Dichotomous Indicators Research Articles

Qualitative-quantitative indicators to regenerate public spaces through Nature-based Solutions

The relationship between public works and communities highlights the inherently multidimensional theme of project and evaluation linked to indicators outlined in investment plans and territorial planning. Within this context, the climate crisis necessitates intervention in the city, where public space serves as an intermediate and proximity item, dynamically recalibrating urban interactions among people, nature, and technology. The objective of this paper is to investigate public space, identifying legislative criteria in terms of sustainability and the technological-environmental solutions present in the major environmental certification protocols currently available worldwide, as well as their application in national and international case studies. This analysis allows to define an original framework of dichotomous qualitative-quantitative indicators, simultaneously examining the limitations and future developments of the research. This contribution forms part of the research outcomes undertaken, both completed and ongoing, within the framework of the 2017 PRIN Research “Tech-Start” and the research line Mission 4 – Comp. 2 funded by the NRRP.

Tenant Right-to-Counsel and Adverse Birth Outcomes in New York, New York

In 2017, New York, New York, launched the United States' first right-to-counsel program, guaranteeing lawyers to low-income tenants in select zip codes, which was associated with reducing eviction risk by half. Given documented associations between evictions during pregnancy and adverse birth outcomes, the right-to-counsel program may be associated with improved birth outcomes. To measure associations between zip code-level right-to-counsel access and risk of adverse birth outcomes, including preterm birth and low birth weight, among infants born to Medicaid-insured birthing parents. This retrospective cohort study leveraged the staggered rollout of New York's right-to-counsel program from January 2016 to February 2020 as a natural experiment using a population-based sample of live births to Medicaid-insured birthing parents residing in New York, New York. Data were analyzed from February 2022 to September 2024. Zip code right-to-counsel status 9 months prior to birth. Adverse birth outcomes were measured using individual birth records from the New York Bureau of Vital Statistics. Outcomes included dichotomous indicators of low birth weight (<2500 g), preterm birth (<37 weeks' gestation), and a composite of both. Difference-in-differences linear probability models controlled for year, month, and zip code and included clustered standard errors. Among 260 493 live births (mean [SD] birthing parent age, 29 [6] years) from January 2016 to February 2020, 43 081 births (17%) were to birthing parents residing in zip codes where right-to-counsel was available during pregnancy. Exposure to right-to-counsel during pregnancy was associated with statistically significant reductions in infants' probability of adverse birth outcomes, with reductions of 0.73 (95% CI, 0.06-1.41) percentage points in low birth weight, 0.91 (95% CI, 0.10-1.71) percentage points in preterm birth, and 0.96 (95% CI, 0.09-1.84) percentage points in the composite outcome in treated vs untreated zip codes. This cohort study found that right-to-counsel was associated with reduced risk of adverse birth outcomes among Medicaid-insured birthing parents. These findings suggest that eviction prevention via right-to-counsel may have benefits that extend beyond the courtroom and across the life-course.

01 Vaping, mental and physical health in adolescents in a COMPASS-Quebec cohort

Abstract Background Better knowledge of the association between vaping and youth’s health would help raise awareness among adolescents, parents, professionals and decision-makers on the likely threat it represents. Objectives Our objective is to examine the association between vaping, its frequency, and adolescent health. Design/Methods This observational study is based on data from the 2022-23 survey round of COMPASS-Quebec school cohorts through self-reported measures. It includes 45,203 respondents aged from 12 to 18 years old from 99 schools of Eastern Quebec. A four-modality variable depicts the vaping frequency in the last twelve months (abstinence, &amp;lt; once/month, ≥ once/month, ≥ once/week, daily). The measurement of health states is based on 5 dichotomous indicators: (i) good vs poor physical health (excellent, very good, good, vs fair, poor), (ii) maximum oxygen consumption considered at risk for health vs not (estimated VO2max, calculated using Léger’s equation); (iii) good vs poor mental health (excellent, very good, good, vs fair, poor); (iv) the presence vs absence of moderate to severe anxiety (GAD7, score ≥10/30) and; (v) the presence vs absence of significant depressive symptoms (CESD-R, score ≥10/21). Sex, age and family material deprivation level are taken into account as confounding factors. Results The proportion of adolescents who have vaped in the last 12 months is 26.8%. After adjustment, daily vaping is associated with poor physical health, a VO2max considered at risk for health, poor mental health, moderate to severe anxiety and significant depressive symptoms, compared to abstinence (adjusted relative risk [aRR] 2,46 [95%CI: 2,05-2,88]; 1,66 [95%CI: 1,44-1,89]; 1,88 [95%CI: 1,66-2,11]; 1,75 [95%CI: 1,53-1,97]; 1,55 [95%CI: 1,40-1,70]). A gradient in the associations between vaping frequency and lower mental health indicators has been observed. Adolescents who have vaped &amp;lt;once/month, ≥once/month, ≥once/week and daily have more risk of presenting moderate to severe anxiety (aRR 1,21 [95%CI: 1,09-1,33]; 1,44 [95%CI: 1,27-1,61]; 1,54 [95%CI: 1,37-1,72]; 1,75 [95%CI: 1,53-1,97]). Regarding significant depressive symptoms, aRR are 1,23 [95%CI: 1,14-1,32], 1,39 [95%CI: 1,27-1,51], 1,49 [95%CI: 1,36-1,62], 1,55 [95%CI: 1,40-1,70]. Regarding poor mental health, aRR are 1,29 [95%CI: 1,17-1,42], 1,61 [95%CI : 1,43-1,79], 1,63 [95%CI : 1,45-1,81], 1,88 [95%CI: 1,66-2,11]. Conclusion This study suggests a consistent association between health, both physical and mental, and use of electronic cigarettes in adolescents. Longitudinal studies would help clarify possible causal influence of vaping on youth's health.

