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Over the past thirty years, the sense of school belonging received increasing attention in the educational field because of the many developmental and educational advantages associated with it. Previous research suggested that small schools are in a better position to create a strong sense of belonging among students. The aim of our study was to test the effect of school size on students’ sense of school belonging and to test whether this effect holds after considering the effect of the classroom after controlling for individual differences. The study was conducted on a sample of 1698 sixth- and seventh-grade students distributed among 20 school institutes in Switzerland. Multilevel analyses have been conducted. While first results showed an effect of the school size on the sense of school belonging, a comparison of the two-level and three-level hierarchical linear models showed that this effect is no longer significant when considering the intermediate level of the classroom in the analysis, indicating that previous research may have overestimated the effect of school size on the sense of school belonging. These evidence raises the question of which levels of the school environment are more relevant to better understanding individual differences in the sense of school belonging.

Background Universal health coverage (UHC) is part of the global health agenda to tackle the lack of access to essential health services (EHS). This study developed and tested models to examine the individual, neighbourhood and countrylevel determinants associated with access to coverage of EHS under the UHC agenda in low- and middle-income countries (LMICs). Methods We used datasets from the Demographic and Health Surveys (DHSs) of 58 LMICs. Suboptimal and optimal access to EHS were computed using nine indicators. Descriptive and multilevel multinomial regression analyses were performed using R and STATA. Results The prevalence of suboptimal and optimal access to EHS varies across the countries, the former ranging from 5.55% to 100%, and the latter ranging from 0% to 90.36% both in Honduras and Colombia, respectively. In the fully adjusted model, children of mothers with lower educational attainment (relative risk ratio [RRR] 2.11, 95% credible interval [CrI] 1.92 to 2.32) and those from poor households (RRR 1.79, 95% CrI 1.61 to 2.00) were more likely to have suboptimal access to EHS. Also, those with health insurance (RRR 0.72, 95% CrI 0.59 to 0.85) and access to media (RRR 0.59, 95% CrI 0.51 to 0.67) were at lesser risk of having suboptimal EHS. Similar trends, although in the opposite direction, were observed in the analysis involving optimal access. The intra-neighbourhood and intra-country correlation coefficients were estimated using the intercept component variance; 57.50%% and 27.70% of variances in suboptimal access to EHS are attributable to the neighbourhood and country-level factors. Conclusion Neighbourhood-level poverty, illiteracy, and rurality modify access to EHS coverage in LMICs. Interventions aimed at achieving the 2030 UHC goals should consider integrating socioeconomic and living conditions of people.

While infusion of technology into schools has been one of the top priorities of the education reform agenda across the world, findings from many large-scale international assessments indicate that students’ use of information and communication technology (ICT) has mixed effects on their academic achievements. In this paper, we argue that these ambivalent findings were due to the oversight of the indirect effects of ICT use mediated by other ICT-related variables. We employed multilevel structural equation modelling to unfold the relationship between students’ ICT use and their academic achievements based on PISA 2015 data. The results indicated that students’ autonomy in ICT use and students’ interest in ICT use were found to have significant positive direct effects on students’ academic achievements at both within-school and between-school levels. These two variables played a significant role in mediating the indirect effects of ICT use outside school for schoolwork and ICT resources on students’ academic achievements. On the contrary, ICT resources and ICT use at school exerted either no direct effect or a negative direct effect on students’ academic achievements and students’ perceived autonomy related to ICT use, suggesting that mere provision and use of ICT resources in school did not necessarily guarantee success in student performance. At the school level, school’s transformational leadership and collaborative climate helped promote students’ autonomy in ICT use.

Abstract Background Healthcare provider profiling involves the comparison of outcomes between patients cared for by different healthcare providers. An important component of provider profiling is risk-adjustment so that providers that care for sicker patients are not unfairly penalized. One method for provider profiling entails using random effects logistic regression models to compute provider-specific predicted-to-expected ratios. These ratios compare the predicted number of deaths at a given provider given the case-mix of its patients with the expected number of deaths had those patients been treated at an average provider. Despite the utility of this metric in provider profiling, methods have not been described to estimate confidence intervals for these ratios. The objective of the current study was to evaluate the performance of four bootstrap procedures for estimating 95% confidence intervals for predicted-to-expected ratios. Methods We used Monte Carlo simulations to evaluate four bootstrap procedures: the naïve bootstrap, a within cluster-bootstrap, the parametric multilevel bootstrap, and a novel cluster-specific parametric bootstrap. The parameters of the data-generating process were informed by empirical analyses of patients hospitalized with acute myocardial infarction. Three factors were varied in the simulations: the number of subjects per cluster, the intraclass correlation coefficient for the binary outcome, and the prevalence of the outcome. We examined coverage rates of both normal-theory bootstrap confidence intervals and bootstrap percentile intervals. Results In general, all four bootstrap procedures resulted in inaccurate estimates of the standard error of cluster-specific predicted-to-expected ratios. Similarly, all four bootstrap procedures resulted in 95% confidence intervals whose empirical coverage rates were different from the advertised rate. In many scenarios the empirical coverage rates were substantially lower than the advertised rate. Conclusion Existing bootstrap procedures should not be used to compute confidence intervals for predicted-to-expected ratios when conducting provider profiling.

Objectives We aimed to identify the factors related to depression and quality of life in patients with hypertension by using multilevel regression analysis. Methods In 2019, 229 043 participants in the Korean Community Health Survey were selected as the study group. Individual factors were identified using data from the 2019 Community Health Survey. Regional factors were identified using data from the National Statistical Office of Korea. Multilevel regression analysis was conducted to find individual and local factors affecting depression and quality of life in patients with hypertension and to determine any associated interactions. Results As individual factors in patients with hypertension, women, those with lower education-levels, recipients of basic livelihood benefits, and those with poor dietary conditions showed stronger associations with depression and quality of life. As regional factors and individual-level variables in patients with hypertension, lower gross regional personal income, fewer doctors at medical institutions, and lower rates of participation in volunteer activities presented stronger associations with depression and quality of life. In addition, the associations of depression with gross regional personal income, the number of doctors at medical institutions, and dietary conditions were significantly stronger in patients with hypertension than in patients without hypertension. The associations of gender and employment status with quality of life were also significantly greater. Conclusions Policy interventions are needed to adjust health behaviors, prevent depression, and improve quality of life for patients with hypertension, especially for those with the risk factors identified in this study.

