights the necessity of comprehensive health management for older adults with poor physical health or depression symptoms. • The study examineed the reciprocal association between physical health and depressive symptoms among older adults. • There is a bidirectional relationship between physical health and depressive symptoms. • Highlighting the importance of health management for older adults with poor physical health or depression symptoms. [ABSTRACT FROM AUTHOR]

This study aims to review existing literature and research on disruptive innovation and entrepreneurship. The literature was systematically examined according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles for systematic review. Following an exhaustive scan of the Scopus database, 32 peer-reviewed articles were included. Several published works are displayed on disruptive innovation and entrepreneurship from the multilevel analysis, perspective analysis, entrepreneurship industry, and disruptive innovation type. The United States was the top research nation, and the most perspective analysis was strategy level. Further research that can be carried out, such as research on disruptive innovation on entrepreneurship, uses a group of construction, mining, and manufacturing. [ABSTRACT FROM AUTHOR]

With over 75,000 opioid-related overdose drug deaths in the United States between May 2020 and April 2021, illicit opioid use continues to be a critical public health issue. Despite advances in improving opioid treatment availability and access through federal and state initiatives, incarceration during treatment for opioid use disorder (OUD) is an obstacle to treatment retention and continuity of care for this population. This study aimed to identify factors associated with incarceration during opioid treatment in 44 states in the United States. Using 93,556 discharge records from the 2018 and 2019 Treatment Episode Data Set, multilevel binary logistic regression models were fitted to identify factors associated with incarceration during treatment. After adjusting for demographic, treatment, and state clustering effects, the two strongest statistically significant associates of incarceration during treatment were receiving treatment in an outpatient facility (OR = 3.6, p <.001) and being referred by the criminal justice system (OR = 3.4, p <.001). The results from this study underscore the need to investigate treatment retention strategies for legally involved persons who have OUD, especially those in outpatient treatment, and advocate for initiating and expanding OUD treatment in carceral environments. [ABSTRACT FROM AUTHOR]

According to the parasite-stress theory, collectivism serves as a trait of ingroup assortative sociality, providing defense against infectious diseases. This study investigated the association between cultural collectivism and COVID-19 severity at the state (Study 1: N = 51), county (Study 2: N = 3,133), and daily (Study 3: N = 52,806) levels from the beginning of 2020 to the end of 2022. State-level collectivism was assessed using two distinct measures: the U.S. collectivism index, focusing on social interconnectedness and interdependence, and the subjective-culture individualism-collectivism index (reversed), capturing attitudes and beliefs related to religion, abortion, and same-sex marriage. By employing random-intercept multilevel models, the results demonstrated significant and negative effects of state-level collectivism, as measured by the U.S collectivism index, on COVID-19 cases per million, COVID-19 deaths per million, and composite COVID-19 severity index, after controlling for confounding factors, such as socioeconomic development, ecological threats, disease protective behaviors, cultural norms, and political influences. A mini meta-analysis (Study 4: N = 9) confirmed the significance of these effects across studies. These findings supported the proactive role of collectivism in defending against the novel coronavirus in the United States, aligning with the parasite-stress theory of sociality. However, the subjective-culture individualism-collectivism index (reversed) did not exhibit a significant relationship with COVID-19 severity when confounding factors were considered. The high correlation between the subjective-culture individualism-collectivism index (reversed) and the controlled variables suggested shared variance that could diminish its impact on COVID-19 outcomes. Accordingly, the present findings underscore the significance of accounting for confounding factors when examining the association between collectivism and COVID-19 severity at population level. By considering relevant confounding factors, researchers could gain a comprehensive understanding of the complex interplay between cultural collectivism and its influence on COVID-19 severity. Overall, this research contributes to our understanding of how cultural collectivism shapes the COVID-19 pandemic in the United States, emphasizing the importance of adjusting for confounding effects in population level studies. [ABSTRACT FROM AUTHOR]

Background: This study examined the association between residential segregation and obesity for Whites, African Americans, Hispanics, and Asians. This study considered 3 dimensions of residential segregation, isolation, dissimilarity, and concentration. Methods: By combining individual-level data from the Behavioral Risk Factor Surveillance System and county-level data from the County Health Rankings and Roadmaps, the total sample size was 204,610 respondents (160,213 Whites, 21,865 African Americans, 18,027 Hispanics, and 4505 Asians) from 205 counties in the United States. Two-level logistic regression models were performed. Results: African Americans and Hispanics in counties with high levels of isolation, dissimilarity, and concentration were more likely to be obese; these relationships did not hold true for Whites and Asians. Counties with a higher percentage of populations with the income below the poverty line and a higher percentage of fast food restaurants in the county were associated with a higher likelihood of obesity for all racial/ethnic groups. African Americans and Hispanics with low levels of education and income were more likely to be obese. Conclusions: Residential segregation had a contextual influence on weight status, and the context of counties influenced racial/ethnic groups differently. Obesity reduction programs should consider the contextual influence on minority populations and target subgroups living in highly segregated areas. [ABSTRACT FROM AUTHOR]

Background: It is unknown how changes in the percutaneous coronary intervention (PCI) "built environment" have impacted PCI volumes at the community, hospital, and patient levels. This study sought to determine how PCI hospital openings and closures effect community- and hospital-level PCI volumes as well as the likelihood of receiving PCI at a low-volume hospital., Methods: We conducted a retrospective cohort study of 3,966,025 Medicare Fee-For-Service patients in 37,451 zip codes and 2564 U.S. hospitals who underwent PCI from 2006 to 2017. We conducted community-, hospital-, and patient-level analyses using ordinary least squares regressions with fixed effects to determine changes in PCI volumes after PCI hospital openings or closures., Results: Between 2006 and 2017, a total of 17% and 7% of patients lived in communities that experienced PCI hospital openings and closures, respectively. Openings were associated with a 10% increase in community PCI volume, a 2% increase in the share of elective PCI, and a doubling in the likelihood of receiving PCI at a low-volume hospital. In communities with low baseline PCI capacity, openings were associated with a 12% increase in community PCI volume, and in high-capacity communities, an 8% increase. PCI closures were associated with a 9% decrease in community PCI volume in high-capacity communities but no measurable change in low-capacity communities., Conclusions: PCI service expansion is associated with increased PCI at low-volume hospitals and a greater number of elective procedures. Increased governmental oversight may be necessary to ensure that openings and closures of these specialized services yield the desired benefits., (© 2024 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Background: There is substantial hospital-level variation in the use of Inpatient Rehabilitation Facilities (IRFs) versus Skilled Nursing Facilities (SNFs) among patients with stroke, which is poorly understood. Our objective was to quantify the net effect of the admitting hospital on the probability of receiving IRF or SNF care for individual patients with stroke., Methods: Using Medicare claims data (2011-2013), a cohort of patients with acute stroke discharged to an IRF or SNF was identified. We generated 2 multivariable logistic regression models. Model 1 predicted IRF admission (versus SNF) using only patient-level factors, whereas model 2 added a hospital random effect term to quantify the hospital effect. The statistical significance and direction of the random effect terms were used to categorize hospitals as being either IRF-favoring, SNF-favoring, or neutral with respect to their discharge patterns. The hospital's impact on individual patient's probability of IRF discharge was estimated by taking the change in individual predicted probabilities (change in individual predicted probability) between the 2 models. Hospital-level effects were categorized as small (<10%), moderate (10%-19%), or large (≥20%) depending on change in individual predicted probability., Results: The cohort included 135 415 patients (average age, 81.5 [SD=8.0] years, 61% female, 91% ischemic stroke) who were discharged from 1816 acute care hospitals to IRFs (n=66 548) or SNFs (n=68 867). Half of hospitals were classified as being either IRF-favoring (n=461, 25.4%) or SNF-favoring (n=485, 26.7%) with the remainder (n=870, 47.9%) considered neutral. Overall, just over half (n=73 428) of patients were treated at hospitals that had moderate or large independent effects on discharge settings. Hospital effects for neutral hospitals were small (ie, change in individual predicted probability <10%) for most patients (72.5%). However, hospital effects were moderate or large for 78.8% and 84.6% of patients treated at IRF- or SNF-favoring hospitals, respectively., Conclusions: For most patients with stroke, the admitting hospital meaningfully changed the type of rehabilitation care that they received., Competing Interests: None.