Postpartum Insurance Loss: Predicting Factors, Associations with Postpartum Health Service Utilization, and the Role of Medicaid Expansion.

This study investigated the predictors of postpartum insurance loss (PPIL), assessed its association with postpartum healthcare receipt, and explored the potential buffering role of Medicaid expansion. Data from the 2016-2020 Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed, covering 197,820 individuals with live births. PPIL was determined via self-reported insurance status before and after pregnancy. Postpartum visits and depression screening served as key health service receipt indicators. The association between PPIL and maternal characteristics was examined using bivariate analysis. The association of PPIL with health service receipt was assessed through odds ratios derived from multivariate logistic regression models. The role of Medicaid expansion was explored by interacting ACA Medicaid expansion status with the dichotomous PPIL indicator. PPIL was experienced by 7.8% of postpartum people, with higher rates in Medicaid non-expansion states (13.6%) compared to 6.1% in expansion states (p < 0.05). Racial and ethnic disparities were observed, with 16.5% of Hispanic and 4.6% of white people experiencing PPIL. Individuals who experienced PPIL had decreased odds of attending postpartum visits (adjusted odds ratio (aOR) = 0.81, 95% CI = 0.73-0.90) and receiving screening for postpartum depression (aOR = 0.86, 95% CI = 0.78-0.96) compared to those who maintained insurance coverage. People in expansion states with no PPIL had higher odds of postpartum depression screening (aOR = 1.33, 95% CI = 1.08-1.62). No differences in postpartum visits in expansion versus non-expansion were noted (aOR = 1.13, 95% CI = 0.93-1.36). Ensuring consistent postpartum insurance coverage offers policymakers a chance to enhance healthcare access and outcomes, particularly for vulnerable groups.

Comparison of the Measurement Properties of EQ-5D-5L and SF-6Dv2 in COVID-19 Patients in China.

There are limited studies comparing the health utility values of EQ-5D-5L and SF-6Dv2 within the same patient cohorts. The widespread transmission and recurring infections associated with Omicron variants amid the COVID-19 pandemic have resulted in substantial health detriments and increased utilisation of health care resources. This highlights the crucial need to assess the loss in quality-adjusted life years (QALYs). Therefore, this study aims to compare the ceiling and floor effects, agreement, correlation and responsiveness between EQ-5D-5L and SF-6Dv2 based on COVID-19 patients during the Omicron outbreak in China. We recruited 694 COVID-19 patients across mainland China to participant in an online questionnaire survey from January to February 2023. The questionnaire encompassed queries concerning the sociodemographic and health details of the participants, who were requested to recollect their health status during and after experiencing COVID-19 using the EQ-5D-5L and SF-6Dv2 questionnaires. Epanechnikov kernel density plots were used to visualise the ceiling and floor effects for both instruments. Agreement was assessed by Bland-Altman graph and intraclass correlation coefficient (ICC). Correlation was evaluated using linear regression, Pearson's correlation and Spearman's correlation. The standardised response mean (SRM) and relative efficiency (RE) were used to examine the responsiveness of EQ-5D-5L and SF-6Dv2 at detecting the health improvement after COVID-19 infection and the difference in dichotomous health indicators. In total, 648 valid responses from patients aged 35.6 ± 15.0 years were involved in analysis. The EQ-5D-5L utility indices were 0.58 ± 0.33 and 0.92 ± 0.14 during and after COVID-19 infection, respectively, which were significantly higher than indices of the SF-6Dv2 utility (0.43 ± 0.31 and 0.81 ± 0.19, p < 0.001). A ceiling effect of EQ-5D-5L larger than that of SF-6Dv2 was observed during COVID-19 infection (49.5% vs 21.6%). Intraclass correlation coefficients between EQ-5D-5L and SF-6Dv2 during and after COVID-19 infection were 0.69 and 0.55, respectively. The utility indices of EQ-5D-5L and SF-6Dv2 were highly correlated, with Pearson's correlation coefficients of 0.76 and 0.70 (p < 0.001) during and after COVID-19 infection, respectively. The spearman's correlations were moderate to high between dimensions of EQ-5D-5L and SF-6Dv2 (p < 0.01). Both EQ-5D-5L and SF-6Dv2 were responsive to detect health improvement after COVID-19 and the differences in dichotomous health indicators. The utility indices generated by EQ-5D-5L and SF-6Dv2 in COVID-19 patients demonstrate strong correlation and responsiveness. However, the agreement between these two instruments does not reach a satisfactory level. Consequently, these two measures cannot be used interchangeably. In situations where apprehensions about ceiling effects affecting outcome measurement arise, it is advisable to consider SF-6Dv2 as a preferable outcome measure for studies on patients with COVID-19.