Abstract Background Despite the significant benefit of the continuum of care to avert maternal and neonatal mortality and morbidity, still the dropout from the continuum of care remains high and continued to become a challenge in Ethiopia. Therefore, this study aimed to assess the level of completion along the continuum of maternity care and its predictors among reproductive-age women in Ethiopia. Methods A secondary data analysis was done using the 2019 mini Ethiopian demographic health survey. A total weighted sample of 2,905 women aged 15–49 years who gave birth in the last five years preceding the survey and who had antenatal care visits was included. A multilevel mixed-effects logistic regression model was used to examine the predictors that affect the completion of the continuum of maternity care services. Finally, statistical significance was declared at a p-value < 0.05. Results In this study, the overall prevalence of completion along the continuum of maternity care was 12.9% (95%CI: 11.1 – 14.9%). Attending higher education (AOR = 2.03: 95%CI; 1.14 - 3.61), belonged to medium wealth status (AOR = 1.69: 95%CI; 1.07 - 2.66), belonged to rich wealth status (AOR = 2.05: 95%CI; 1.32, 3.17), and informed about danger signs during pregnancy (AOR = 2.23: 95%CI; 1.61, 3.10) were positively associated with the completion of the maternity continuum of care. However, late initiaton of first antenatal care visits (AOR = 0.66: 95%CI; 0.49, 0.89), being rural resident (AOR = 0.67: 95%CI; 0.42 - 0.93), lived in the Afar (AOR = 0.36: 95%CI; 0.12 – 0.83) and Gambella (AOR = 0.52: 95%CI; 0.19 – 0.95) regional states were negatively associated with the completion of the continuum of maternity care. Conclusion Despite most of the women using at least one of the maternity services, the level of completion along the continuum of care after antenatal care booking remains low in Ethiopia. Therefore, enhancing female education and economic transitions with special consideration given to rural, Afar, and Gambella regional state residents. Counseling towards the danger signs of pregnancy and its complications during antenatal care follow-upshould be strengthened. . Furthermore, the identified predictors should be considered when designing new policies or updating policies and strategies on maternity services uptake to step-up its full utilization, which in turn helps in the achievement of the sustainable development goals of ending preventable causes of maternal, neonatal, and child death by 2030.

Abstract Background Very little is known about factors influencing adolescent childbearing despite an upward trend in adolescent childbearing prevalence in Burundi, and its perceived implications on the rapid population growth and ill-health of young mothers and their babies. To adress this gap, this study aimed to examine the prevalence, trends and determinants of adolescent childbearing in Burundi. Methods Secondary analyses of the 1987, 2010 and 2016–17 Burundi Demographic and Health Surveys (BDHS) data were conducted using STATA. Weighted samples of 731 (1987 BDHS), 2359 (2010 BDHS) and 3859 (2016-17BDHS) adolescent girls aged 15–19 years old were used for descriptive and trend analyses. Both bivariable and multivariable two-level logistic regression analyses were performed to identify the main factors associated with adolescent childbearing using only the 2016–17 BDHS data. Results The prevalence of adolescent childbearing increased from 5.9% in 1987 to 8.3% in 2016/17. Factors such as adolescent girls aged 18–19 years old (aOR =5.85, 95% CI: 3.54–9.65, p

Abstract Background Understanding how urban environments influence people’s health, especially as individuals age, can help identify ways to improve health in the rapidly urbanizing and rapidly aging populations. Objectives To investigate the association between age and self-reported health (SRH) in adults living in Latin-American cities and whether gender and city-level socioeconomic characteristics modify this association. Methods Cross-sectional analyses of 71,541 adults aged 25–97 years, from 114 cities in 6 countries (Argentina, Brazil, Colombia, Chile, El Salvador, and Guatemala), as part of the Salud Urbana en America Latina (SALURBAL) Project. We used individual-level age, gender, education, and self-reported health (SRH) data from harmonized health surveys. As proxies for socioeconomic environment we used a city-level socioeconomic index (SEI) calculated from census data, and gross domestic product (GDP) per-capita. Multilevel Poisson models with a robust variance were used to estimate relative risks (RR), with individuals nested in cities and binary SRH (poor SHR vs. good SRH) as the outcome. We examined effect modification by gender and city-level socioeconomic indicators. Results Overall, 31.4% of the sample reported poor SRH. After adjusting for individual-level education, men had a lower risk of poor SRH (RR = 0.76; CI 0.73–0.78) compared to women, and gender modified the association between age and poor SRH (p-value of interaction

Abstract Background Unskilled birth attendance is a major public health concern in Sub-Saharan Africa (SSA). Existing studies are hardly focused on the socio-demographic correlates and geospatial distribution of unskilled birth attendance in Chad (a country in SSA), although the country has consistently been identified as having one of the highest prevalence of maternal and neonatal deaths in the world. This study aimed to analyse the socio-demographic correlates and geospatial distribution of unskilled birth attendance in Chad. Methods The study is based on the latest Demographic and Health Survey (DHS) data for Chad. A total of 10,745 women aged between 15 and 49 years were included in this study. A multilevel analysis based on logistic regression was conducted to estimate associations of respondents’ socio-demographic characteristics with unskilled birth attendance. Geographic Information System (GIS) mapping tools, including Getis-Ord Gi hotspot analysis tool and geographically weighted regression (GWR) tool, were used to explore areas in Chad with a high prevalence of unskilled birth attendance. Results The findings show that unskilled birth attendance was spatially clustered in four Chad departments: Mourtcha, Dar-Tama, Assoungha, and Kimiti, with educational level, occupation, birth desire, birth order, antenatal care, and community literacy identified as the spatial predictors of unskilled birth attendance. Higher educational attainment, higher wealth status, cohabitation, lowest birth order, access to media, not desiring more births, and higher antenatal care visits were associated with lower odds of unskilled birth attendance at the individual level. On the other hand, low community literacy level was associated with higher odds of unskilled birth attendance in Chad whereas the opposite was true for urban residency. Conclusions Unskilled birth attendance is spatially clustered in some parts of Chad, and it is associated with various disadvantaged individual and community level factors. When developing interventions for unskilled birth attendance in Chad, concerned international bodies, the Chad government, maternal health advocates, and private stakeholders should consider targeting the high-risk local areas identified in this study.

Abstract Background Abortion is one of the top five causes of maternal mortality in low and middle-income countries. It is associated with a complication related to pregnancy and childbirth. Despite this, there was limited evidence on the prevalence and associated factors of abortion in East African countries. Therefore, this study aimed to investigate the prevalence and associated factors of abortion among reproductive-aged women in East African countries. Methods The Demographic and Health Surveys (DHS) data of 12 East African countries was used. A total weighted sample of 431,518 reproductive-age women was included in the analysis. Due to the hierarchical nature of the DHS data, a multilevel binary logistic regression model was applied. Both crude and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was calculated for potential associated factors of abortion in East Africa. In the final model, variables with a p value

Abstract Background During the 2020 COVID-19 pandemic, governments imposed numerous regulations to protect public health, particularly the (mandatory) use of face masks. However, the appropriateness and effectiveness of face mask regulations have been widely discussed, as is apparent from the divergent measures taken across and within countries over time, including mandating, recommending, and discouraging their use. In this study, we analyse how country-level policy stringency and individual-level predictors associate with face mask use during the early stages of the global COVID-19 pandemic. Method First, we study how (self and other-related) risk perception, (direct and indirect) experience with COVID-19, attitude towards government and policy stringency shape face mask use. Second, we study whether there is an interaction between policy stringency and the individual-level variables. We conduct multilevel analyses exploiting variation in face mask regulations across countries and using data from approximately 7000 students collected in the beginning of the pandemic (weeks 17 through 19, 2020). Results We show that policy stringency is strongly positively associated with face mask use. We find a positive association between self-related risk perception and mask use, but no relationship of mask use with experience with COVID-19 and attitudes towards government. However, in the interaction analyses, we find that government trust and perceived clarity of communication moderate the link between stringency and mask use, with positive government perceptions relating to higher use in countries with regulations and to lower use in countries without regulations. Conclusions We highlight that those countries that aim for widespread use of face masks should set strict measures, stress self-related risks of COVID-19, and use clear communication.

