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Food insecurity (FI) has been identified as a determinant of child development, yet evidence quantifying this association using the newly developed Early Childhood Development Index 2030 (ECDI2030) remains limited. Herein, we provide national estimates of early childhood development (ECD) risks using the ECDI2030 and examined to what extent FI was associated with ECD among children aged 24-59 months in Nigeria. This population based cross-sectional analyses used data from the UNICEF-supported 2021 Multiple Indicator Cluster Survey in Nigeria. The analytic sample comprised children aged 24-59 months (weighted N = 12,112). We measured early childhood development for each child using the ECDI2030, measured across three domains: learning, psychosocial well-being and health. Food insecurity was assessed using the Food Insecurity Experience Scale (FIES), categorized as none/mild, moderate and severe. We fitted mixed-effects multilevel logistic regression models, with random intercepts, to estimate the odds of association between FI status and ECD. A total of 11,494 children aged 24-59 months (mean ± SD age, 43.4 ± 9.9 months), including 5,797 boys (50.2%) and 5,697 girls (49.8%), were included in the study. Approximately 46.4% of children were developmentally off track and about 76% of children lived in food-insecure households. The intercept-only model indicated significant variation in ECD prevalence across communities (τ00 = 0.94, intraclass correlation = 0.22, p < 0.0001), suggesting nonignorable variability in ECD across communities. Adjusting for confounders, we observed no significant association between FI and ECD. However, increasing child's age and disability status appeared as significant risk factors for higher odds of children being developmentally off track. These findings highlight that while FI alone may not explain ECD, a combination of individual and contextual factors plays a crucial role. Future interventions addressing ECD in Nigeria should consider these multidimensional influences to promote optimal child development.

PURPOSEAlthough financial hardship in childhood cancer contributes to poor outcomes, no standardized tool to assess its impact exists. Existing methods are heterogeneous and designed using high-income country (HIC), adult perspectives. This project aimed to construct a stakeholder-informed conceptual framework of financial hardship in childhood cancer with global relevancy.METHODSGroup concept mapping, a participatory mixed-methods approach, was used. Participants were parents or caregivers of a child with cancer, childhood cancer survivors, and clinical or nonclinical support personnel, fluent in English, Spanish, or Portuguese. A representative panel established a comprehensive list of relevant items. Participants individually sorted these items into concepts and then rated each item for impact using a four-point Likert scale. Multidimensional scaling and hierarchical cluster analysis identified concepts. Descriptive statistics were calculated for impact ratings.RESULTSOne fourth (21/80) of participants were parents/caregivers or childhood cancer survivors. Participants worked in clinical (44/80), charity/volunteer (27/80), and other nonclinical (13/80) roles. Of the 41 represented countries, 78.0% (32) were low- and middle-income countries (LMICs). Conceptual themes spanned six distinct clusters: medical, nonmedical, assistance and support, treatment impact, family impact, and caregiver impact. These were distinct in composition compared with an existing framework for adult oncology. Caregiver impact (mean, 3.39) and treatment impact (mean, 3.29) were the highest rated clusters, and impact ratings were higher in LMICs compared with HICs.CONCLUSIONWe developed a framework for financial hardship in childhood cancer that reflects the voices of stakeholders, including parents and caregivers, from diverse global contexts. The findings lay a foundation for the development and validation of tools to systematically assess financial hardship in families of children with cancer and inform effective policies and interventions.

Abstract Background Prior studies have reported conflicting results regarding the association of prenatal maternal depression with offspring cortisol levels. We examined associations of high levels of prenatal depressive symptoms with child cortisol biomarkers. Methods In Project Viva (n = 925, Massachusetts USA), mothers reported their depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy, cord blood glucocorticoids were measured at delivery, and child hair cortisol levels were measured in mid-childhood (mean (SD) age: 7.8 (0.8) years) and early adolescence (mean (SD) age: 13.2 (0.9) years). In the Generation R Study (n = 1644, Rotterdam, The Netherlands), mothers reported depressive symptoms using the Brief Symptom Inventory (BSI) during pregnancy, and child hair cortisol was measured at a mean (SD) age of 6.0 (0.5) years. We used cutoffs of ≥ 13 for the EPDS and > 0.75 for the BSI to indicate high levels of prenatal depressive symptoms. We used multivariable linear regression models adjusted for child sex and age (at outcome), and maternal pre-pregnancy BMI, education, social support from friends/family, pregnancy smoking status, marital status, and household income to assess associations separately in each cohort. We also meta-analyzed childhood hair cortisol results from both cohorts. Results 8.0% and 5.1% of women respectively experienced high levels of prenatal depressive symptoms in Project Viva and the Generation R Study. We found no associations between high levels of maternal depressive symptoms during pregnancy and child cortisol biomarkers in either cohort. Conclusions The present study does not find support for the direct link between high levels of maternal depressive symptoms and offspring cortisol levels.