Development of a Population-Level Dichotomous Indicator of Minimum Dietary Diversity as a Proxy for Micronutrient Adequacy in Adolescents Aged 10–19 Y in the United States

BackgroundDiversity is a key component of diet quality and health, but no indicator exists for adolescents under the age of 15 y. ObjectivesTo establish a dichotomous indicator for population-level assessment of adolescent dietary diversity as a proxy for micronutrient adequacy. MethodsWe used the probability approach to construct mean probability of adequacy (MPA) of 11 micronutrients from 2 d of 24-h dietary recall data from NHANES, 2007–2018. For each micronutrient, probability of adequacy (PA) was calculated using the best linear unbiased predictor of usual intake. Adolescent dietary diversity score (ADDS) was derived with a maximum score of 10 food groups. Generalized linear mixed models were used to examine associations between ADDS and MPA. Receiver operating characteristic analysis was used to establish a cutoff for minimum dietary diversity for adolescents (MDD-A) using an energy-adjusted logistic model with ADDS predicting MPA > 0.6. ResultsPA was >80% for all nutrients except vitamin C (42.1%), folate (65.7%), and calcium (23.8%). Population MPA was 79.4%, and nearly 92% of adolescents had an MPA > 0.6. ADDS was positively associated with MPA, and energy was a significant confounder. The area under the curve was >0.8 on both days with sensitivity and specificity ranging from 0.71 to 0.80. The MDD-A cutoff was calculated as 5.12 and 5.10 food groups on days 1 and 2, respectively. ConclusionsIn U.S. adolescents, the best cutoff for a dichotomous indicator of dietary diversity as a proxy for micronutrient adequacy is 6 food groups in a given day. Future research could validate MDD-A and its associated cutoff for use across country contexts.

Polytomous Effectiveness Indicators in Complex Problem-Solving Tasks and Their Applications in Developing Measurement Model.

Recent years have witnessed the emergence of measurement models for analyzing action sequences in computer-based problem-solving interactive tasks. The cutting-edge psychometrics process models require pre-specification of the effectiveness of state transitions often simplifying them into dichotomous indicators. However, the dichotomous effectiveness becomes impractical when dealing with complex tasks that involve multiple optimal paths and numerous state transitions. Building on the concept of problem-solving, we introduce polytomous indicators to assess the effectiveness of problem states and state-to-state transitions . The three-step evaluation method for these two types of indicators is proposed and illustrated across two real problem-solving tasks. We further present a novel psychometrics process model, the sequential response model with polytomous effectiveness indicators (SRM-PEI), which is tailored to encompass a broader range of problem-solving tasks. Monte Carlo simulations indicated that SRM-PEI performed well in the estimation of latent ability and transition tendency parameters across different conditions. Empirical studies conducted on two real tasks supported the better fit of SRM-PEI over previous models such as SRM and SRMM, providing rational and interpretable estimates of latent abilities and transition tendencies through effectiveness indicators. The paper concludes by outlining potential avenues for the further application and enhancement of polytomous effectiveness indicators and SRM-PEI.

Testing Criterion Validity in Hierarchical Models of Psychopathology: Comparison of Latent-Variable and Factor-Score Approaches

The Hierarchical Taxonomy of Psychopathology is a quantitative diagnostic system that is gaining traction as a framework for studying the correlates of mental-health problems. However, it remains unknown how best to operationalize hierarchically related psychopathology dimensions during criterion validity tests. In a series of simulations, we evaluated the performance of latent-variable (i.e., structural equation modeling [SEM]) and factor-score representations of hierarchical psychopathology constructs in criterion validity analyses. In models based on continuously distributed psychopathology indicators (e.g., symptom composites), SEM and factor-score methods both tended to yield unbiased estimates of criterion validity coefficients. In contrast, for models based on dichotomous indicators (e.g., categorical diagnoses), SEM led to more accurate estimates than factor scores in most cases. We offer recommendations for psychopathology researchers based on these results and provide an R function ( https://osf.io/u3j5d/ ) that investigators can use to apply the approaches studied here in real-world data sets.