Protest is the result of complex multilevel processes. It is triggered by contextual factors such as political opportunities or events, it depends on organizations' mobilizing capacity as well as on the type of people who protest, and it is shaped by the characteristics of the populations they come from. To effectively study the antecedents that operate at various levels, social movement research needs to integrate data from multiple analytical levels and systematically examine the relationships across the various levels. While large N statistical techniques of multilevel modelling are well understood, less is known about applying multilevel analysis research examining small number of cases. The article develops conceptual and methodological tools for multilevel analysis of protests in studies with a small number of cases. First, it demonstrates the empirical requirements associated with analyzing three types of multilevel effects: contextual effects, composition effects, and cross-level interactions. Next, specific multilevel small N designs that can be used to examine the three multilevel effects are presented. The last section uses the multilevel approach to examine the demobilization of anti-Iraq War protests in the United States. [ABSTRACT FROM AUTHOR]

Background: Given the relatively low graduation and retention rate in undergraduate engineering programs in the United States, the factors that influence student success outcomes need to be examined. However, limited research systematically studied both student- and school-level factors and how they influenced undergraduate engineering student success outcomes. We gathered responses from 458 engineering undergraduate students in a cross-sectional multilevel multi-school (14 schools) survey. These 14 schools included both large state universities and liberal arts colleges. The survey measured various student-level factors, including demographic, skills, and personality variables, along with seven school-level factors, such as student–faculty ratio and school type (i.e., public versus private). The data were analyzed using the hierarchical multilevel modeling approach. Results: The results showed that female students reported better outcomes than male students, racial minority students reported better outcomes than White students, but first-generation students reported poorer outcomes. Communication competency was associated with student learning outcomes, GPA, and program satisfaction, whereas conflict management preferences were not significantly correlated with any student success outcomes. The results of the school-level factors' influences on student success outcomes were not consistent, but some factors, such as student–faculty ratios and diversity rate, were significantly related to some student outcomes. Conclusion: Engineering education is a complex, multi-faceted issue that requires more collaborative and systematic research. We hope our findings help educators understand the different factors that could potentially influence engineering students and inform better program design and policymaking. [ABSTRACT FROM AUTHOR]

Objective: The objective of this paper is to examine how state-level characteristics relate to social support and mental health outcomes among Latino sexual minority men in the U.S., Methods: Multilevel linear regression analyses were used to estimate the effect of social support and contextual-level characteristics on mental health and alcohol use among Latino sexual minority men (n = 612). Individual-level data were collected via a national, online survey between November 2018 and May 2019. State-level data were drawn from the 2019 American Community Survey and the Human Rights Campaign's 2018 State Equality Index score cards., Results: The interaction between friend support and supportive LGBTQ+ policies was associated with anxiety (B = 1.77; 95% CI 0.69, 2.85; p = 0.001) and depression (B = 2.25; 95% CI 0.99, 3.50; p<0.001). The interaction between friend support and Latino population size was associated with greater problematic alcohol use (B = 0.06; 95% CI 0.03, 0.10; p<0.001). The interaction between partner support and supportive LGBTQ+ policies were also associated problematic drinking (B = -1.72; 95% CI -3.05, -0.38; p<0.012)., Conclusions: Contextual factors can affect the everyday experiences of Latino sexual minority men. The effect of social support on mental health outcomes may depend on state-level factors. Public health efforts that seek to address the mental health and problematic drinking behaviors of Latino sexual minority men must consider the impact of macro-level policies on program and intervention development., (© 2023. W. Montague Cobb-NMA Health Institute.)

• Position-generated network resources may vary by local occupational structures. • We examine such spatial effects by integrating two national surveys from the United States. • Occupational compositions in county, metropolis, and state serve as macro-level constraints. • Multilevel analyses show spatial effects on professional-type resources significant across all three levels. • The effects on the farming and production resources are more apparent at the county level. Recent studies have paid more attention to how position-generated social capital varies by an individual's characteristics, and less to how geographical distributions of occupations may constrain position-specific connections. By integrating two national surveys from the United States, we differentiate the extent to which individual social capital fluctuates by occupational compositions at the county, metropolis, and state levels. Multilevel analyses show that when more people at all three levels work in education, training, and library occupations, residents have a greater chance to gain access to professional-type resources. Similar spatial effects on farming and production resources, however, are more apparent at the county level. Not only does the association between individual social capital and local occupational structures vary across different occupations, but the magnitude of such spatial effects also differs by the scope of the geographical areas. The findings underscore how contextual factors and geographical location may contribute to building occupation-specific network resources. [ABSTRACT FROM AUTHOR]