Abstract Background Examining the correlates of adolescent’s physical activity (PA) and how they may differ according to the intersection of gender and family socioeconomic status (SES) can support the development of tailored interventions to more effectively promote adolescents’ PA. This study explored how the associations between psychosocial, behavioural and environmental factors and adolescent’s PA differed according to gender and family SES. Methods This study used data from the Dutch Youth Health Survey 2015. Adolescents (n = 9068) aged 12–19 were included in the study. The associations between psychosocial, behavioural, and environmental factors and PA (days per week engaging in at least one hour of PA) were examined with multilevel linear regression analysis. Potential interactions between these correlates, gender and family SES were explored. Results On average, adolescents engaged in at least one hour of PA for 4,2 days per week. Poor self-perceived health, low peer social support, and a weak connection with the environment were all associated with lower PA in adolescents. Daily smoking, cannabis use, risk of problematic gaming and social media use, as well as lack of daily consumption of fruit, vegetables, water and breakfast were associated with lower PA, whereas binge drinking was not. Interactions revealed that poor self-perceived health was associated with lower PA in adolescents from moderate- and high-SES families, but not in low-SES adolescents, whereas cannabis use was only associated with lower PA amongst low-SES adolescents. Low peer social support was associated with lower PA across all groups, but it was most strongly associated with lower PA amongst male adolescents from low-SES families than in other subgroups. Amongst low-SES males, low peer social support was associated with a 1.47 reduction in days engaging in sufficient PA, compared with a 0.69 reduction for high-SES males. Conclusions This study identified several psychosocial, behavioural and environmental factors that can be targeted to potentially increase adolescent’s PA. We also found that correlates of PA differed according to the intersection of gender and family SES. Our findings suggest that PA interventions should be tailored according to gender and SES to address the specific needs, barriers and facilitators of different subgroups.

Stunting is still a global nutritional problem. Stunting is a picture of the occurrence of chronic nutritional problems. Stunting caused by multiple factors, especially if it occurs in the first 1000 days of birth. Malaka Regency is one of the regions in NTT that recorded an increase in the percentage of stunting, from the previous 25% to 30% with the number of children experiencing stunting in Malaka currently reaching 4,909 people. With this number, Malaka is in 11th place with stunting in NTT (Malaka District Health Office, 2020). The purpose of the study was to determine the determinants of stunting in children under five in Malaka Regency. Research design. This research is analytic observational. This research is an observational analytic. The approach is case control and using a multilevel model which is one of the analytical techniques to determine the relationship between various variables in health with the Stata-13 program. This research was conducted by simple random sampling. The sampling technique used in this study. The sampling technique used in this study was stratified random sampling. The method used at the first level was to randomly select 10 villages in the district of Malaka, the second level to randomly select 25 integrated health care (IHC). Eight research subjects will be taken from each integrated service post so that the sample studied is 200 research subjects. Data was collected using a questionnaire and height measurement using a microtoise measuring instrument. The results of this study indicate that the factors causing stunting are exclusive breastfeeding (55.5%), Basic Sanitation (61.5%), Parenting (67.5%), and early marriage (32.0%). The results of this study indicate that the causes of stunting based on these variables have a significant difference (p < 0.05). Recommendations for health workers conduct socialization and counseling about exclusive breastfeeding, the importance of hygiene practices in daily life including caring for children, maximizing the community-based total sanitation program and conducting socialization related to the influence of early marriage.

Background: This study assessed the clustering of children' caries experience, plaque accumulation and gingival inflammation in families and villages in Northwestern Egypt and the factors related to the severity of these conditions. Methods: This was a secondary analysis of a 2019 household survey of children in villages around Alexandria, Egypt. Clinical examination assessed primary and permanent teeth caries experience (dmft/ DMFT using the World Health Organization criteria), plaque accumulation (Plaque Index (PlI)) and gingival inflammation (Gingival Index (GI)). A child questionnaire assessed child's age, sex, the frequency of toothbrushing (at least twice daily versus less) and frequency of consuming eight types of sugary products (daily sugar consumption score, sum of sugary products consumed daily). Mothers' questionnaire assessed the number of children in the family, mother's education (at least high school versus less), at least twice daily toothbrushing and daily sugar consumption similar to the child. Multilevel regression analyses assessed clustering, calculated by the intraclass correlation coefficient (ICC) of the three conditions in families and villages. Regression estimates (B) and 95% confidence intervals (CIs) of individual and family factors were calculated. Results: Complete data were available for 450 children (246 families, seven villages], mean = 9.9 years-old and 56% females. The mean caries experience score = 3.6, mean plaque index = 1.5 and mean gingival index = 1.2. Caries experience, plaque accumulation and gingival inflammation were not clustered in villages (ICC < 0.01) but clustered in families (ICC = 0.10, 0.44 and 0.29). Child factors significantly improved model fit for caries experience and gingivitis (p < 0.001) but not plaque accumulation (p = 0.90). Family factors did not improve any model fit (p > 0.05). Child's age was significantly associated with caries experience (B= -0.48, p < 0.001) and gingival inflammation (B = 0.032, p < 0.001). Children who brushed their teeth twice daily had significantly more caries experience (B = 1.04, p = 0.01). Conclusion: The three oral conditions were not clustered in villages but clustered in families. Plaque accumulation showed the greatest within-family clustering. Family factors were not associated with the three conditions and individual factors indicated the need for interventions to promote preventive behaviors and identify families at risk of oral conditions. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) pandemic has greatly changed our daily life. Owing to the imposed restrictions, many educational facilities have introduced remote teaching. This study aims to clarify the association between remote teaching and Japanese university students' sleeping habits. Methods: The participants were medical students at Aichi Medical University. We used data from an ongoing longitudinal sleeping habits survey. For the participants who enrolled in the university during 2018–2020, multilevel analyses of sleep duration during weekdays and weekends across 3 years were conducted, adjusting for sex, grade, place of stay, sleep problems and lifestyle habits. Results: Among the students enrolled in the university, the data of 677 in 2018, 657 in 2019, and 398 in 2020 was available for analysis. The mean sleep duration during weekdays (in minutes) was 407.6 ± 60.3 in 2018, 406.9 ± 63.0 in 2019, and 417.3 ± 80.9 in 2020. The mean sleep duration during weekends (in minutes) was 494.5 ± 82.5 in 2018, 488.3 ± 87.9 in 2019, and 462.3 ± 96.4 in 2020. Multilevel analysis conducted for the 684 participants who enrolled during 2018–2020 showed that sleep duration during weekdays was associated with the place of stay and survey year. Moreover, students reported significantly longer sleep duration during weekdays in 2020 than in 2019, but no significant difference in sleep duration was found between 2018 and 2019. The other multilevel analysis found sleep duration during weekends to be associated with the survey year, sex and always doing something before going to bed. Sleep duration during weekends was shorter in 2020 than in 2019 and longer for male students and students who always do something before going to bed. Ten students were reported to have a delayed sleep phase in 2020. Conclusions: Students' sleep duration increased during weekdays and decreased during weekends in 2020. This difference could be explained by the COVID-19 pandemic and the introduction of remote teaching. [ABSTRACT FROM AUTHOR]