Defining a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity Among Pregnant Adolescent Girls and Women: A Secondary Analysis of Quantitative 24-h Recalls from Rural Settings in Bangladesh, Burkina Faso, India, and Nepal

BackgroundThe Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) indicator was validated as a proxy of micronutrient adequacy among nonpregnant women in low- and middle-income countries (LMICs). At that time, indeed, there was insufficient data to validate the indicator among pregnant women, who face higher micronutrient requirements. ObjectiveThis study aimed to validate a minimum food group consumption threshold, out of the 10 food groups used to construct MDD-W, to be used as a population-level indicator of higher micronutrient adequacy among pregnant women aged 15–49 y in LMICs. MethodsWe used secondary quantitative 24-h recall data from 6 surveys in 4 LMICs (Bangladesh, Burkina Faso, India, and Nepal, total n = 4909). We computed the 10-food group Women's Dietary Diversity Score (WDDS-10) and calculated the mean probability of adequacy (MPA) of 11 micronutrients. Linear regression models were fitted to assess the associations between WDDS-10 and MPA. Sensitivity, specificity, and proportion of individuals correctly classified were used to assess the performance of MDD-W in predicting an MPA of >0.60. ResultsIn the pooled sample, median values (interquartile range) of WDDS-10 and MPA were 3 (1) and 0.20 (0.34), respectively, whereas the proportion of pregnant women with an MPA of >0.60 was 9.6%. The WDDS-10 was significantly positively associated with MPA in each survey. Although the acceptable food group consumption threshold varied between 4 and 6 food groups across surveys, the threshold of 5 showed the highest performance in the pooled sample with good sensitivity (62%), very good specificity (81%), and percentage of correctly classified individuals (79%). ConclusionsThe WDDS-10 is a good predictor of dietary micronutrient adequacy among pregnant women aged 15–49 y in LMICs. Moreover, the threshold of 5 or more food groups for the MDD-W indicator may be extended to all women of reproductive age, regardless of their physiologic status.

Access to Reproductive Health Services Among People With Disabilities

People with disabilities face inequitable access to reproductive health (RH) services, yet the national prevalence of barriers to access experienced across disability types and statuses is unknown. To assess the national prevalence of barriers to RH access experienced by people with disabilities. This cross-sectional study analyzed results of an online probability-based national survey of RH experiences that was conducted from December 2021 to January 2022. The national sample consisted of English- and Spanish-speaking panel members of a market research firm. Panelists were invited to participate in a survey on their RH experiences and opinions. These participants were aged 15 to 49 years and assigned female at birth (AFAB). Weighted proportions were estimated, and bivariable and multivariable regression analyses were performed to assess associations between disability status and barriers to accessing RH services. Using 5 of the 6 Washington Group Short Set on Functioning items, 8 dichotomous disability indicators were created: (1) vision, (2) hearing, (3) mobility, (4) activities of daily living, (5) communication, (6) overall disability status (a lot or more difficulty functioning in ≥1 domain), (7) some difficulty functioning (below the disability threshold; some or more difficulty functioning in ≥1 domain), and (8) multiple disabilities (a lot or more difficulty functioning in ≥2 domains). Number and types of barriers (logistical, access, cost, privacy, and interpersonal relationship) to accessing RH services in the past 3 years. After exclusion, the final sample included 6956 people AFAB, with a mean (SD) age of 36.0 (8.3) years. Of these participants, 8.5% (95% CI, 7.6%-9.5%) met the disability threshold. Participants with disabilities compared with those without disabilities were disproportionately more likely to be non-Hispanic Black (18.8% [95% CI, 14.4%-24.1%] vs 13.2% [95% CI, 11.9%-14.5%]) or Hispanic or Latinx (completed survey in English: 18.1% [95% CI, 14.0%-23.0%] vs 14.6% [95% CI, 13.3%-16.0%]; completed survey in Spanish: 8.9% [95% CI, 6.2%-12.8%] vs 6.2% [95% CI, 5.4%-7.1%]) individuals, to identify as LGBTQAI (lesbian, gay, bisexual, transgender, queer [or questioning], asexual [or allied], intersex; 16.4% [95% CI, 12.3%-21.6%] vs 11.8% [95% CI, 10.6%-13.1%]), to live below the federal poverty level (27.3% [95% CI, 22.3%-32.8%] vs 10.7% [95% CI, 9.7%-11.9%]), and to ever experienced medical mistreatment (49.6% [95% CI, 43.7%-55.5%] vs 36.5% [95% CI, 34.8%-38.2%]). Among those who had ever tried to access RH services (n = 6027), people with disabilities vs without disabilities were more likely to experience barriers (69.0% [95% CI, 62.9%-74.5%] vs 43.0% [95% CI, 41.2%-44.9%]), which were most often logistical (50.7%; 95% CI, 44.2%-57.2%) and access (49.9%; 95% CI, 43.4%-56.4%) barriers. The disability domains with the highest proportion of people who experienced 3 or more barriers in the past 3 years included activities of daily living (75.3%; 95% CI, 61.1%-85.6%), communication (65.1%; 95% CI, 49.5%-78.1%), and multiple (59.9%; 95% CI, 45.6%-72.7%) disabilities. This cross-sectional study found large disparities in access to RH services among people AFAB with disabilities. Findings indicated a need to alleviate barriers to RH care, including improving the transportation infrastructure and reinforcing patient-centered approaches that engender inclusivity in health care settings.