This study examined discourses related to an Indonesian soccer stadium stampede on 1st October 2022 using comments posted on Twitter. We conducted a lexicon-based sentiment analysis to identify the sentiments and emotions expressed in tweets and performed structural topic modeling to identify latent themes in the discourse. The majority of tweets (87.8%) expressed negative sentiments, while 8.2% and 4.0% of tweets expressed positive and neutral sentiments, respectively. The most common emotion expressed was fear (29.3%), followed by sadness and anger. Of the 19 themes identified, “Deaths and mortality” was the most prominent (15.1%), followed by “family impact”. The negative stampede discourse was related to public concerns such as “vigil” and “calls for bans and suspension,” while positive discourse focused more on the impact of the stampede. Public health institutions can leverage the volume and rapidity of social media to improve disaster prevention strategies.

In this study, we examined the patterns of subjective well-being (SWB) measures among pregnant women and quantified the extent to which pregnancy intendedness is associated with low SWB measures during pregnancy. We analyzed data from the 2021 Nigeria Multiple Indicator Cluster Survey comprising 3,491 pregnant women. The associations between pregnancy intention and low SWB measures (unhappiness, low life satisfaction [LS] and diminished optimism) were determined by fitting series of multilevel logistic regression models with random intercepts. Among pregnant women in our sample 20%, 37.5% and 9.6%, reported being unhappy, experiencing low LS and having diminished optimism, respectively. However, we found no significant association between pregnancy intention and being unhappy (mistimed: adjusted odds ratio [aOR] = 1.19, 95% CI = 0.88–1.60; unwanted: aOR = 1.16, 95% CI = 0.71–1.91), experiencing low LS (mistimed: aOR = 1.07, 95% CI = 0.83–1.37; unwanted: aOR = 1.06, 95% CI = 0.69–1.65) and having diminished optimism (mistimed: aOR = 1.22, 95% CI = 0.82–1.82; unwanted: aOR = 1.07, 95% CI = 0.56–2.04). Findings from the study suggest that pregnant women in Nigeria who reported having either a mistimed or unwanted pregnancy were just as likely to report being unhappy, experience low LS and have diminished optimism as women whose pregnancy was intended.

This study examined the association between caregivers’ self-rated general health, poor physical/mental health days, disease morbidity and asthma control in children from the United States with current asthma. The data analyzed for this study were obtained from 7522 children aged 0–17 years who participated in the 2012–2014, 2015–2017, 2018, and 2019 cycles of the Behavioral Risk Factor Surveillance System Asthma Call-back Survey (ACBS). We employed univariate analysis to describe the study population and weighted binary logistic regression to examine the association of predictors with asthma control. Approximately 50% of the children had uncontrolled asthma. The results show that caregivers who reported fair general health had a 61% higher likelihood of reporting uncontrolled asthma in their children compared to those who reported good/very good/excellent health (adjusted odds ratio [aOR] = 1.61; 95% confidence interval [CI], 1.14–2.26). Poor caregiver general health did not reach statistical significance in predicting uncontrolled asthma (aOR = 1.05, 95% CI, 0.62–1.75). Furthermore, having 1 to 14 poor physical/mental health days ([aOR] = 1.70; 95% CI, 1.28–2.227) and ≥15 poor physical/mental health days (aOR = 1.82, 95% CI, 1.31–2.53) was predictive of uncontrolled asthma in children. Additionally, endorsing one reported disease (aOR = 1.49, 95% CI, 1.15–1.93) and ≥2 diseases (aOR = 1.38, 95% CI, 1.08–1.78) was associated with uncontrolled child asthma. These findings underscore the association between caregivers’ self-reported general health, poor mental/physical health days, disease morbidity and uncontrolled asthma among children from the U.S. with asthma. Pediatricians and child health practitioners should recall the importance of this relationship. To facilitate the identification of caregivers at risk and provide more comprehensive and effective care for children with asthma, healthcare practitioners should utilize every child asthma care encounter to inquire about the overall health of caregivers.