Background: The purpose of the study was to explore, analyse, and describe the patterns of public dental service utilisation among the refugee populations in Victoria, Australia, and determine their predictors at the individual and contextual levels. Methods: Data on the refugees who attended Victorian public dental services between July 2016 to June 2020 was gathered from the Dental Health Program dataset. Latent profile analysis was used to identify discrete groups among the refugee clientele with similar mean utilisation patterns across six indicator variables describing the attributes of dental services received and the site of care provision, over the study period. Multilevel multinomial logistic regression analysis was performed to examine the individual and contextual level correlates of the identified utilisation patterns. Results: Six distinct profiles of public dental service utilisation were identified among the study population (n = 25,542). The largest group comprised refugees predominantly using restorative services under general course of care (38.10%), followed by extraction services under emergency course of care (23.50%). Only a small proportion were estimated as having a higher mean utilisation of preventive services under general course of care (9.10%). Multilevel analysis revealed that the following variables had a significant association with refugee utilisation pattern: at the individual-level – demographic and ethnic attributes including age, gender, region of birth, preferred language for communication, use of language interpreter services, and type of eligibility card; at the contextual-level – characteristics of refugees' neighbourhood of residence including urbanicity, socioeconomic disadvantage, delivery of Refugee Health Program at the community health centres, and spatial accessibility to public dental services via driving and public transit modes of travel. Conclusions: The study represents a significant step towards the development of an evidence-based knowledge around public dental service utilisation among Victorian refugees. Overall, the study findings reiterate the critical need for targeted strategies to promote the importance of routine dental visits, oral disease prevention, and timely intervention among refugee groups. [ABSTRACT FROM AUTHOR]

The multilevel paradigm is omnipresent in the organizational sciences, with scholars recognizing data are almost always nested – either hierarchically (e.g., individuals within teams) or temporally (e.g., repeated observations within individuals). The multilevel paradigm is moored in the assumption that relationships between constructs often reside across different levels, often requiring data from a lower-level (e.g., employee-level justice perceptions) to be aggregated to a higher-level (e.g., team-level justice climate). Given the increased scrutiny in the social sciences around issues of clarity, transparency, and reproducibility, this paper first introduces a set of data aggregation principles that are then used to guide a brief literature review. We found that reporting practices related to data aggregation are quite variable with little standardization as to what information and statistics are included by authors. We conclude our paper with a Data Aggregation Checklist and a new R package, WGA (Within-Group Agreement & Aggregation), intended to improve the clarity and transparency of future multilevel studies. [ABSTRACT FROM AUTHOR]

This study focuses on Switzerland where child-care is limited in offer and costly. It examines what child-care patterns parents of 0- to 4-years old children use; and, how different arrangements relate to several domains of mothers' and fathers' cognitive and affective subjective well-being (SWB). A major contribution of the present study is the distinction between child-care provided by parents, grandparents, relatives, formal institutions and mixed arrangements. Based on data from the Swiss Household Panel (SHP) from 2002 to 2017, multilevel regression models are applied to estimate the relationship between child-care arrangements and both parents' SWB. The results demonstrate that grandparental care relates positively to both parents' SWB: Compared to grandparental child-care, relatives and formal or mixed child-care arrangements tend to decrease most of the satisfaction dimensions. Formal child-care and child-care provided by relatives as well as mixed arrangements relate to a decrease in positive affect. Negative affect is not significantly associated to the different child-care arrangements. Highlights: Based on a nationally representative sample, this study differentiates a large array of child-care arrangements. The relationship between child-care type and five dimensions of both parents' subjective well-being (SWB) is analyzed. Relatives, formal and mixed child-care arrangements decrease the level of most of the satisfaction dimensions of SWB. Child-care provided by relatives as well as formal and mixed arrangements relate to a decrease in positive affect. Grandparental care relates positively to both parents' SWB dimensions. [ABSTRACT FROM AUTHOR]

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Background: Early sexual initiation is a major public health concern globally, specifically in Sub-Saharan African (SSA) countries where reproductive health care services are limited. It is strongly related to increased risk of HIV/AIDS, sexually transmitted diseases, unwanted pregnancy, adverse birth outcomes, and psychosocial problems. However, there is limited evidence on the prevalence and associated factors of early sexual initiation among youth females in SSA. Methods: A secondary data analysis was employed based on the recent DHSs of sub-Saharan African countries. A total weighted sample of 184,942 youth females was considered for analysis. Given the hierarchical nature of DHS data, a multilevel binary logistic regression model was fitted. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), and Likelihood Ratio (LR) test were used to assess the presence of clustering. Four nested models were fitted and the model with the lowest deviance (-2LLR0 was selected as the best-fitted model. Variables with p-value < 0.2 in the bivariable multilevel binary logistic regression analysis were considered for the multivariable analysis. In the multivariable multilevel binary logistic regression analysis, the Adjusted Odds Ratio (AOR) with the 95% Confidence Interval (CI) was reported to declare the strength and statistical significance of the association. Results: The prevalence of early sexual initiation among youth females in sub-Saharan Africa was 46.39% [95%CI: 41.23%, 51.5%] ranging from 16.66% in Rwanda to 71.70% in Liberia. In the final model, having primary level education [AOR = 0.82, 95% CI; 0.79, 0.85], and [AOR = 0.50, 95%CI; 0.48, 0.52], being rural [AOR = 1.05, 95%CI: 1.03, 1.07], having media exposure [AOR = 0.91, 95%CI: 0.89, 0.94], and belonged to a community with high media exposure [AOR = 0.92, 95%CI: 0.89,0.96] were found significantly associated with early sexual initiation. Conclusion: The prevalence of early sexual initiation among youth females in SSA was high. Educational status, wealth index, residence, media exposure, and community media exposure have a significant association with early sexual initiation. These findings highlight those policymakers and other stakeholders had better give prior attention to empowering women, enhancing household wealth status, and media exposure to increase early sexual in the region. [ABSTRACT FROM AUTHOR]