Can we more precisely classify exposure to antenatal depression and anxiety in multivariable prediction models of pregnancy and birth outcomes: a population-based cohort study

BackgroundDepression and anxiety are highly prevalent within the perinatal period and have been associated with myriad adverse pregnancy and birth outcomes. In this study, we sought to investigate whether population-based data can be used to build complex, longitudinal mental health histories that improve our ability to predict adverse pregnancy and birth outcomes.MethodsUsing population-based, administrative datasets, we examined individual-level mental health services use of all birth parents who delivered a live infant in British Columbia, Canada between April 1, 2000, and December 31, 2013, and who were registered with the provincial Medical Services Plan for over 100 days per year from 10-years preconception to 1-year postpartum. We operationalized variables to proxy severity, persistence, and frequency of depression/anxiety from preconception through pregnancy, then constructed predictive regression models for postpartum depression/anxiety and preterm birth.ResultsPredictive modeling of postpartum depression/anxiety and preterm birth revealed better predictions and stronger performance with inclusion of a more detailed preconception mental health history. Incorporating dichotomous indicators for depression/anxiety across preconception markedly improved predictive power and model fit. Our detailed measures of mental health service use predicted postpartum depression/anxiety much better than preterm birth. Variables characterizing use of outpatient psychiatry care and outpatient visit frequency within the first five years preconception were most useful in predicting postpartum depression/anxiety and preterm birth, respectively.ConclusionWe report a feasible method for developing and applying more nuanced definitions of depression/anxiety within population-based data. By accounting for differing profiles of mental health treatment, mental health history, and current mental health, we can better control for severity of underlying conditions and thus better understand more complex associations between antenatal mental health and adverse outcomes.

Introducing ViNSAR: Dyadic Data on Violent Non-State Actor Rivalry

A growing line of research examines causes and consequences of militant group competition. However, empirical work on these topics has limitations. Most quantitative research uses relatively rough proxies for competition, such as counts of groups in a country. Other work uses dichotomous indicators, ignoring the intensity or degree of rivalries. Additionally, many studies examine either terrorist organizations or rebel groups, overlooking cross-type rivalry (e.g., terrorist vs. rebel). We address these issues by introducing time-varying dyadic rivalry data on hundreds of groups – rebels, terrorists, and pro-government militias – in Africa and Asia, 1990-2015. Rivalry levels include denouncements, threats, and violence. After presenting the data, we test the “outbidding” hypothesis: the notion that inter-organizational competition leads to more terrorism. This argument has found support in qualitative analyses, but quantitative tests using rivalry proxies show mixed results. Using our data we find support for the hypothesis. We conclude with research questions that could be addressed with the data.

Immunosuppressive Medications and COVID-19 Outcomes in Patients with Noninfectious Uveitis in the Era of COVID-19 Vaccinations