Complementary and Alternative Medicines/Therapies (CAM) are commonly used by US asthma adults, yet little is known about recent trends in their use. Our aim was to report trends in CAM use among US adults with current asthma. We conducted a serial cross-sectional study using nationally representative data from the BRFSS Asthma Call-Back Survey (ACBS) collected between 2008 and 2019 (sample size per cycle, 8222 to 14,227). The exposure was calendar time, as represented by ACBS cycle, while the main outcomes were use of at least one CAM and eleven alternative therapies. We analyzed CAM use overall and by population subgroups based on age, gender, race/ethnicity, income, and daytime and night-time asthma symptoms. Our findings show that there was an increase in the use of at least one CAM from 41.3% in 2008 to 47.9% in 2019 (p-trend < 0.001) and an upward trend in the use of herbs, aromatherapy, yoga, breathing exercises, homeopathy, and naturopathy (p-trend < 0.05). However, the use of vitamins, acupuncture, acupressure, reflexology, and other CAM therapies remained stable (p-trend > 0.05). These trends varied according to population characteristics (age, sex, race, income) and asthma symptoms. In conclusion, our study suggests that CAM use among US adults with current asthma is either increasing or stable, and further studies are needed to explore the factors influencing these trends.

BackgroundThe decision of the US Supreme Court to repeal Roe vs. Wade sparked significant media attention. Although primarily related to abortion, opinions are divided about how this decision would impact disparities, especially for Black, Indigenous, and people of color. We used advanced natural language processing (NLP) techniques to examine ethno-racial contents in Twitter discourses related to the overturn of Roe vs. Wade.MethodsWe screened approximately 3 million tweets posted to Roe vs. Wade discussions and identified unique tweets in English-language that had mentions related to race, ethnicity, and racism posted between June 24 and July 10, 2022. We performed lexicon-based sentiment analysis to identify sentiment polarity and the emotions expressed in the Twitter discourse and conducted structural topic modeling to identify and examine latent themes.ResultsOf the tweets retrieved, 0.7% (n = 23,044) had mentions related to race, ethnicity, and racism. The overall sentiment polarity was negative (mean = −0.41, SD = 1.48). Approximately 60.0% (n = 12,092) expressed negative sentiments, while 39.0% (n = 81,45) expressed positive sentiments, and 3.0% (n = 619) expressed neutral sentiments. There were 20 latent themes which emerged from the topic model. The predominant topics in the discourses were related to “racial resentment” (topic 2, 11.3%), “human rights” (topic 2, 7.9%), and “socioeconomic disadvantage” (topic 16, 7.4%).ConclusionsOur study demonstrates wide ranging ethno-racial concerns following the reversal of Roe and supports the need for active surveillance of racial and ethnic disparities in abortion access in the post-Roe era.

Abstract Background In 2019, 1 in every 10 infants born in the United States was preterm. Prematurity has life-threatening consequences and causes a range of developmental disabilities, of which learning disability is a prevalent complication. Despite the availability of special services for children living with learning disability, gaps still exist in terms of access due to socioeconomic factors. The aim of this study is to evaluate socioeconomic and sociodemographic correlates of learning disability in preterm children. Methods This cross-sectional study used data from the 2016–2018 National Survey of Children’s Health. Weighted multivariable analyses were conducted to ascertain the association of sociodemographic and socioeconomic factors on learning disability among preterm children. The main outcome variable was the presence of learning disability. Results Among 9555 preterm children in our study population, 1167 (12%) had learning disability. Learning disability was significantly associated with health insurance, food situation, and poverty level after adjustment for other variables. Children currently insured had lower odds of having learning disability compared to those without health insurance (OR = 0.79, 95% C.I. = 0.70–0.91). Also, children living in households that cannot afford nutritious meals are more likely to have learning disability compared to those that can afford nutritious meals at home (OR = 1.55, 95% C.I. = 1.22–1.97). Conclusion These findings highlight the need for intervention efforts to target these children living with a learning disability to achieve the 2004 Individuals with Disabilities Education Act of promoting educational equality and empowerment of children living with a learning disability.