Background: In low-and-middle-income, including Ethiopia, high-risk fertility behavior is a major public health concern. High-risk fertility behavior has an adverse influence on maternal and child health, which hampered efforts to reduce maternal and child morbidity and mortality in Ethiopia. Therefore, this study aimed to assess the spatial distribution and associated factors of high-risk fertility behavior among reproductive-age women in Ethiopia using recent nationally representative data. Methods: Secondary data analysis was done with a total weighted sample of 5865 reproductive-aged women using the latest mini EDHS 2019. The spatial distribution of high-risk fertility behavior in Ethiopia was determined using spatial analysis. Multilevel multivariable regression analysis was used to identify predictors of high-risk fertility behavior in Ethiopia. Results: The prevalence of high-risk fertility behavior among reproductive-age women in Ethiopia was 73.50% (95% CI 72.36%, 74.62%). Women with primary education [AOR = 0.44; 95%CI; 0.37, 0.52], women with secondary and above education [AOR = 0.26; 95%CI; 0.20, 0.34], being Protestant religion followers [AOR = 1.47; 95%CI; 1.15, 1.89], being Muslim religion follower [AOR = 1.56; 95%CI; 1.20, 2.01], having television [AOR = 2.06; 95%CI; 1.54, 2.76], having ANC visit [AOR = 0.78; 95%CI; 0.61, 0.99], using contraception [AOR = 0.77; 95%CI; 0.65, 0.90], living in rural areas [AOR = 1.75; 95%CI; 1.22, 2.50] were significantly associated with high-risk fertility behavior. Significant hotspots of high-risk fertility behavior were detected in Somalia, SNNPR, Tigray region, and Afar regions of Ethiopia. Conclusions: A significant proportion of women in Ethiopia engaged in high-risk fertility behavior. High-risk fertility behavior was distributed non-randomly across Ethiopian regions. Policymakers and stakeholders should design interventions that take into account the factors that predispose women to have high-risk fertility behaviors and women who reside in areas with a high proportion of high-risk fertility behaviors to reduce the consequences of high-risk fertility behaviors. [ABSTRACT FROM AUTHOR]

The aims of this study were to develop a revised version of the Meaning In Life Measure (MILM; Hill et al., 2019) and investigate its multilevel measurement invariance at the between-person and within-person levels and multi-group measurement invariance across gender, age, and cultural groups. We analyzed an international dataset including data from 1600 sessions with 384 clients in five continents (Africa, Asia, Europe, Latin America, and North America) using multilevel item response theory and multilevel factor analysis. We found that the revised 5-item MILM-5 had satisfactory reliability and structural validity with the overall sample. Further, it demonstrated measurement invariance across the between- and within-person levels, and also across gender and age groups. Across representative countries within continents, the MILM-5 had the same overall factor structure but all factor loadings and item intercepts significantly differed across cultural contexts. Implications are discussed regarding the assessment of meaning in life in international clinical settings. [ABSTRACT FROM AUTHOR]

Background Child marriage among women has become a major threat to the rights of women, especially in low- and middle-income countries. The marriage of girls below age 18 y is a major public and global health challenge. Therefore, this study examined the spatial pattern and factors associated with child marriage in Nigeria. Methods The data were sourced from the 2018 Nigeria Demographic and Health Survey. The study included a total of 4283 young women aged 20–24 y. The findings were provided in the form of spatial maps and adjusted ORs (aORs) with 95% confidence interval (CI). Results Hotspot areas for child marriage in Nigeria were located in Sokoto, Kebbi, Katsina, Kano, Jigawa, Yobe, Bauchi, Niger, Borno, Gombe, and Adamawa. The prevalence of child marriage in Nigeria was 41.50%. The likelihood of child marriage in Nigeria was high among those currently working (aOR=1.31; 95% CI 1.11 to 1.55) compared with young women who were not working. On the other hand, young women whose partners had secondary education and above (aOR=0.57; 95% CI 0.45 to 0.73) were less likely to report child marriage in Nigeria compared with those whose partners had no education. Conclusions The findings of the study indicate that there are several hotspots in Nigeria that need to be targeted when implementing interventions aimed at eliminating child marriage in the country. [ABSTRACT FROM AUTHOR]

Objective: Self-monitoring and behavioral feedback are widely used to help people monitor progress toward daily physical activity goals. Little information exists about the optimal dosing parameters for these techniques or if they are interchangeable in digital physical activity interventions. This study used a within-person experimental design to evaluate associations between the frequency of two different prompt types (one for each technique) and daily physical activity. Method: Insufficiently active young adults were assigned monthly physical activity goals and wore smartwatches with activity trackers for 3 months. They received zero to six randomly selected and timed watch-based prompts each day, with individual prompts either providing behavioral feedback or prompting the participant to self-monitor. Results: Physical activity increased significantly over the 3-month period (step counts d= 1.03; moderate-to-vigorous physical activity duration d =0.99). Mixed linear models revealed that daily step counts were positively associated with the frequency of daily self-monitoring prompts up to approximately three prompts/day (d =0.22) after which additional prompts provided minimal or reduced benefit. Daily step counts were not associated with the frequency of behavioral feedback prompts. Daily moderate-to-vigorous physical activity was not associated with the frequency of either prompt. Conclusions: Self-monitoring and behavioral feedback are not interchangeable behavior change techniques in digital physical activity interventions, and only self-monitoring prompts show signs of a dose-response association with physical activity volume. Activity trackers, such as smartwatches and mobile apps, should provide an option to replace behavioral feedback prompts with self-monitoring prompts to promote physical activity among insufficiently active young adults. [ABSTRACT FROM AUTHOR]

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Aim: Over half the world's population, mostly from developing countries, use solid fuel for domestic purposes and are exposed to very high concentrations of harmful air pollutants with potential health effects. The effect of indoor air pollution becomes much more severe for older adults because of their weakened immune system with multiple health risk factors. Compared with ambient air pollution, little is known about cognitive health in relation to indoor air pollution. Therefore, this study explores the association between indoor air pollution due to solid fuel use and cognitive function of older adults in India. Subject and methods: The study used data from wave 1 of the WHO Study on global AGEing and adult health (SAGE). Bivariate analysis and a two-stage multilevel linear regression model were applied. Results: Our findings indicated that indoor air pollution is strongly associated with cognitive function. Results show lower cognitive function scores among older adults in households using solid fuel, women with lower or no education, and belonging to the disadvantaged section of the society. Older adults from poor socioeconomic backgrounds were more exposed to indoor air pollution compared to their counterparts, which indirectly increases the risk of poor cognitive function. Conclusion: Indoor air pollution from solid fuel use may be a salient factor for the cognitive health of older adults in India. A large proportion of India's population relies on solid fuel pointing to the need for urgent intervention programmes to reduce the usage of solid fuel in the country. [ABSTRACT FROM AUTHOR]