To determine the risk of coronavirus disease 2019 (COVID-19) infection, hospitalization, and death in the era of COVID-19 vaccination among patients with noninfectious uveitis (NIU) taking immunosuppressive therapies. Retrospective cohort study from July 1, 2021, to June 30, 2022, using data from the Optum Labs Data Warehouse (OLDW) de-identified claims database. Patients with a diagnosis of NIU from January 1, 2017, and who had ≥ 1year of continuous enrollment in the OLDW. Incidence rates (IRs) were calculated for each COVID-19 outcome. Unadjusted and adjusted hazard ratios (HRs) were estimated for each variable and COVID-19 outcome using Cox proportional hazards models with time-updated dichotomous indicators for outpatient immunosuppressive medication exposure. To assess the dose-dependent effect of systemic corticosteroid (SC) exposure, the average daily dose of prednisone over the exposed interval was included in the adjusted models. Hazard ratios and IRs for COVID-19 infection, hospitalization, and death. This study included 62 209 patients with NIU. A total of 12 895 (20.7%) were exposed to SCs during the risk period. Incidence rates were increased when exposed to SCs versus unexposed for all COVID-19 outcomes. Incidence rates were also increased for all COVID-19 outcomes when exposed to SCs without COVID-19 vaccination versus exposed to SCs with ≥ 1 vaccination. In adjusted models, SCs were associated with increased risk of COVID-19 infection (HR, 3.57; 95% confidence interval [CI], 3.24-3.93; P<0.0001), hospitalization (HR, 2.75; 95% CI, 2.07-3.65; P<0.0001), and death (HR, 2.49; 95% CI 1.29-4.82; P= 0.007). Incremental increases in SC dose were associated with a greater risk for all outcomes. Disease-modifying anti-rheumatic drugs were associated with a decreased risk of infection (HR, 0.84; 95% CI, 0.74-0.96; P= 0.01), and tumor necrosis factor-α inhibitors were associated with an increased risk of infection (HR, 1.18; 95% CI, 1.01-1.39; P= 0.04). Systemic corticosteroid exposure continues to be associated with greater risk of COVID-19 infection, hospitalization, and death among patients with NIU in an era of widespread COVID-19 vaccination. Unvaccinated individuals who are exposed to immunosuppressive treatments have a greater risk of severe outcomes. Coronavirus disease 2019 vaccination should be strongly encouraged in these patients. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Healthcare utilization and readiness outcomes among soldiers with post-deployment at-risk drinking, by multimorbidity class

Although alcohol use disorder (AUD) regularly co-occurs with other conditions, there has not been investigation of specific multimorbidity classes among military members with at-risk alcohol use. We used latent class analysis (LCA) to cluster 138,929 soldiers with post-deployment at-risk drinking based on their co-occurring psychological and physical health conditions and indicators of alcohol severity. We examined the association of these multimorbidity classes with healthcare utilization and military readiness outcomes. Latent class analysis was conducted on 31 dichotomous indicators capturing alcohol use severity, mental health screens, psychological and physical health diagnoses, and tobacco use. Longitudinal survival analysis was used to examine the relative hazards of class membership regarding healthcare utilization (e.g., emergency department visit, inpatient stay) and readiness outcomes (e.g., early separation for misconduct). Latent class analysis identified five classes: Class 1 –Relatively Healthy (51.6 %); Class 2 – Pain/Tobacco (17.3 %); Class 3 – Heavy Drinking/Pain/Tobacco (13.1 %); Class 4 – Mental Health/Pain/Tobacco (12.7 %); and Class 5 – Heavy Drinking/Mental Health/Pain/Tobacco (5.4 %). Musculoskeletal pain and tobacco use were prevalent in all classes, though highest in Classes 2, 4, and 5. Classes 4 and 5 had the highest hazards of all outcomes. Class 5 generally exhibited slightly higher hazards of all outcomes than Class 4, demonstrating the exacerbation of risk among those with heavy drinking/AUD in combination with mental health conditions and other multimorbidity. This study provides new information about the most common multimorbidity presentations of at-risk drinkers in the military so that targeted, individualized care may be employed. Future research is needed to determine whether tailored prevention and treatment approaches for soldiers in different multimorbidity classes is associated with improved outcomes.

Could Children’s Gender Predict Their Parents’ Housework Behavior?

This study’s objective was to examine whether parents show different patterns in housework behavior in relation to children’s gender. Previous studies have suggested that children’s gender might shape family processes through various paths. However, in married couples, housework behavior is mainly explained by the economic or structural differences between partners, but little is known about the potential relevance between children’s gender and parents’ housework behavior. Using nationally representative data from the Chinese General Social Survey, we examined the link between children’s gender and parents’ weekly housework hours. Two dichotomous indicators represented children’s gender: having at least one son (or not) and having at least one daughter (or not). An ordinary least squares regression model was employed for the analysis. The results indicated that parents who have at least one son, rather than those who have at least one daughter, showed significant differences in housework behavior, with mothers spend more time on housework whereas fathers spend less. The findings suggest that parents do behave differently in relation to children’s gender. By emphasizing its symbolic attribute, we argue that children’s gender constitutes part of the social gender structure related to family processes.

Does universal insurance influence disparities in high-quality hospital use for inpatient pediatric congenital heart defect care within the first year of diagnosis?