This study sought to quantify the contributions of state-level factors including income inequality, state's legislature political control, and Medicaid expansion in new and established Latinx destination states on Latinx individuals' treated hypertension. Mixed-effects logistic regression analyses were conducted to analyze 2017 Behavioral Risk Factor Surveillance System data from 7524 Latinx adults nested within 39 states. Overall, 70% reported being pharmacologically treated for hypertension, and 66% resided in established destination states. Compared with Latinx people in established destination states, Latinx people in new destinations had lower odds of having treated hypertension (odds ratio [OR] = 0.72, 95% CI = 0.54-0.95). Within established Latinx destinations, the odds of treated hypertension were lower in states where legislatures expanded Medicaid than in states that did not expand Medicaid (OR = 0.84, 95% CI = 0.79-0.89). However, after controlling for the effects of individual-level factors, this association was no longer statistically significant. In new Latinx destination states, Medicaid expansion, legislatures' political control, and income inequality were not associated with treated hypertension. The study results highlight the importance of considering both individual- and state-level factors, as the interplay of such factors could hinder the successful implementation of cardiovascular risk reduction interventions., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Policy protections for transgender adults in the United States are consistently associated with positive health outcomes. However, studies over-represent non-Latinx White transgender people and obscure variation in policies' intended goals. This study examined racial differences in the relationship between transgender-related policies and transgender women's self-rated health. Guided by Critical Race Theory, we hypothesized that policies conferring access to resources (e.g., healthcare) would be associated with better self-rated health among all participants while policies signifying equality (e.g., nondiscrimination laws) would be associated with better self-rated health only for White participants., Methods: Using cross-sectional data collected between March 2018-December 2020 from 1566 transgender women, we analyzed 7 state-level 'access policies,' 5 'equality policies,' and sum indices of each. Participants represented 29 states, and 54.7% were categorized as people of color. We fit a series of multilevel ordinal regression models predicting self-rated health by each policy. Multivariate models were adjusted for relevant covariates at the individual- and state-level. We then tested moderation by race/ethnicity using interaction terms and generated stratified predicted probability plots., Results: In bivariate models, 4 access policies, 2 equality policies, and both indices were associated with better self-rated health, but associations did not persist in adjusted models. Results from the multivariable models including interaction terms indicated that policies concerning private insurance coverage of gender-affirming care, private insurance nondiscrimination, credit nondiscrimination, and both indices were statistically significantly associated with better self-rated health for White participants and worse self-rated health for participants of color., Conclusions: The policies included in this analysis do not mitigate racism's effects on access to resources, indicating they may be less impactful for transgender women of color than White transgender women. Future research and policy advocacy efforts promoting transgender women's health must center racial equity as well as transgender people of color's priorities., (© 2024. The Author(s).)

We introduced a multilevel model of value shift to describe the changing social context of wildlife conservation. Our model depicts how cultural‐level processes driven by modernization (e.g., increased wealth, education, and urbanization) affect changes in individual‐level cognition that prompt a shift from domination to mutualism wildlife values. Domination values promote beliefs that wildlife should be used primarily to benefit humans, whereas mutualism values adopt a view that wildlife are part of one's social network and worthy of care and compassion. Such shifts create emergent effects (e.g., new interest groups) and challenges to wildlife management organizations (e.g., increased conflict) and dramatically alter the sociopolitical context of conservation decisions. Although this model is likely applicable to many modernized countries, we tested it with data from a 2017–2018 nationwide survey (mail and email panel) of 43,949 residents in the United States. We conducted hierarchical linear modeling and correlational analysis to examine relationships. Modernization variables had strong state‐level effects on domination and mutualism. Higher levels of education, income, and urbanization were associated with higher percentages of mutualists and lower percentages of traditionalists, who have strong domination values. Values affected attitudes toward wildlife management challenges; for example, states with higher proportions of mutualists were less supportive of lethal control of wolves (Canis lupus) and had lower percentages of active hunters, who represent the traditional clientele of state wildlife agencies in the United States. We contend that agencies will need to embrace new strategies to engage and represent a growing segment of the public with mutualism values. Our model merits testing for application in other countries. Article impact statement: Application of a multilevel model of social change reveals implications of a shift in public values for wildlife conservation in the United States. [ABSTRACT FROM AUTHOR]

Aims This exploratory study aims to model the impact of sex and age on the percentage of pre-drinking in 27 countries, presenting a single model of pre-drinking behaviour for all countries and then comparing the role of sex and age on pre-drinking behaviour between countries. Methods Using data from the Global Drug Survey, the percentages of pre-drinkers were estimated for 27 countries from 64,485 respondents. Bivariate and multivariate multilevel models were used to investigate and compare the percentage of pre-drinking by sex (male and female) and age (16–35 years) between countries. Results The estimated percentage of pre-drinkers per country ranged from 17.8% (Greece) to 85.6% (Ireland). The influence of sex and age on pre-drinking showed large variation between the 27 countries. With the exception of Canada and Denmark, higher percentages of males engaged in pre-drinking compared to females, at all ages. While we noted a decline in pre-drinking probability among respondents in all countries after 21 years of age, after the age of 30 this probability remained constant in some countries, or even increased in Brazil, Canada, England, Ireland, New Zealand and the United States. Conclusions Pre-drinking is a worldwide phenomenon, but varies substantially by sex and age between countries. These variations suggest that policy-makers would benefit from increased understanding of the particularities of pre-drinking in their own country to efficiently target harmful pre-drinking behaviours. [ABSTRACT FROM AUTHOR]

AIM The aim of this study was to examine student-level and school-level variation in pride and competency in accelerated nursing programs and the relationship between student satisfaction with instructional methods and perceptions of pride and competency. BACKGROUND Nursing students in accelerated, second-degree programs have a greater need to feel competent when compared to traditionally educated nurses; however, evidence to illuminate a relationship between faculty instructional methods and student pride and competency is lacking. METHOD The method was a secondary analysis of data collected from 3,506 students in 130 programs over seven years. RESULTS Higher levels of satisfaction with instructional methods were associated with higher levels of pride and competency in nursing skills. There was no significant variation in pride and competency in nursing skills across institutions. CONCLUSION Student satisfaction with instructional methods in accelerated nursing education has an impact on student pride and competency. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to evaluate how gender, socioeconomic position (SEP), race/ethnicity and nationality intersect to structure social inequalities in adult oral health among American adults., Methods: Data from adults aged 20 years or over who participated in the National Health and Nutrition Examination Survey (NHANES) 2009-2018 were analysed. The outcomes were poor self-rated oral health and edentulism among all adults (n = 24 541 and 21 446 participants, respectively) and untreated caries and periodontitis among dentate adults (n = 16 483 and 9829 participants, respectively). A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was conducted for each outcome, by nesting individuals within 48 intersectional strata defined as combinations of gender, SEP, race/ethnicity and nationality. Intersectional measures included the variance partition coefficient (VPC), the proportional change in variance (PCV) and predicted excess probability due to interaction., Results: Substantial social inequalities in the prevalence of oral conditions among adults were found, which were characterized by high between-stratum heterogeneity and outcome specificity. The VPCs of the simple intersectional model showed that 9.4%-12.7% of the total variance in the presentation of oral conditions was attributed to between-stratum differences. In addition, the PCVs from the simple intersectional model to the intersectional interaction model showed that 84.1%-97.1% of the stratum-level variance in the presentation of oral conditions was attributed to the additive effects of gender, SEP, race/ethnicity and nationality. The point estimates of the predictions for some intersectional strata were suggestive of an intersectional interaction effect. However, the 95% credible intervals were very wide and the estimations inconclusive., Conclusions: This analysis highlights the value of the intersectionality framework to understand heterogeneity in social inequalities in oral health. These inequalities were mainly due to the additive effect of the social identities defining the intersectional strata, with no evidence of interaction effects., (© 2023 The Authors. Community Dentistry and Oral Epidemiology published by John Wiley & Sons Ltd.)