Background: Measuring multiple and higher‐order interaction effects between multiple categorical variables proves challenging. Objectives: To illustrate a multilevel modelling approach to studying complex interactions. Methods: We apply a two‐level random‐intercept linear regression to a binary outcome for individuals (level‐1) nested within strata (level‐2) defined by all observed combinations of multiple categorical exposure variables. As a pedagogic application, we analyse 36 strata defined by five risk factors of preeclampsia (parity, previous preeclampsia, chronic hypertension, multiple pregnancies, body mass index category) among 652,603 women in the Swedish Medical Birth Registry between 2002 and 2010. Results: The absolute risk of preeclampsia was 4% but was predicted to vary from 1% to 44% across strata. The stratum discriminatory accuracy was 30% according to the variance partition coefficient (VPC) and 0.73 according to the area under the receiver operating characteristic curve (AUC). While the risk heterogeneity across strata was primarily due to the main effects of the categories defining the strata, 5% of the variation was attributable to their two‐ and higher‐way interaction effects. One stratum presented a positive interaction, and two strata presented negative interaction. Conclusions: Multilevel modelling is an innovative tool for identifying and analysing higher‐order interaction effects. Further work is needed to explore how this approach can best be applied to making causal inferences. [ABSTRACT FROM AUTHOR]

Objective: Socio-economic status (SES) and smoking are risk factors for periodontitis; however, their interaction has not been determined. We investigated the effect of modification of SES and smoking with periodontal conditions. Materials and methods: Data on the social background, smoking status, and dental examination of 1033 individuals residing in the Tokyo Metropolitan District were analyzed. The outcomes were the number of remaining teeth and the proportion of teeth with probing pocket depth (PPD) ≥ 4 mm and ≥ 6 mm. Multilevel linear and Poisson regression analyses were performed after adjusting for possible confounding factors, including SES, assessed by the average income of the residential area. Results: The mean number of remaining teeth was 24.6 ± 4.8, and the proportion of teeth with PPD ≥ 4 mm and ≥ 6 mm was 31.2 ± 28.5% and 12.2 ± 18.1%, respectively. After adjusting for confounding factors, the lowest-income population had significantly lesser teeth (coefficient: − 0.46, 95% CI − 0.89, 0.02, p = 0.039) and a higher proportion of teeth with PPD ≥ 4 mm than the highest-income population (ratio of means: 1.22, 95% CI 1.03–1.44, p = 0.013). Significant interactions were observed; income inequalities in periodontitis were significant only among current smokers. Conclusion: Inequality in socio-economic status is associated with oral health inequalities. The adverse effects of smoking on periodontitis might be greater in the low-income population. Clinical relevance: The low-income population, especially current smokers, had significantly more compromised oral health than the high-income population. In addition to the emphasis on smoking cessation, the promotion of universal health coverage for dental care is necessary to reduce oral health inequalities. [ABSTRACT FROM AUTHOR]

The observation that gender differences in Japanese language use are becoming less prevalent as women increasingly use 'men's language' appears in popular media from time to time. Some empirical studies support this view. However, such observations are usually based on the consideration of only one or two linguistic features, especially sentence‐final forms and personal pronouns. In contrast, this study analyzes the use of multiple linguistic and paralinguistic features related to gender, regarding them as resources for styling identity. According to our analysis of eight same‐gender and mixed‐gender dyadic conversations of college students, these speakers' use of features other than sentence‐final forms, which we found to vary little by gender, is normatively gendered to a large extent. The study thus demonstrates that the analysis of multiple and multilevel variables enables us to better understand the complex process of styling through the speaker's negotiation of linguistic gender norms in actual practice. [ABSTRACT FROM AUTHOR]

Purpose: Based on the transactional theory of stress and coping, this study aims to understand the daily impact of coronavirus disease 2019 (COVID-19) on employee goal progress. In particular, the authors explore how COVID-19 induces anxiety related to task setbacks that consequently influences one's goal progress. Design/methodology/approach: A daily diary study was conducted with a total of 558 observations from 60 participants. The data were analyzed using multilevel path analysis with random slopes. Findings: The perceived risk of COVID-19 infection was positively associated with COVID-19 task setback anxiety, which in turn improved end-of-day goal progress. Lower employee conscientiousness strengthened the relationship between perceived risk of COVID-19 infection and COVID-19 task setback anxiety, and lower supervisor bottom-line mentality strengthened the relationship between COVID-19 task setback anxiety and end-of-day goal progress. Practical implications: Although COVID-19 task setback anxiety results in higher end-of-day goal progress, the authors recommend caution as the cost of coping exists. Thus, supervisors should focus on supporting the employees rather than having a bottom-line mentality. Originality/value: This study advances stress and coping literature by examining how employees appraise and cope with COVID-19 in work context. The authors demonstrate that a perceived risk of COVID-19 induces task setbacks related to anticipatory anxiety, which in turn influences employee outcomes. In addition, the authors identify employee conscientiousness and supervisor bottom-line mentality as a boundary condition of this process. [ABSTRACT FROM AUTHOR]

BackgroundUnintended pregnancy is one of the most serious health issues in low and Middle-Income Countries (LMICs), posing significant health, economic, and psychosocial costs to individuals and communities. However, there is limited evidence on the prevalence of unintended pregnancies and their determinants in LMICs. Hence, this study aimed to assess the prevalence of unintended pregnancy and its associated factors among childbearing-age women in LMICs.MethodData for the study were drawn from a recent 61 Demographic and Health Surveys (DHS) conducted in LMICs. A total sample of 187,347 mothers who gave birth in the five years preceding the survey was included. STATA version 16 was used to clean and analyze the data. Multilevel multivariable logistic regression was employed to identify individual and community-level factors of unintended pregnancy in LMICs. In the multivariable analysis, an adjusted odds ratio with a 95% confidence level was reported to indicate statistical association.ResultsThe pooled magnitude of unintended pregnancy in LMICs was 26.46%% (95% CI: 25.30%, 27.62%), ranging from 19.25%% in Egypt to 61.71% in Bolivia. Working status (AOR = 1.03; 95% CI: 1.01, 1.06), having a husband with no education (AOR = 1.07; 95% CI: 1.00, 1.15), and primary education (AOR = 1.05; 95% CI: 1.01, 1.11), women from male-headed households (AOR = 1.04; 95% CI: 1.00, 1.08), media exposure (AOR = 1.05; 95% CI: 1.02, 1.08), unmet need for contraception (AOR = 1.05; 95% CI: 1.02, 1.08), distance from a health facility (AOR = 1.03; 95% CI: 1.00, 1.06) were significantly associated with unintended pregnancy.ConclusionUnintended pregnancy rates remain high in LMICs. Women whose husband has no education and primary education, women with media exposure, working status, women who live in a household headed by male, women with unmet need for contraception, and women with a big problem of distance to health facilities were variables that were significant predictors of unintended pregnancy. When attempting to minimize unintended pregnancy in LMICs, these factors need to be considered. Furthermore, most of these attempts should be driven by government entities in low and middle-income countries.