BackgroundHealthcare disparities are an issue in the management of Congenital Heart Defects (CHD) in children. Although universal insurance may mitigate racial or socioeconomic status (SES) disparities in CHD care, prior studies have not examined these effects in the use of High-Quality Hospitals (HQH) for inpatient pediatric CHD care in the Military Healthcare System (MHS). To assess for racial and SES disparities in inpatient pediatric CHD care that may persist despite universal insurance coverage, we performed a cross-sectional study of the HQH use for children treated for CHD in the TRICARE system, a universal healthcare system for the U.S. Department of Defense. In the present work we evaluated for the presence of disparities, like those seen in the civilian U.S. healthcare system, among military ranks (SES surrogate) and races and ethnicities in HQH use for pediatric inpatient admissions for CHD care within a universal healthcare system (MHS).MethodsWe conducted a cross-sectional study using claims data from the U.S. MHS Data Repository from 2016 to 2020. We identified 11,748 beneficiaries aged 0 to 17 years who had an inpatient admission for CHD care from 2016 to 2020. The outcome variable was a dichotomous indicator for HQH utilization. In the sample, 42 hospitals were designated as HQH. Of the population, 82.9% did not use an HQH at any point for CHD care and 17.1% used an HQH at some point for CHD care. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of SES status. Patient demographic information at the time of index admission post initial CHD diagnosis (age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, and provider region) and clinical information (complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity) were used as covariates in multivariable logistic regression analysis.ResultsAfter controlling for demographic and clinical factors including age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, provider region, complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity, we did not find disparities in HQH use for inpatient pediatric CHD care based upon military rank. After controlling for demographic and clinical factors, lower SES (Other rank) was less likely to use an HQH for inpatient pediatric CHD care; OR of 0.47 (95% CI of 0.31 to 0.73).ConclusionsWe found that for inpatient pediatric CHD care in the universally insured TRICARE system, historically reported racial disparities in care were mitigated, suggesting that this population benefitted from expanded access to care. Despite universal coverage, SES disparities persisted in the civilian care setting, suggesting that universal insurance alone cannot sufficiently address differences in SES disparities in CHD care. Future studies are needed to address the pervasiveness of SES disparities and potential interventions to mitigate these disparities such as a more comprehensive patient travel program.

Quantifying Factors Associated with Personal Hygiene as Measured by the qPHAT Methodology: Andilaye Trial, Ethiopia.

Many water, sanitation, and hygiene (WASH) interventions target improvements in personal hygiene behaviors. Yet measuring personal hygiene behaviors is a challenge due to a lack of reliable, valid, objective, and simple-to-use approaches. The purpose of this study was to examine differences between two types of hygiene outcome measures and their ability to detect relationships between WASH-related behavioral factors and behaviors. We compared hygiene outcomes generated by the Quantitative Personal Hygiene Assessment Tool (qPHAT), which yields objective measures of cleanliness on an 11-point scale, and those generated by conventional, dichotomous indicators of cleanliness. We used cross-sectional data on hygiene outcomes related to facial and hand cleanliness collected during the Andilaye Trial, an impact evaluation of a community-based WASH intervention implemented in Amhara, Ethiopia. We fit multivariable models to examine associations between measures of children's facial and hand cleanliness, via both qPHAT and dichotomous indicators, and 1) household WASH conditions, 2) psychosocial factors, and 3) reported personal hygiene practices. The qPHAT-generated outcomes were able to detect relationships between intermediate behavioral factors and hygiene outcomes that dichotomous indicators were not, including associations with water insecurity and various psychosocial factors. qPHAT-generated outcomes were negatively associated with reported face washing practices, suggesting a bias in reported behaviors. Our study highlights the limitations of reported practices and dichotomous hygiene indicators and indicates that using more quantitative hygiene outcome measures, such as those generated by qPHAT, may reveal important intermediate factors that influence hygiene behavior and support improved monitoring and evaluation of interventions.

Educational Disparities in Hypertension Prevalence and Blood Pressure Percentiles in the Health and Retirement Study.

Hypertension and uncontrolled high blood pressure (BP) are more prevalent among less-educated older adults than those with more schooling. However, these dichotomous indicators may fail to fully characterize educational disparities in BP, a continuous measure that predicts morbidity and mortality across much of its range. This study therefore focuses on the distribution of BP, assessing educational disparities across BP percentiles in addition to disparities in hypertension and uncontrolled BP. Data are from the 2014-2016 Health and Retirement Study, a nationally representative survey of older U.S. adults (n = 14,498, ages 51-89). To examine associations between education, hypertension, and uncontrolled BP, I estimate linear probability models. To assess relationships between education and BP, I fit linear and unconditional quantile regression models. Less-educated older adults are not only more likely to have hypertension and uncontrolled BP than those with more schooling, they also have higher systolic BP across nearly the entire BP distribution. Educational disparities in systolic BP increase in magnitude across BP percentiles and are largest at the highest levels of BP. This pattern is observed for those with and without diagnosed hypertension, is robust to early-life confounders, and is only partially explained by socioeconomic and health-related circumstances in adulthood. Among older U.S. adults, the distribution of BP is compressed at lower, healthier levels for those with more education, and skewed toward the highest, most harmful levels among those with less education. Educational inequities in hypertension awareness and treatment efficacy may underlie these patterns. Implications for fundamental cause theory are discussed.