Purpose: Over the past three decades, Hepatocellular Carcinoma (HCC) is one of few cancers for which incidence has increased in the United States (US). It is likely social determinants at the population level are driving this increase. We designed a population-based study to explore whether social determinants at the neighborhood level are geographically associated with HCC incidence in Louisiana by examining the association of HCC incidence with neighborhood concentrated disadvantage. Methods: Primary HCC cases diagnosed from 2008 to 2012 identified from the Louisiana Tumor Registry were geocoded to census tract of residence at the time of diagnosis. Neighborhood concentrated disadvantage index (CDI) for each census tract was calculated according to the PhenX Toolkit data protocol based on population and socioeconomic measures from the US Census. The incidence of HCC was modeled using multilevel binomial regression with individuals nested within neighborhoods. Results: The study included 1,418 HCC cases. Incidence of HCC was greater among males than females and among black than white. In multilevel models controlling for age, race, and sex, neighborhood CDI was positively associated with the incidence of HCC. A one standard deviation increase in CDI was associated with a 22% increase in HCC risk [Risk Ratio (RR) = 1.22; 95% CI (1.15, 1.31)]. Adjusting for contextual effects of an individual's neighborhood reduced the disparity in HCC incidence. Conclusion: Neighborhood concentrated disadvantage, a robust measure of an adverse social environment, was found to be a geographically associated with HCC incidence. Differential exposure to neighborhoods characterized by concentrated disadvantage partially explained the racial disparity in HCC for Louisiana. Our results suggest that increasing rates of HCC, and existing racial disparities for the disease, are partially explained by measures of an adverse social environment. [ABSTRACT FROM AUTHOR]

Objective: To examine changes in minimum wage associated with changes in women's weight status.Design: Longitudinal study of legislated minimum wage levels (per month, purchasing power parity-adjusted, 2011 constant US dollar values) linked to anthropometric and sociodemographic data from multiple Demographic and Health Surveys (2000-2014). Separate multilevel models estimated associations of a $10 increase in monthly minimum wage with the rate of change in underweight and obesity, conditioning on individual and country confounders. Post-estimation analysis computed predicted mean probabilities of being underweight or obese associated with higher levels of minimum wage at study start and end.Setting: Twenty-four low-income countries.Subjects: Adult non-pregnant women (n 150 796).Results: Higher minimum wages were associated (OR; 95 % CI) with reduced underweight in women (0·986; 0·977, 0·995); a decrease that accelerated over time (P-interaction=0·025). Increasing minimum wage was associated with higher obesity (1·019; 1·008, 1·030), but did not alter the rate of increase in obesity prevalence (P-interaction=0·8). A $10 rise in monthly minimum wage was associated (prevalence difference; 95 % CI) with an average decrease of about 0·14 percentage points (-0·14; -0·23, -0·05) for underweight and an increase of about 0·1 percentage points (0·12; 0·04, 0·20) for obesity.Conclusions: The present longitudinal multi-country study showed that a $10 rise in monthly minimum wage significantly accelerated the decline in women's underweight prevalence, but had no association with the pace of growth in obesity prevalence. Thus, modest rises in minimum wage may be beneficial for addressing the protracted underweight problem in poor countries, especially South Asia and parts of Africa. [ABSTRACT FROM AUTHOR]

Scholarship on interest groups and lobbying has become bifurcated between the dominant micro-level research on the choices of individual groups and macro-level research on group-level populations, especially the work of Gray and Lowery, with almost no integration of the two. Failure to integrate levels of analysis, unfortunately, will impede future progress in the subfield. I discuss some of the challenges to integrating research at multiple levels and then propose a solution which I test by re-analyzing two of my micro-level research projects now combined with Gray and Lowery’ macro-level density variable using hierarchical modeling. It turns out that grouping micro-level observations by group interest niches matters in the statistical analysis, though the effects of varying group population density are more subtle. [ABSTRACT FROM AUTHOR]

Morbidity and mortality from colorectal cancer (CRC) can be attenuated through guideline concordant screening and intervention. This study used Medicaid and commercial claims data to examine individual and geographic factors associated with CRC testing rates in one state (Oregon). A total of 64,711 beneficiaries (4516 Medicaid; 60,195 Commercial) became newly age-eligible for CRC screening and met inclusion criteria (e.g., continuously enrolled, no prior history) during the study period (January 2010-December 2013). We estimated multilevel models to examine predictors for CRC testing, including individual (e.g., gender, insurance, rurality, access to care, distance to endoscopy facility) and geographic factors at the county level (e.g., poverty, uninsurance). Despite insurance coverage, only two out of five (42%) beneficiaries had evidence of CRC testing during the four year study window. CRC testing varied from 22.4% to 46.8% across Oregon's 36 counties; counties with higher levels of socioeconomic deprivation had lower levels of testing. After controlling for age, beneficiaries had greater odds of receiving CRC testing if they were female (OR 1.04, 95% CI 1.01-1.08), commercially insured, or urban residents (OR 1.14, 95% CI 1.07-1.21). Accessing primary care (OR 2.47, 95% CI 2.37-2.57), but not distance to endoscopy (OR 0.98, 95% CI 0.92-1.03) was associated with testing. CRC testing in newly age-eligible Medicaid and commercial members remains markedly low. Disparities exist by gender, geographic residence, insurance coverage, and access to primary care. Work remains to increase CRC testing to acceptable levels, and to select and implement interventions targeting the counties and populations in greatest need. [ABSTRACT FROM AUTHOR]

Purpose: Studies have found a variety of evidence regarding the association between residential segregation measures and health outcomes in the United States. Some have focused on any individuals living in residentially segregated places, whereas others have examined whether persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity have differential outcomes. This article compares and contrasts these two approaches in the study of predictors of late-stage colorectal cancer (CRC) diagnoses in a cross-national study. We argue that it is very important when interpreting results from studies like this to carefully consider the geographic scope of the analysis, which can significantly change the context and meaning of the results.Methods: We use US Cancer Statistics Registry data from 40 states to identify late-stage diagnoses among over 500,000 CRC cases diagnosed during 2004-2009. We pool data over the states and estimate a multilevel model with person, county, and state levels and a random intercepts specification to ensure robust effect estimates. The isolation index of residential segregation is defined for racial and ethnic groups at the county level using Census 2000 data. The association between isolation indices and late-stage CRC diagnosis was measured by (1) anyone living in minority-segregated areas (place-centered approach) and by (2) individuals living in areas segregated by one's own racial or ethnic peers (person-centered approach).Results: Findings from the place-centered approach suggest that living in a highly segregated African American community is associated with lower likelihood of late-stage CRC diagnosis, whereas the opposite is true for people living in highly segregated Asian communities, and living in highly segregated Hispanic communities has no significant association. Using the person-centered approach, we find that living in places segregated by one's racial or ethnic peers is associated with lower likelihood of late-stage CRC diagnosis.Conclusions: In a model that covers a large geographic area across the nation, the place-centered approach is most likely picking up geographic disparities that may be deepened by targeted interventions in minority communities. By contrast, the person-centered approach provides a national average estimate suggesting that residential isolation may confer community cohesion or support that is associated with better CRC prevention. [ABSTRACT FROM AUTHOR]

Objective: State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability., Methods: Data were drawn from the 2015-2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign's State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy., Results: An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability., Conclusions: Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.