In the last decades, and especially since 2010, the intersectionality paradigm is being increasingly used as theoretical framework for examining and explaining social inequalities in various areas – both with qualitative and quantitative methods. So far, there is no standard for applying intersectionality in quantitative social research. Therefore, this paper aims to present how intersectionality can be applied in quantitative research and to elaborate on and evaluate several methodological approaches in this regard. More precisely, we describe the tenets of three different quantitative approaches: multivariate linear models, conventional multilevel analysis, and multilevel analysis of individual heterogeneity and discriminatory accuracy (MIAHDA). We compare the three approaches and outline their methodological benefits and limitations.

Data from international studies reveal that the mathematics literacy of Spanish students is significantly lower than that of students from nearby countries. Therefore, in recent years, interest in identifying the factors that influence students’ mathematics results in Spain has grown considerably. Often, these factors are sought among the socioeconomic characteristics of the students or among variables related to the schools, ignoring the psychological and emotional factors of the students. This paper analyzes the impact of certain psychoemotional characteristics of Spanish students on their literacy in mathematics. For this purpose, multilevel regression models are applied to the data of the Spanish sample of the 2018 edition of PISA (Programme for International Student Assessment), which is composed of 35,943 15-year-old students. The instruments for data collection are the mathematics literacy tests and the contextual questionnaires on students’ personal situation and well-being used by PISA. As dependent variable, students’ mathematics literacy has been considered, measured through the plausible values provided by PISA, and as independent variables, different indices measuring students’ psychoemotional well-being obtained from the contextual information collected by PISA. Results indicate that resilience, motivation for the achievement of learning objectives, competitiveness, perceived cooperation at school, and social connectedness with parents have a positive impact on students’ mathematics literacy, while experiences related to bullying, physical self-concept, meaning in life and perceived competitiveness at school have a negative impact.

Objective: To find out the determinants of minimum dietary diversity (MDD) among under-five children in East Africa based on the 2017 revised indicator.Methods: Secondary data from the demographic and health survey (DHS) of eight countries in East Africa were combined. A total of 27,223 weighted samples of children aged 6–59 months were included. Multi-level logistic regression analysis was employed to identify the determinants of dietary diversity.Results: The magnitude of adequate MDD in East Africa was found to be 10.47% with 95% CI (10.12–10.84) with the lowest and highest magnitude in Ethiopia and Rwanda respectively. Having a mother in the age group of 35–49, having a mother with higher educational attainment, and having a post-natal check-up within 2 months were significant factors in determining adequate MDD.Conclusion: The magnitude of adequate MDD intake among children aged 6–59 months in East Africa is relatively low. Therefore, strengthening interventions focused on improving the economic status of households, the educational status of mothers, and diversified food consumption of children aged 6–59 months should get priority to improve the recommended feeding practice of children.

IntroductionSchool dropout is an increasing worldwide phenomenon, marked by inequality and educational exclusion. In Chile, many students who have dropped out of regular schools attempt to reenter youth and adult education (YAE). However, some of them drop out again from YAE.ObjectiveThe aim of this study was to identify and jointly analyze school and individual factors that influence dropout in YAE.MethodsThis secondary multilevel analysis of official datasets from Chile’s Ministry of Education focused on students enrolled in YAE (N = 10,130).ResultsAccording to the findings, YAE dropout can be explained by the individual risk factors of age (19–24 years), low academic achievement, and school-level factors such as number of teachers (raw and student-to-teacher ratio), economic resources, and school management quality.DiscussionWe discuss the need to develop school-level protective factors that build connections, foster student engagement, and ultimately, promote students’ permanence and progress in YAE.

Abstract: Although mortality from ischemic heart disease has declined over the past decades in Argentina, ischemic heart disease remains one of the most frequent causes of death. This study aimed to describe the role of individual and contextual factors on premature ischemic heart disease mortality and to analyze how educational differentials in premature ischemic heart disease mortality changed during economic fluctuations in two provinces of Argentina from 1990 to 2018. To test the relationship between individual (age, sex, and educational level) and contextual (urbanization, poverty, and macroeconomic variations) factors, a multilevel Poisson model was estimated. When controlling for the level of poverty at the departmental level, we observed inequalities in premature ischemic heart disease mortality according to the educational level of individuals, affecting population of low educational level. Moreover, economic expansion was related to an increase in ischemic heart disease mortality, however, expansion years were not associated with increasing educational inequalities in ischemic heart disease mortality. At the departmental level, we found no contextual association beween area-related socioeconomic level and the risk of ischemic heart disease mortality. Despite the continuing decline in ischemic heart disease mortality in Argentina, this study highlighted that social inequalities in mortality risk increased over time. Therefore, prevention policies should be more focused on populations of lower socioeconomic status in Argentina.

The goal of the present study was to investigate the effects of automatically generated, adaptive feedback on daily self-regulated learning (SRL) in an experimental field study. University students reported their application of SRL strategies in the morning and in the evening over the course of 36 days using electronic learning diaries. Students were randomly assigned to the experimental group with feedback (LDF, n = 98) or the control group without feedback (LD, n = 96). Based on their self-reports, students in group LDF received daily written feedback regarding their satisfaction with the study day, adherence to time schedule, procrastination, and effort. This feedback either reinforced students in their study approach (confirmative feedback), encompassed information on learning outcomes or processes (informative feedback), or included feed forward on how to improve learning processes (transformative feedback). Multilevel analysis of daily process data revealed better average goal setting, planning and adherence to time schedule, as well as higher self-efficacy, and satisfaction with the study day in group LDF compared to group LD. Motivation, procrastination and effort were not affected by feedback. In contrast to the process measures, pre-post comparisons of students’ self-reported general use of SRL strategies (trait measures) did not reveal any effects of feedback on SRL. Further explorative analyses investigated the effects of confirmative, informative, and transformative feedback on next day’s learning behavior, showing that confirmative and transformative feedback had stronger effects on students’ satisfaction and procrastination than informative feedback. Transformative feedback, which included specific strategies for moving forward, was effective in improving time management. Results provide theoretical insight into the interplay of feedback and SRL and offer practical implications regarding the design of feedback in a learning context.