Neuroimaging biomarkers of the Amyloid, Tau, Neurodegeneration and Vascular framework in association with sleep duration changes over time

AbstractBackgroundBoth short and long sleep duration were previously associated with incident dementia, but underlying mechanisms of this association remains unknown. This project aims to evaluate how self‐reported sleep duration and its change over time associate with (A)myloid, (T)au, (N)eurodegeneration and (V)ascular neuroimaging markers of Alzheimer’s disease (AD).MethodWithin the Framingham Heart Study, two samples were studied: 271 participants (age:53.6±8.0 years; 51%M) who underwent 11C‐PiB amyloid (global, precuneus) and 18F‐Flortaucipir tau (several medial cortical limbic structures) PET imaging; and 2165 participants (age:61.3±11.1 years; 45%M) who underwent an MRI. To estimate neurodegeneration, total brain volume was extracted from MRI. Vascular MRI metrics included white matter hyperintensities (continuous, and dichotomous indicator for extensive for age), covert brain infarcts, and average free‐water. Self‐reported sleep duration was assessed both at the time of neuroimaging testing and around 15 years before, and split by categories (≤6h, 7‐8h, ≥9h). Sleep duration change over time was assessed by change between categories and by continuous delta change (split by negative and positive values for decreased or increased respectively). Logistic and linear regression models were tested between self‐reported sleep duration and neuroimaging metrics, adjusted for age and age2, sex, PET camera, APOE4 carrier status, depression, diabetes, hypertension, and prevalent cardiovascular diseases.ResultsNo association was observed between cross‐sectional self‐reported sleep duration and neuroimaging metrics. Transitioning to longer sleep over time (≤6h to ≥9h and 7‐8h to ≥9h as compared to consistently sleeping 7‐8h) was associated with higher white matter hyperintensities burden (extensive, OR[95%CI]:3.50[0.95‐12.92], p = 0.040;ß[SE]:0.25[0.10], p = 0.015) and higher free‐water (ß[SE]:0.021[0.007], p = 0.003;ß[SE]:0.009[0.002], p = 0.0002). When looking at continuous sleep duration change, increasing sleep duration over time was also associated with higher white matter hyperintensities burden (extensive, OR[95%CI]:1.26[1.02‐1.55], p = 0.032;ß[SE]:0.10[0.04], p = 0.007) and higher free‐water (ß[SE]:0.002[0.001], p = 0.031). Self‐reported sleep duration change was not associated with PET amyloid or tau outcomes.ConclusionVascular pathology in the brain as evidenced by higher white matter hyperintensities burden and free‐water is associated with sleep duration that is getting longer over time, thus potentially explaining its association with dementia risk. In fact, elongation of sleep duration may be an early change in the AD trajectory.

It's all about time: the influence of behaviour and timelines on suspect disclosure during investigative interviews

ABSTRACT Research on confession has usually focused on showing that it is significantly associated with individual, crime-related, and situational/contextual variables and is both a static event and a dichotomous indicator of interview success. Recent work, however, suggests that investigative interviews are a dynamic process in which interrogation strategies change over time. Using a Game Theory perspective, this study looks at the impact of behaviours of both players (interviewer and suspect) on the production of investigation-relevant information (IRI). The sub-objective is to demonstrate the usefulness of applying Game Theory to the study of investigative interviews by considering time and interaction between players as an integrative part of the analysis. Videotaped interviews related to online child sexual exploitation (n = 130) were analysed and the different behaviours of suspects and interviewers were analysed to determine if they involved (1) rapport building/active denial, (2) collaboration, (3) confrontation, (4) emotion/response, and (5) elicitation of information related to the case. Results showed that information relevant to the investigation is often provided shortly after a suspect has offered additional information or given responses that meet emotional needs (e.g. justifications). The interviewer's use of available evidence increases the likelihood that additional information will be provided, while the ability to build a rapport with the suspect is effective in the longer term, even if a positive effect is not immediately observed. Using a dynamic process approach in analysing investigative interviews provides a starting point for the creation of practical guidelines to help practitioners increase suspect collaboration during investigative interviews.