Food insecurity (FI) remains a key priority for sustainable development. Despite the well-known consequences of food insecurity on health and well-being, evidence regarding the burden and determinants of FI among pregnant women in Nigeria is limited. Framed by the social-ecological model, this study aimed to determine the prevalence of FI, and its associations with individual-/household-level and contextual-level factors among pregnant women in Nigeria. A cross-sectional study based on the Nigerian Multiple Indicator Cluster Survey (2021 Nigerian MICS6) was conducted among a sample of 3519 pregnant women aged 15-49 years. Several weighted multilevel multinomial logistic regression models were fitted to assess the association between individual-/household-s level and community-level characteristics with FI. We estimated and reported both fixed effects and random effects to measure the associations and variations, respectively. Results: The prevalence of FI among pregnant women in Nigeria was high, with nearly 75% of the participants reporting moderate to severe FI in the past 12 months (95% CI = 71.3%-75.8%) in 2021. There were also significant differences in all the experiences of food insecurity due to lack of money or resources, as measured by the Food Insecurity Experience Scale (FIES), except for feeling hungry but not eating because of lack of money or resources (p < 0.0001). Multivariate analysis revealed that higher parity, households with 5 or more members, household wealth index, urban residence, and community-level poverty were significantly associated with FI. Our study demonstrates a significantly high prevalence of FI among pregnant women in Nigeria in 2021. Given the negative consequences of FI on maternal and child health, implementing interventions to address FI during pregnancy remains critical to improving pregnancy outcomes.

Purpose: Mitochondrial trifunctional protein deficiency (TFPD) and isolated long chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) are two related defects of fatty acid β -oxidation. While NBS has decreased mortality, morbidity remains significant. Additionally, the relationship of genotype to clinical outcome remains unclear. To better understand these issues, we collected natural history data for these conditions by reviewing seven years of retrospective data from 45 cases of TFPD or LCHADD in the Inborn Errors of Metabolism – Information System. Methods: Available data included age at database entry, last datapoint, and development of various complications. Data were analyzed by clinical assigned diagnosis (LCHADD or TFPD), subdivided by method of ascertainment (newborn screening-NBS, or other than by newborn screening-NNBS), then re-analyzed based on four genotype groups: homozygous c.1528GC (p.E510Q) (common LCHAD variant); heterozygous c.1528GC (p.E510Q), other HADHA variants; and HADHB variants. Results: Forty-five patients from birth to 34 years of age were analyzed by assigned diagnosis (30 LCHADD and 15 TFPD) and method of ascertainment. Thirty had further analysis by genotype (22 biallelic HADHA variants and 8 biallelic HADHB variants). With regards to maternal complications, retinopathy, cardiomyopathy and hypoglycemia, patients with biallelic HADHA variants (with or without the common LCHAD variant) manifest a traditional LCHADD phenotype, while those with HADHB gene variants more commonly reported neuromusculoskeletal type TFPD phenotype. While retinopathy, rhabdomyolysis and peripheral neuropathy tended to present later in childhood, many features including initial report of cardiomyopathy and hypoglycemia presented across a wide age spectrum. Conclusion: This study demonstrates the utility of genotypic confirmation of patients identified with LCHADD/TFPD as variants in the HADHA and HADHB genes lead to different symptom profiles. In our data, biallelic HAHDA variants conferred a LCHADD phenotype, regardless of the presence of the common LCHAD variant.

While the impacts of community gardens have been well documented, research has mainly been concentrated in only a few urban areas of the United States. This paper highlights the social impacts of community gardens on west central Florida individuals, families, and communities. We use theories of community engagement to explore relationships between members and their larger spheres of influence. In this study, we surveyed 75 members of eight community gardens in Tampa Bay and used geographic information systems (GIS) mapping to show spatial distribution of gardens and members. Findings highlight multilevel impacts of community engagement in social, educational, and altruistic domains. Community gardens promote community engagement among members. The impacts of community gardens extend beyond the membership structure.