This study investigates employee behavior of unauthorized access attempts on information systems (IS) applications in a financial institution and examines how opportunity contexts facilitate such behavior. By contextualizing multilevel criminal opportunity theory, we develop a model that considers both employee- and department-level opportunity contexts. At the employee level, we hypothesize that the scope and data value of the applications that an employee has legitimately accessed, together with the time when and location where the employee initiates access, affect the likelihood of the employee making unauthorized access attempts. At the department level, we hypothesize that department size moderates the impact of employee-level contextual variables on the likelihood of an employee making unauthorized attempts. To test these hypotheses, we collected six months of access log data from an enterprise single sign-on system of a financial institution. We find the hypothesized main effects of all employee-level contextual variables and department size are supported. In addition, department size reinforces the effects of data value, off-hour access, off-site access, and their interaction term, except for that of scope, on the outcome variable. Robustness analyses indicate that the proposed model does not align with those employees who might not know the systems well enough or who might make honest mistakes. We also discuss the theoretical and practical implications of the study. [ABSTRACT FROM AUTHOR]

Intercultural service encounters, in which customers and service employees from different cultures interact, are becoming more common in the market. Despite the importance of such encounters for international marketers, limited research attention has been directed to this area. Drawing on social exchange theory, this study examines how frontline employees' cultural intelligence (CQ) influences customer loyalty outcomes of service quality perceptions. Specifically, the authors propose that the three components of CQ—cognitive, emotional/motivational, and physical—have differential moderating effects on the perceived service quality (PSQ)–customer loyalty link and that these effects vary across two national markets. Data collected with a multirespondent (i.e., frontline service employees and customers) cross-cultural research design indicate that cognitive CQ negatively mitigates the impact of PSQ on customer loyalty in an emerging-market context while emotional/motivational CQ has a positive moderating effect in a mature-market setting. When service employees have high physical CQ, the positive role of PSQ in creating and maintaining customer loyalty is strengthened in both markets. The authors discuss these implications for theory and practice. [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]

The CalEnviroScreen created by the Office of Environmental Health Hazard Assessment, Sacramento, USA, is a place-based dataset developed to measure environmental and social indicators that are theorized to have cumulative health impacts on populations. The objective of this study was to examine the extent to which the composite scores of the CalEnviroScreen tool are associated with pediatric asthma hospitalization. This was a retrospective analysis of California hospital discharge data from 2010 to 2012. Children who were hospitalized for asthma-related conditions, were aged 0-14 years, and resided in California were included in analysis. Rates of hospitalization for asthma-related conditions among children residing in California were calculated. Poisson multilevel modeling was used to account for individual- and neighborhood-level risk factors. Every unit increase in the CalEnviroScreen Score was associated with an increase of 1.6% above the mean rate of pediatric asthma hospitalizations (rate ratio (RR) = 1.016, 95% confidence interval (CI) = 1.014-1.018). Every unit increase in racial/ethnic segregation and diesel particulate matter was associated with an increase of 1.1% and 0.2% above the mean rate of pediatric asthma, respectively (RR = 1.011, 95% CI = 1.010-1.013; RR = 1.002, 95% CI = 1.001-1.004). The CalEnviroScreen is a unique tool that combines socioecological factors and environmental indicators to identify vulnerable communities with major health disparities, including pediatric asthma hospital use. Future research should identify mediating factors that contribute to community-level health disparities.

Background: Only 10% of patients with alcohol and other drug (AOD) disorders receive treatment. The AOD Initiation and Engagement in Treatment (AOD-IET) measure was added to the national Healthcare Effectiveness Data and Information Set (HEDIS) to improve access to care. This study identifies factors related to improving AOD-IET rates. Methods: We include data from 7 health systems with differing geographic, patient demographic, and organizational characteristics; all used a common Virtual Data Warehouse containing electronic health records and insurance claims data. Multilevel logistic regression models examined AOD-IET among adults (18+). Results: A total of 86,565 patients had an AOD diagnosis qualifying for the HEDIS denominator. The overall initiation rate was 27.9% with wide variation; the overall engagement rate was 11.5% and varied from 4.5% to 17.9%. Women versus men (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.76-0.86); Hispanics (OR = 0.85, 95% CI = 0.79-0.91), black/African Americans (OR = 0.82, 95% CI = 0.75-0.90), and Asian Americans (OR = 0.83, 95% CI = 0.72-0.95) versus whites; and patients aged 65+ versus 18-29 (OR = 0.82, 95% CI = 0.74-0.90) had lower odds of initiation. Patients aged 30-49 versus 18-29 (OR = 1.11, 95% CI = 1.04-1.19) and those with prior psychiatric (OR = 1.26, 95% CI = 1.18-1.35) and medical (OR = 1.18, 95% CI = 1.10-1.26) conditions had higher odds of initiation. Identification in primary care versus other departments was related to lower odds of initiation (emergency department [ED]: OR = 1.55, 95% CI = 1.45-1.66; psychiatry/AOD treatment: OR = 3.58, 95% CI = 3.33-3.84; other outpatient: OR = 1.19, 95% CI = 1.06-1.32). Patients aged 30-49 versus 18-29 had higher odds of engagement (OR = 1.26, 95% CI = 1.10-1.43). Patients aged 65+ versus 18-29 (OR = 0.51, 95% CI = 0.43-0.62) and black/African Americans versus whites (OR = 0.64, 95% CI = 0.53-0.77) had lower odds. Those initiating treatment in psychiatry/AOD treatment versus primary care (OR = 7.02, 95% CI = 5.93-8.31) had higher odds of engagement; those in inpatient (OR = 0.40, 95% CI = 0.32-0.50) or other outpatient (OR = 0.73, 95% CI = 0.59-0.91) settings had lower odds. Discussion: Rates of initiation and engagement varied but were low. Findings identified age, race/ethnicity, co-occurring conditions, and department of identification as key factors associated with AOD-IET. Focusing on these could help programs develop interventions that facilitate AOD-IET for those less likely to receive care.

This study examined the empirical structure (i.e., size, density, duration) of transgender women's social networks and estimated how network alters' perceived HIV risk/protective behaviors influenced transgender women's own HIV risk/protective behaviors. From July 2015 to September 2016, 271 transgender women completed surveys on sociodemographic characteristics, HIV risk/protective behaviors, and social networks. Hierarchical generalized linear models examined the associations of social network alter member data 'nested' within participant data. Analyses revealed that social network factors were associated with HIV risk/protective behaviors, and that the gender identity of the alters (cisgender vs. transgender), and social network sites and technology use patterns ("SNS/tech") moderated these associations. Among network alters with whom the participant communicated via SNS/tech, participants' HIV risk behavior was positively associated with alters' HIV risk behavior (cisgender alters aOR 4.10; transgender alters aOR 5.87). Among cisgender alters (but not transgender alters) with whom the participant communicated via SNS/tech, participants' HIV protective behavior was positively associated with alters' HIV protective behavior (aOR 8.94).

Safe and stable housing is integral to addiction recovery. Across numerous studies, recovery housing has been found to be associated with improvements in a variety of domains. Although procedures for operating some types of recovery housing have been manualized and national standards established, there are few empirical findings identifying which recovery residence characteristics may lead to improved outcomes. Using data from 330 newly admitted residents recruited from 49 sober living houses in California and re-contacted for 6- and 12-month follow-up interviews, this study examines the effects of organizational, operational, and programming characteristics on substance use, criminal justice, and employment outcomes. Results from multilevel analyses adjusting for resident demographics and length of stay indicate that organizational characteristics were associated with outcomes. Residents recruited from houses that were part of a larger organization or group of houses had increased odds of total abstinence (aOR = 3.98, p