ABSTRACT BACKGROUND Adverse birth outcomes are more common among adolescent versus adult mothers, but little is known about school-based services that may improve birth outcomes in this group. METHODS Data from Waves I and IV of the National Longitudinal Study of Adolescent Health were analyzed. Girls and women who gave birth to singleton live infants after Wave I and before age 20, were still in secondary school while pregnant, and had complete data (N = 402) were included. Mothers reported infants' birthweight and gestational age. School administrators reported whether family planning counseling, diagnostic screening (including sexually transmitted diseases [ STDs]), STD treatment, and prenatal/postpartum health care were provided on-site at school at Wave I. Multilevel models adjusted for individual and school characteristics were conducted. RESULTS Few schools offered reproductive health care services on-site. In multilevel analyses, availability of family planning counseling (Est. β = 0.21, 95% confidence interval [ CI] 0.04-0.38 p < 0.05) and prenatal/postpartum health care (Est. β = 0.21, 95% CI 0.02-0.40 p < 0.05) were significantly associated with increased infant birthweight. No services examined were significantly associated with increased gestational age. CONCLUSIONS Some school-based reproductive health services may improve subsequent birth outcomes among adolescent mothers. Future analyses should examine the mechanisms by which services impact birth outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study used the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to examine the individual and interactional impact of personal characteristics, state vocational rehabilitation (VR) services, and state environmental factors on employment quality for people with disabilities served by the state-federal VR system. DESIGN: Quantitative descriptive research design using multilevel analysis. PARTICIPANTS: Data extracted from the Rehabilitation Services Administration (RSA) case service report (RSA-911) database and other related databases from FY 2007 to 2009 were analyzed using multilevel (hierarchical) linear modeling to investigate patterns explaining variations among state VR agencies in achieving quality employment outcomes for consumers whose cases were closed successfully. RESULTS: Consumer characteristics predominantly predicted employment quality among the personal, service, and environmental factors studied. Personal factors also explained a considerable amount of between-state differences in quality employment outcomes. Improvement in educational attainment was related to higher employment quality, whereas receiving supported employment and job placement-related services were associated with lower employment quality. Additionally, the proportion of consumers receiving social security benefits in a particular state and state per capita income factors were strong environmental predictors of employment quality. CONCLUSION: Personal and environmental factors used in the present study were useful in predicting the quality of employment outcomes of VR consumers. However, developing a better measurement model for assessing quality employment and including additional factors in future research is warranted. [ABSTRACT FROM AUTHOR]

This article examines the relationship between racial/ethnic composition and neighborhood economic change in a multilevel and longitudinal framework. I employ multilevel modeling to examine how neighborhood minority composition is associated with change in neighborhood relative economic status from 1970 to 2010 in the largest 100 metropolitan areas of the USA. In the multilevel framework, the empirical analysis shows that the shares of black and Hispanic residents are consistently negatively related to neighborhood economic gain even when metropolitan-level factors are taken into account. This study also finds that the negative effect of neighborhood minority composition on neighborhood economic gain is differentiated by deindustrialization and minority composition at the metropolitan level. In the longitudinal framework, the findings show that the negative effect of neighborhood minority composition on neighborhood economic gain has declined over time. [ABSTRACT FROM PUBLISHER]

This study investigated the interaction between physical demands and job strain on musculoskeletal symptoms in upper extremities (MSUE) and work performance. Two years of prospective data were analysed from 713 full-time workers from twelve manufacturing and healthcare facilities in Washington in the United States. Physical exposure was measured by the Strain Index and Threshold Limit Value for hand activity, giving rise to safe, action, and hazardous physical demand groups. Job strain was calculated as the ratio of psychological job demands to job control. Multilevel modelling analysis showed that job strain affected MSUE and limited work performance less in the high physical demand group than the safe group because the protective effect of job control was smaller in these groups. Findings may suggest that high physical demand jobs are structured such that workers have low job control or high physical demand groups experience job strain not adequately captured by psychosocial variables. Practitioner Summary: The effects of job strain and job control on musculoskeletal symptoms in upper extremities and work performance were smaller among workers with higher physical demands. This could imply that high physical demand jobs limit job control or psychosocial variables may not adequately capture job strain among high physical demand groups.

This study examined the association between child welfare workers' safety concerns and organizational commitment, with specific attention to the possible cross-level interaction effect of leader-member exchange (LMX) on the relationship between workers' safety concerns (organizational level) and organizational commitment (individual level). Results suggested that frequent exposure to unsafe working environments were associated with lower levels of organizational commitment. Cross-level interaction of LMX was found, which indicates that as the quality of leader-member exchange improves, the negative relationship between unsafe climate and organizational commitment decreases. The importance of workplace safety and its relevance for administrative practice are discussed. [ABSTRACT FROM AUTHOR]

Previous research suggests that the likelihood of runaway episodes among children in out-of-home care varies across different communities/regions. However, the potential regional variation has rarely been reflected in attempts to understand runaway episodes in out-of-home care systems. The current study examines the effects of child characteristics, family characteristics and child welfare system-related characteristics on the likelihood of runaway episodes among children in out-of-home care, while accounting for county-level variations in the risk of runaway behaviours. The authors employed multilevel analyses using data on children aged 12-17 from the 2009 AFCARS database. Results demonstrate that the likelihood of runaway episodes varied across counties. Accounting for county variation, children's ages, gender, diagnosed clinical conditions, family structures, number of removals, number of placements, removal manner, and case plan goals significantly predicted runaway status. Implications are discussed. [ABSTRACT FROM AUTHOR]

General labor market condition is an important contextual factor influencing employment opportunities and outcomes for people with disabilities and is particularly significant given the recent economic recession. Yet, longstanding data analytic strategies have focused only on individual predictors rather than the dynamic interaction among individual level and organizational/environmental level variables, such as considering the role of labor market conditions. This study used the Rehabilitation Services Administration Case Service Report (RSA-911) data for fiscal years 2005 and 2009 to represent two distinct time periods, one before and one during the U.S. economic recession, respectively. Hierarchical linear modeling was used to examine the relationship between state unemployment rate and its interaction with personal factors influencing the employment outcomes of people with disabilities receiving state vocational rehabilitation services. Results found negligible between-state differences, but state unemployment rates were found to moderate the relationships between some demographic variables and successful competitive employment vocational rehabilitation (VR) case closure. Specifically, the significance and magnitude of those effect sizes varied by general economic context. These findings call attention for the need to consider the role of contextual variables, such as state unemployment rates, and their impact on the predictive strength of specific demographic and disability variables on employment outcomes for people with disabilities. [ABSTRACT FROM PUBLISHER]