Background Studies in low- and middle-income regions suggest that child marriage (Methods and findings Birth registrations with US resident mothers aged ≤24 years with complete information on marital status were drawn from the 2014 to 2019 Natality Public Use Files (n = 5,669,824). Odds ratios for the interaction between marital status and maternal age group were estimated using multivariable logistic regression, adjusting for covariates such as maternal race/ethnicity and nativity status, federal program participation, and paternal age. Marriage prevalence was 3.6%, 13.2%, and 34.1% among births to mothers aged Conclusions Marriage among mothers below age 18 is associated with both adverse and favorable reproductive, maternal, and infant health indicators. Heterogeneity exists in the relationship between marriage and reproductive health across adolescent maternal age groups, suggesting girl child marriages must be examined separately from marriages at older ages. In a population-based study, Andrée-Anne Fafard St-Germain and colleagues examine the joint associations of marriage and adolescent maternal age group (Why was this study done? Research in low- and middle-income countries indicates that child marriage, namely marriage before age 18 years, has negative implications for the reproductive health and well-being of women compared to marriage at an older age. In high-income countries where childbearing increasingly occurs outside marriage, it is unclear how marriage among mothers below age 18 relates to different indicators of reproductive health. Studies in high-income countries show that marriage is associated with positive reproductive health outcomes, but it is unknown whether these beneficial associations apply to mothers below age 18. What did the researchers do and find? We analyzed cross-sectional information from more than 5.5 million birth registrations with mothers aged ≤24 years in the United States from 2014 to 2019 to examine how marriage and maternal age jointly relate to reproductive health. Marriage was associated with increased odds of prior pregnancy termination, repeat childbearing, maternal smoking, and infant morbidity among births to mothers below age 18, but the association of marriage with these indicators was weaker or reversed among births to older mothers. Protective associations with marriage were observed for preterm birth, small-for-gestational-age birth, sexually transmitted infection, prenatal care initiation, and breastfeeding among births to mothers aged 20–24 years, but for births to mothers aged What do these findings mean? Our study indicates that the health advantage of marriage observed among mothers aged 20–24 years in the United States may not consistently apply to younger mothers. It suggests that the association between marriage below age 18 and reproductive health indicators is context- and outcome-dependent. Although this study cannot establish causation, it suggests the need for further research on the driving forces and the health and social consequences of marriage before age 18 in the US and other high-income countries, and that such research may benefit from longitudinal study designs.

Abstract Background U.S. mortality rate of term infants is higher than most other developed countries. Term infant mortality is associated with exogenous socio-environmental factors. Previous research links low socioeconomic status and rurality with high infant mortality, but does not examine the effect of individual level factors on this association. Separating out the effect of contextual factors from individual level factors has important implications for targeting interventions. Therefore, we aim to estimate the independent effect of poverty and urban-rural classification on term infant mortality. Methods We used linked 2013 period cohort birth-infant death files from the National Center for Health Statistics (NCHS). Counties were assigned to low, medium and high poverty groups using US Census Bureau county-level percent of children ≤18 years living in poverty, and were classified based on NCHS urban-rural classification. Bivariate and multilevel logistic regression models were used to estimate odds of term infant death, accounting for individual and county level variables. Results There were 2,551,828 term births in 2013, with an overall term mortality of 2.1 per 1000 births. Odds of term infant mortality increased from 1.4 (95% CI: 1.2, 1.6) to 1.8 (95% CI: 1.6, 2.0) comparing births over increasing county poverty to those in the lowest. The associations remained significant in the multivariable model, for highest poverty 1.3 (95% CI: 1.1, 1.5). Similarly, the odds of term infant mortality increased with increasing rurality, from 1.3 (95% CI: 1.2, 1.5) in medium metro counties to 1.7 (95% CI: 1.5, 2.0) in non-core counties compared to large fringe metro counties. However, only rural non-core counties remained statistically associated with increased risk of term infant mortality after adjusting for individual level maternal characteristics. Conclusions High poverty and very rural counties remained associated with term infant mortality independent of individual maternal sociodemographic, health and obstetric factors. Interventions should focus on contextual factors such as economic environment and availability of health and social services in addition to individual factors to reduce term infant mortality.