Abstract: This study examined the association between ozone and fine particulate (PM2.5) exposure and asthma risk by place of residence. We linked 412,832 adult respondents from the 2009 U.S. Behavioral Risk Factor Surveillance System to their residence counties. Observed and interpolated ozone and PM2.5 concentration data from 2006 to 2009 were used as exposures. We linked self-reported current asthma status and other individual risk factors to county-level risk factors in multilevel logistic regressions. Results indicated spatially varied asthma risks and spatially varied associations between ambient air pollution and asthma risk. Residents in counties not located within a metropolitan statistical area (MSA) and in inner ring suburbs had a relatively higher asthma risk. Positive ozone–asthma associations were detected across all spatial settings, while positive PM2.5-asthma associations were detected only in central cities of an MSA and in outer ring suburbs, indicating that residence location modified the relationship between ambient air pollution and asthma risk. [Copyright &y& Elsevier]

Racial disparity in preterm is a major problem in the US. Although significant strides have been made in identifying some of the risk factors, the complexities between community and individual factors are not understood. This study examines the influence of individual and community level factors affecting preterm birth among Black and White women in an urban setting. A 10-year live birth registry dataset from a mid-sized, racially diverse city was analyzed (N = 30,591). Data were geocoded and merged with block group level Census data. Five hierarchical models were examined using PROC GLIMMIX. Education, illicit drug use, pregnancy complications, previous preterm birth, paternal presence, inadequate and adequate plus prenatal care, and poverty were associated with preterm births in both Blacks and Whites. In Black women, increasing maternal age, maternal smoking, and a previous infant death were significant predictors of preterm births, which was not the case for White women. Residing in medium or high poverty neighborhoods resulted in 19% and 28% higher odds, respectively, of preterm birth for Black women. In addition to individual level factors, neighborhood poverty is an important risk factor influencing preterm birth. It is essential to engage multisectoral agencies in addressing factors influencing preterm birth. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Social and economic contextual factors may promote concurrent sexual partnerships, which can accelerate population HIV transmission and are more common among African Americans than U.S. Whites. We investigated the relationship between contextual factors and concurrency. Methods: We analyzed past 12-month concurrency prevalence in the 2002 National Survey of Family Growth and its contextual database in relation to county sex ratio (among respondent's racial and ethnic group), percentage in poverty (among respondent's racial and ethnic group), and violent crime rate. Analyses examined counties with balanced (0.95–1.05 males/female) or low (<0.9) sex ratios. Results: Concurrency prevalence was greater (odds ratio [OR]; 95% confidence interval [CI]) in counties with low sex ratios (OR, 1.67; 95% CI, 1.17–2.39), more poverty (OR, 1.18; 95% CI, 0.98–1.42 per 10 percentage-point increase), and higher crime rates (OR, 1.04; 95% CI, 1.00–1.09 per 1000 population/year). Notably, 99.5% of Whites and 93.7% of Hispanics, but only 7.85% of Blacks, lived in balanced sex ratio counties; about 5% of Whites, half of Hispanics, and three-fourths of Blacks resided in counties with >20% same-race poverty. Conclusions: The dramatic Black-White differences in contextual factors in the United States and their association with sexual concurrency could contribute to the nation's profound racial disparities in HIV infection. [Copyright &y& Elsevier]

Although interpersonal violence and suicide are two of the leading causes of death among young Americans, analyses focusing simultaneously on violence and suicide in sociological inquiry are sparse. Analyses also tend to be limited by their focus on either the individual-level predictors of suicidal behaviors or the aggregate-level predictors of suicide rates, despite the recognition that psychological and sociological forces contribute independently as well as interactively to facilitate suicide. To address these issues, I use data from the Project on Human Development in Chicago Neighborhoods (PHDCN) to examine the direct and moderating effects of individual- and neighborhood-level violence on attempted suicide. Estimates from hierarchical logistic regression models indicate that individual acts of violent aggression, but not neighborhood levels of violence, increase the likelihood of attempting suicide. Furthermore, the well-established relationship between depression and attempted suicide is conditioned by individual- and neighborhood-level violence, such that the effect of depression is (1) amplified for individuals living in neighborhoods characterized by violence and (2) attenuated for individuals engaging in violent behavior. Finally, the combined effect of neighborhood violence and individual violent aggression on the depression/suicide relationship is greater than the partial moderating effects of these variables. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to explore the extent to which neighborhood poverty was associated with the utilization of dental care by American adolescents. Methods: To accomplish the study goals we conducted multilevel modeling analyses of two nationally representative data sets: National Longitudinal Study of Adolescent Health (Add Health) and the Early Childhood Longitudinal Study, Kindergarten Class of 1998-1999 (ECLS-K). Results: As hypothesized, neighborhood poverty predicted frequency of dental care in both studies ( t = 6.06; P < 0.001; t = 2.44; P < 0.05). Even after accounting for individual level predictors such as household income, health insurance, and parental education, adolescents living in poor neighborhoods are less likely than their counterparts in non-poor neighborhoods to utilize dental care. Conclusions: The findings from this study indicate that neighborhoods influence dental care utilization patterns in adolescents. [ABSTRACT FROM AUTHOR]

A two-part serial survey of 49 broiler breeder farms was conducted in four south-eastern states: Arkansas, Alabama, Georgia and North Carolina. Broiler breeder farms from three to five broiler company complexes in each state were visited on two separate occasions to document management practices and perform environmental sampling for Salmonella prevalence estimation. Salmonella was detected in 88% of the broiler breeder houses that were sampled and was identified on all 49 farms enrolled. Many management characteristics were consistent across the different states and companies. Multilevel analysis was used to evaluate management characteristics as risk factors for Salmonella prevalence and to estimate the proportion of variance residing at the different hierarchical sampling levels. Management characteristics associated with increased Salmonella prevalence included treatment of the flock for any disease, having dusty conditions in the house, having dry conditions under the slats and walking through the house more than one time per day to pick-up dead birds. After adjusting for state as a fixed effect, the percentages of variance in Salmonella prevalence occurring at the complex, farm, visit, house and individual sample levels were 5.2%, 6.8%, 11.8%, 2.8% and 73.4%, respectively. The intraclass correlations for samples collected from the same house; for samples from different houses during the same visit; for samples from different visits to the same farm; and for samples from different farms in the same complex were as follows: 0.27, 0.24, 0.12 and 0.05, respectively. [ABSTRACT FROM AUTHOR]

In the past two decades, although access to higher education for American students has improved, student persistence in 4-year institutions is far from assured. There have been a number of research studies on student persistence/dropout in higher education, but most have focused on the characteristics and behavior of students as illustrated by the 'student-centered research tradition'. This study focuses on what institutional characteristics contribute to conditions that reduce student dropout risks. By analyzing longitudinal and hierarchical data, this research proposes and tests a multilevel event history model that identifies the major institutional attributes related to student dropout risk in a longitudinal process. Evidence indicates that institutional expenditure on student services is negatively associated with student dropout behavior. Implications of the results for institutional practices and future research are discussed. [ABSTRACT FROM AUTHOR]

When comparing health care providers, patient experience data are usually adjusted for case-mix associations to ensure fair comparisons. Previous studies in the United States showed that case-mix associations sometimes vary across health care providers. Such variation could indicate differential provider behavior for patient subgroups, in which case current adjustment techniques might be inappropriate. To see whether this variation is also apparent in a health care system different from the U.S. system, the authors analyzed Dutch patients’ experiences with family practice care. Using multilevel random slope models, the associations between age, general health status, mental health status, education, sex, and ethnicity on one hand and reported experiences on the other hand were assessed across family practices. The authors found only five significant variances between case-mix coefficients, all for outcomes related to health care professionals’ conduct. These findings correspond to previous U.S. findings, suggesting that the case-mix variations reported here and previously constitute a rather robust phenomenon. [ABSTRACT FROM AUTHOR]

Adverse socioeconomic conditions, at both the individual and the neighborhood level, increase the risk of colorectal cancer (CRC) death, but little is known regarding whether CRC survival varies geographically and the extent to which area-level socioeconomic deprivation affects this geographic variation. Using data from the National Institutes of Health (NIH)-AARP Diet and Health Study, the authors examined geographic variation and the role of area-level socioeconomic deprivation in CRC survival. CRC cases (n = 7,024), identified during 1995–2003, were followed for their CRC-specific vital status through 2005 and overall vital status through 2006. Bayesian multilevel survival models showed that there was significant geographic variation in overall (variance = 0.2, 95% confidence interval (CI): 0.1, 0.2) and CRC-specific (variance = 0.3, 95% CI: 0.1, 0.4) risk of death. More socioeconomically deprived neighborhoods had a higher overall risk of death (most deprived quartile vs. least deprived: hazard ratio = 1.2, 95% CI: 1.1, 1.4) and a higher CRC-specific risk of death (most deprived quartile vs. least deprived: hazard ratio = 1.2, 95% CI: 1.1, 1.5). However, neighborhood socioeconomic deprivation did not account for the geographic variation in overall and CRC-specific risks of death. In future studies, investigators should evaluate other neighborhood characteristics to help explain geographic heterogeneity in CRC survival. Such research could facilitate interventions for reducing geographic disparity in CRC survival. [ABSTRACT FROM PUBLISHER]

Recent scholarship on criminal punishments increasingly highlights the importance of courtroom social contexts. Combining recent data from the U.S. Sentencing Commission (FY1997–2000) with aggregate data on federal districts, the current study examines interdistrict variations in the application of downward departures from the federal sentencing guidelines. Findings indicate that substantial variation exists in the probability of both prosecutor-initiated substantial assistance departures and judge-initiated downward departures. This variation is accounted for, in part, by organizational court contexts, such as caseload pressures, and by environmental considerations, such as the racial composition of the district. Additional evidence suggests that individual trial penalties and race disparities are conditioned by aggregate court contexts. Drawing on interviews with federal justice personnel, this article concludes with a discussion of future directions for research on federal guidelines departures. Part of the glory of the federal system...is that you've got this one big organization, but it can be molded to different needs... - An assistant U.S. attorney - [ABSTRACT FROM AUTHOR]

Despite documented preferences for home death, the majority of deaths from terminal illness occur in hospital. To better understand variation in place of death, we conducted a systematic literature review and a multilevel analysis in which we linked death certificates with county and state data. The results of both components revealed that opportunities for home death are disproportionately found in certain groups of Americans; more specifically, those who are White, have greater access to resources and social support, and die of cancer. From the multilevel analysis, the higher the proportion minority and the lower the level of educational attainment, the higher the probability of hospital death while investment in institutional long-term care, measured by regional density of nursing home beds and state Medicaid payment rate, was associated with higher probability of nursing home death. These results reinforce the importance of both social and structural characteristics in shaping the end-of-life experience. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to investigate the relation between state-level social capital and adult health-related quality of life (HRQOL) in the United States. Methods: Using data from the 2001 Behavioral Risk Factor Surveillance System survey and other surveys and administrative sources, we conducted a two-level, multivariable analysis of 173,236 adults in 48 U.S. states to estimate the associations of state-level social capital (along two scales) with individual-level self-rated general health and the numbers of recent days of poor physical health, poor mental health, and activity limitation. Results: For each social capital scale, living in a state intermediate or high (vs. low) in social capital was each associated with 10% to 11% lower odds of fair/poor health. Higher state-level social capital also predicted fewer recent days of poor physical and mental health and activity limitation. Differential returns of social capital to HRQOL according to state-level mean income and individual-level age and race/ethnicity were observed. Furthermore, evidence was found compatible with mediation by social capital of income inequality effects on HRQOL. Conclusions: This study yields new evidence consistent with protective effects of state-level social capital on individual HRQOL. Promoting social capital may provide a means of improving the health-related quality of life of Americans. [Copyright &y& Elsevier]

Abstract: Although social capital has been linked to a variety of health outcomes, its association with obesity has yet to be elucidated. This study explored the relations between social capital measured at the US state and county levels and individual obesity and leisure-time physical inactivity. Individual-level data were drawn from the 2001 Behavioral Risk Factor Surveillance System survey, while data from other surveys and administrative sources were used to construct contextual measures. Two state-level social capital scales were derived from 10 indicators and two county-level scales from five indicators. In 2-level analyses of over 167,000 adults nested within 48 states plus the District of Columbia, residence in a state above the median on one or both state social capital scales (vs. neither scale) was associated with lower relative odds of obesity and physical inactivity, controlling for individual-level covariables and state-level estimates of mean household income, the Gini coefficient, and the percentage of Black residents. In 3-level analyses, the adjusted odds ratio (OR) for physical inactivity associated with residence in a county above the median on one or both county social capital scales was significantly below 1, while the association with obesity was not significant. Significantly weaker inverse ORs for the relations between state- and county-level social capital and obesity were observed among American Indians/Alaska Natives compared to Whites. Meanwhile, little support was found for mediation by social capital of the associations of urban sprawl and income inequality with obesity or physical inactivity. Overall, this study provides some evidence for the promotion of social capital as a potential strategy for addressing the burgeoning obesity epidemic. [Copyright &y& Elsevier]

Objectives: To assess the relationship between neighborhood effects and the severity of dental caries among low-income African-Americans.Methods: A multistage probability sample of African-American families living in the poorest 39 census tracts in Detroit was drawn. During 2002-03, cross-sectional data of a cohort that includes 1021 caregivers were collected in the first of three waves of interviews and examinations. Multilevel analyses focused on 27 neighborhood clusters and involved a combination of individual (Level-1) and neighborhood (Level-2) data including census and geocoded (address matching to census geographic areas) information.Results: There is significant variation in the severity of caries between low-income neighborhood clusters. Caries severity decreases with a higher number of churches, while it increases with a higher number of grocery stores in the clusters after accounting for individual characteristics. Only 14% of the inter-individual variability in caries was explained by classical individual risk factors for this condition.Conclusion: Neighborhoods contribute something unique to caregivers' oral health, beyond socioeconomic position and individual risk factors. Multilevel interventions are necessary to reduce disparities among African-Americans and churches may offer a promising venue from which to conduct them. [ABSTRACT FROM AUTHOR]