Background: Influenza vaccine rates in pregnant women remain suboptimal despite the recommendations from healthcare organizations. Though pharmacists can provide immunization services as a result of the standing order, few studies have examined the role of the pharmacist in providing immunization to pregnant women or explored their perspective on their role in providing influenza vaccines among pregnant women. Purpose: This study explored the perceptions and knowledge of Florida pharmacists in administering inactivated influenza vaccines (IIV) to pregnant women. Methods: Semi-structured in-depth interviews guided by the theory of planned behavior were conducted with 18 licensed Florida pharmacists, including clinical and retail pharmacists. A thematic analysis was conducted. Results: The majority of pharmacists (94%) were knowledgeable about the IIV in pregnant women. Participants expressed mixed attitudes, identified barriers and facilitators, and subjective norms influencing vaccine administration in pregnant women. Participants expressed the importance of trust and how that influenced vaccine uptake. Participants also expressed their position not to only provide immunization services but also to counsel and educate patients. Conclusion: There is a need to strengthen immunization services, provided by pharmacists to more individuals, including high-risk groups such as pregnant women.

Background: There is a high risk for morbidity and mortality in pregnant women associated with influenza virus illness. Vaccine uptake rates in pregnant women remain lower than the targeted Healthy People 2020 goals despite recommendations from the Centers for Disease Control (CDC). Few studies have examined the role of the pharmacist in providing immunization services to pregnant women, fewer still have directly examined the PharmD curricula and the perspectives of pharmacy students on how they perceive their role in providing influenza inactivated vaccine (IIV) to pregnant women. Objective: This study examined the PharmD curricula instruction with regard to immunizing pregnant women and how pharmacy students perceive it. Methods: Semi-structured, in-depth, in-person qualitative interviews were conducted with the six Academic Deans of the accredited schools of pharmacy in Florida, and three focus group sessions were held with third- and fourth-year pharmacy students (n = 18) in Florida. A thematic analysis was conducted. Results: Most academic deans reported providing instruction on immunization in schools with respect to vaccine administration in pregnant women and called for a need for all schools to make it compulsory to include pregnant-women-specific content. Pharmacy students reported a gap in knowledge of content related to administering the IIV in pregnant women, but feel that when presented with the opportunity, they will be willing to provide IIV to pregnant women. Conclusions: Pharmacists are in a good position to play a role in increasing IIV rates among pregnant women. Implications for practice include the need for incorporation of pregnancy-specific content to immunization curricula.

Information is increasingly digital, creating opportunities to respond to pressing issues about human populations in near real time using linked datasets that are large, complex, and diverse. The potential social and individual benefits that can come from data-intensive science are large, but raise challenges of balancing individual privacy and the public good, building appropriate socio-technical systems to support data-intensive science, and determining whether defining a new field of inquiry might help move those collective interests and activities forward. A combination of expert engagement, literature review, and iterative conversations led to our conclusion that defining the field of Population Data Science (challenge 3) will help address the other two challenges as well. We define Population Data Science succinctly as the science of data about people and note that it is related to but distinct from the fields of data science and informatics. A broader definition names four characteristics of: data use for positive impact on citizens and society; bringing together and analyzing data from multiple sources; finding population-level insights; and developing safe, privacy-sensitive and ethical infrastructure to support research. One implication of these characteristics is that few people possess all of the requisite knowledge and skills of Population Data Science, so this is by nature a multi-disciplinary field. Other implications include the need to advance various aspects of science, such as data linkage technology, various forms of analytics, and methods of public engagement. These implications are the beginnings of a research agenda for Population Data Science, which if approached as a collective field, can catalyze significant advances in our understanding of trends in society, health, and human behavior.

Low birth weight (LBW) is an important public health issue in the US as well as worldwide. The two main causes of LBW are premature birth and fetal growth restriction. Socio-economic status, as measured by family income has been correlated with LBW incidence at both the individual and population levels. In this paper, we investigate the impact of household income on LBW incidence at di erent geographical levels. To show this, we choose to examine LBW incidences collected from the state of Georgia, in the US, at both the county and public health (PH) district. The data at the PH district are an aggregation of the data at the county level nested within the PH district. A spatial scaling effect is induced during data aggregation from the county to the PH level. To address the scaling effect issue, we applied a shared multiscale model that jointly models the data at two levels via a shared correlated random effect. To assess the bene t of using the shared multiscale model, we compare it with an independent multiscale model which ignores the scale effect. Applying the shared multiscale model for the Georgia LBW incidence, we have found that income has a negative impact at both the county and PH levels. On the other hand, the independent multiscale model shows that income has a negative impact only at the county level. Hence, if the scale effect is not properly accommodated in the model, a different interpretation of the ndings could result.