Objectives. To examine (1) whether county‐level income inequality is associated with depression among Americans aged 70 and older, taking into consideration county‐level mean household income and individual‐level socioeconomic status (SES), demographic characteristics, and physical health, and (2) whether income inequality effects are stronger among people with lower SES and physical health. Data Sources. The individual‐level data from the first wave of the Assets and Health Dynamics among the Oldest Old survey (1993–1994) were linked with the county‐level income inequality and mean household income data from the 1990 Census. Study Design. Multilevel analysis was conducted to examine the association between income inequality (the Gini coefficient) and depression. Principal Findings. Income inequality was significantly associated with depression among older Americans. Those living in counties with higher income inequality were more depressed, independent of their demographic characteristics, SES, and physical health. The association was stronger among those with more illnesses. Conclusions. While previous empirical research on income inequality and physical health is equivocal, evidence for income inequality effects on mental health seems to be strong. [ABSTRACT FROM AUTHOR]

Objective: To explore the association of clinical guideline-related variables, demographics and Medicaid expansion on pre-exposure prophylaxis (PrEP) uptake in one of the largest US sample of men who have sex with men(MSM) and transgender and gender non-binary (TGNB) people ever analysed., Methods: We cross-sectionally analysed predictors of current PrEP use using demographic and HIV risk-related variables (level-1), as well as state-level variables (level-2) (ie, Medicaid expansion status). We further explored the role state of residence plays in PrEP uptake disparities across the USA., Results: We found that the odds of PrEP use were significantly greater in older age, white, cisgender men. Moreover, individuals who reported recent post-exposure prophylaxis use, a recent sexually transmitted infection diagnosis and recent drug use were significantly more likely to report PrEP use. Finally, we found that the median odds of PrEP use between similar individuals from different states were 1.40 for the ones living in the Medicaid expansion states, compared with those not living in Medicaid expansion states. State of residence did not play a significant role in explaining PrEP disparities overall., Conclusion: Our analysis showed that PrEP use is less common in communities standing to benefit the most from it-young MSM and TGNB of colour. However, individuals meeting federal guidelines for PrEP were significantly more likely to use PrEP. Though we found a positive association between living in Medicaid expansion states and PrEP use; that variable, as well as one's state of residency, were not suitable to explain variations in PrEP use in the US., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Though higher rates of binge drinking have been reported among sexual minority (lesbian, gay, and bisexual) youths compared to their heterosexual peers in the United States, questions remain about which specific structural factors drive these inequities. We test whether state LGBTQ (lesbian, gay, bisexual, transgender, queer/questioning) policy climate is associated with youth binge drinking, as well as whether that association is unique to sexual minority youth., Methods: We use LGBTQ policy scores compiled by the Movement Advancement Project in 2017 and analyze 2017 Youth Risk Behavior Survey data (126,432 youths living in 24 states). We fit multi-level logistic regression models to estimate odds ratios for binge drinking with state-level LGBTQ policy scores., Result: More progressive state-level overall LGBTQ policies were associated with lower odds of binge drinking among sexual minority youths (interaction term OR = 0.990, CI 0.984-0.996, p = 0.0009), but not among heterosexuals (OR = 1.001, CI 0.992, 1.009, p = 0.881). For sexual minorities, living in the most LGBTQ-affirming state was associated with a probability of binge drinking 27% lower than that of those living in the least LGBTQ-affirming state. In sensitivity analyses, policies specific to LGBTQ youth (opposed to general LGBTQ people) were even more strongly related to sexual minorities' binge drinking (interaction term: state-level youth policy score × individual-level sexual identity-of OR = 0.949, CI 0.927-0.971, p = 0.00001). In sex-stratified models, associations with overall LGBTQ policy scores were significant only for girls (OR = 0.986, CI 0.979-0.993, p < 0.001), not boys (OR = 0.997, CI 0.986-1.008, p = 0.551), while associations with youth-focused LGBTQ policies were significant for both sexual minority girls and boys., Conclusion: Our findings point to state-level LGBTQ policy climate as a potential social determinant of binge drinking problems among sexual minority youths., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

The objective of this study was to evaluate the effects of geometric design on crash risk on freeway segments with closely spaced entrance and exit ramps. Traffic flow, geometric design features and crash data from 80 segments on 14 freeways in the state of California, United States were applied. A multilevel logistic regression model with cross-level interactions was developed, where traffic variables were put on the case level, and their estimated coefficients were defined as a function of geometric design variables on the segment level. A basic logistic model and a multilevel logistic model without cross-level interactions were developed for comparison. The result shows that the one with cross-level interactions provides the best goodness of fit. The results indicate that six categories of geometric design variables are significantly associated with crash risk, i.e. lane configuration, basic number of lanes, ramp spacing, theoretical gore, inner shoulder width and speed limit. All but one (inner should width) geometric design variables have significant interaction terms with traffic flow variables. The effects of geometric design variables on crash risk are not fixed but vary with traffic conditions. The findings of this study can provide design guidance to improve road safety of freeway segments with closely spaced entrance and exit ramps., (Copyright © 2021. Published by Elsevier Ltd.)

Local-level childhood overweight and obesity data are often used to implement and evaluate community programs, as well as allocate resources to combat overweight and obesity. The most current substate estimates of US childhood obesity use data collected in 2007. Using a spatial multilevel model and the 2016 National Survey of Children's Health, we estimated childhood overweight and obesity prevalence rates at the Census regional division, state, and county levels using small-area estimation with poststratification. A sample of 24,162 children aged 10-17 years was used to estimate a national overweight and obesity rate of 30.7% (95% confidence interval: 27.0%, 34.9%). There was substantial county-to-county variability (range, 7.0% to 80.9%), with 31 out of 3,143 counties having an overweight and obesity rate significantly different from the national rate. Estimates from counties located in the Pacific region had higher uncertainty than other regions, driven by a higher proportion of underrepresented sociodemographic groups. Child-level overweight and obesity was related to race/ethnicity, sex, parental highest education (P < 0.01 for all), county-level walkability (P = 0.03), and urban/rural designation (P = 0.02). Overweight and obesity remains a vital issue for US youth, with substantial area-level variability. The additional uncertainty for underrepresented groups shows surveys need to better target diverse samples., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Older adults often experience functional limitations that affect their everyday lives, but many of them continue to make positive contributions to society and benefit from these contributions themselves. We examine (a) whether older adults' functional limitations are associated with diurnal cortisol patterns and (b) whether these associations vary on volunteering days versus nonvolunteering days., Methods: Participants were adults aged older than 60 years (N = 435) from the National Study of Daily Experiences, part of the Midlife in the United States Study. They completed an initial interview on functional limitations and background characteristics, indicated volunteering activities in daily interviews, and also provided salivary samples across 4 days., Results: Multilevel models showed that older adults with greater functional limitations exhibited dysregulated cortisol awakening responses and diurnal cortisol slopes throughout the rest of the day, compared to older adults with lower limitations. Yet, we also observed a significant moderating effect of volunteering on these associations., Discussion: This study advances our understanding of functional limitations and cortisol stress responses, revealing the benefits of volunteering to older adults who experience these limitations. Rather than treating these older adults solely as care recipients, interventions should offer them opportunities to help others., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)