Multilevel Ordinal Logistic Regression Research Articles

Exploring digital solutions for sustainable production: academic insights and practical applications

ABSTRACT Digital technology adoption in sustainable production practices is increasingly recognised as pivotal for advancing sustainability objectives. However, existing literature predominantly focuses on the technological aspects, leaving the nuanced experiences and insights of academic scholars underexplored. This study addresses this gap by surveying 314 scholars from diverse regions to evaluate the influence of various digital technologies on economic, operational, and environmental performance in sustainable production. Utilising multilevel ordinal logistic regression (M-OLR), the research identifies six critical digital technologies that significantly enhance sustainable production outcomes. The application of M-OLR effectively accounts for spatial heterogeneity, providing a more robust analysis compared to standard ordinal logistic regression (OLR) models. The findings underscore the essential role of digitalisation in facilitating sustainable transitions, offering novel insights into how digital technologies can drive improvements across economic, operational, and environmental dimensions. The implications extend to policy formulation and strategic planning of digital technologies to achieve comprehensive sustainability goals.

Exploring factors influencing childhood immunization status in East Africa using multilevel ordinal logistic regression analysis.

Childhood vaccinations are crucial in safeguarding children from infectious diseases and are recognized as one of the most cost-effective public health interventions. However, children in East African countries face more than a fifteen-fold increased risk of death from vaccine-preventable diseases compared to those in high-income nations. This study aimed to identify the factors influencing childhood immunization status in East Africa. A sample of 22,734 children aged 12 to 23 months was included to assess immunization status, utilizing recent data from the Demographic and Health Survey conducted between 2015 and 2022 across ten East African countries. A Level-3 multilevel generalized odds model with a logit link function was employed for the analysis. Among the 22,734 children in the sample, only 67.4% were fully immunized, 27.7% were partially immunized, and the remaining were not immunized at all. The null hypothesis of proportionality was rejected based on the Brant test. Consequently, various partial and non-proportional odds models were fitted, with the generalized odds model demonstrating the best fit compared to other ordinal regression models. The findings indicated that 43.14% of the variation in children's immunization status was attributable to differences between countries, while 18.18% was due to variations between regions. Specific factors associated with immunization status revealed that mothers who attended antenatal care were 1.23 times more likely to fully immunize their children compared to those who did not, and those who received postnatal care were 1.13 times more likely to do so. Additionally, mothers who had antenatal and postnatal services were 1.07 and 1.08 times more likely, respectively, to fully or partially immunize their children compared to those who did not. The fitted generalized odds model indicated that several factors significantly associated with childhood immunization status included maternal age, number of antenatal and postnatal care visits, tetanus injections received by mothers, vitamin A intake, presence of health documentation, place of delivery, birth order, mother's occupation, sex of the household head, distance to health facilities, maternal education, community maternal education, community wealth index, and community media exposure. Therefore, it is recommended that interventions focus on enhancing household wealth, educating mothers, and improving health systems.

Changes and determinants of pneumococcal vaccine uptake in Ethiopia.

Pneumococcal pneumonia is one of the most common causes of severe pneumonia and pneumonia-related mortality globally. It ranked among the leading causes of morbidity and mortality in children under five years in Ethiopia. Vaccination reduces the burden of pneumonia and pneumococcal infections in both children and adults. This study assesses changes in pneumococcal vaccine coverage over time and identifies factors associated with the vaccine uptake. The study was based on secondary data from the Ethiopian Demographic and Health Surveys (EDHS) in 2016 and 2019, involving 1,929 children in 2016 and 1,008 in 2019, aged 12-23 months. A cross-sectional study design was conducted. The percentage change in pneumococcal conjugate vaccine (PCV) coverage was used to quantify the degree of change over time, while multilevel ordinal logistic regression identifies significant factors. All statistical tests were performed using a 5% significance threshold. The study found a significant 21.8% (95% CI: 9.8-35.2) change in the proportion of children receiving complete doses of PCV, from 49.1% in 2016 to 59.8% in 2019. Children in rural areas were 69% less likely to receive more doses of PCV vaccinations than those living in urban areas (AOR = 0.307, 95% CI: 0.127 - 0.742). Second or higher-order births were associated with greater uptake doses of PCV (AOR = 2.519, 95% CI: 1.143-5.548). Child born in health facilities were 2.35 times more likely to receive full vaccination than those born at home (AOR = 2.350, 95% CI: 1.132-4.882). Additionally, children whose mothers had more antenatal care (ANC) visits were more likely to complete their pneumococcal vaccination. Despite the increase in uptake, Ethiopia remains far from reaching its immunization goals. The study showed that place of residence, birth order, place of delivery, antenatal care and regional variation were significantly associated with pneumococcal vaccine uptake.

Quality of life and quality of care experience in Australian residential aged care: a retrospective cohort study of 1,772 residents

BackgroundIn April 2023, quality of life (QOL) and quality of care experience (QCE) indicators were introduced as mandatory indicators in Australian residential aged care (RAC) to measure and monitor wellbeing and consumer experience respectively. In this study, we used data for the initial four months after their introduction to describe QOL and QCE scores, explore related factors and assess variations by completion mode and facility.MethodsA retrospective cohort study using electronic data (Mar–Jun 2023) from 1,772 residents in 22 RAC facilities in metropolitan Sydney, Australia. QOL was measured by the Quality of Life-Aged Care Consumer (QOL-ACC) scale, and QCE by the Quality of Care Experience-Aged Care Consumer (QCE-ACC) scale, both through three completion modes: self, interviewer-facilitated and proxy completion. Propensity score matching was used to compare QOL/QCE differences by completion mode; multilevel ordinal logistic regression to investigate QOL-/QCE-related factors; and funnel plots to explore facility-level score variations.ResultsOf 1,772 residents, 1,706 completed the QOL-ACC survey and 1,686 the QCE-ACC. The median score was 21 (interquartile range 18–24) for QOL and 23 (interquartile range 20–24) for QCE, both indicating ‘excellent’ outcomes. The leisure activities component of QOL, and social relationships and complaint lodging of QCE, were rated relatively lower than other dimensions. The scores of both indicators were significantly higher for self-completion versus other completion modes. Significant variation in QOL and QCE scores by facility were also observed, with seven and four facilities with lower-than-expected proportions of residents with ‘excellent’ or ‘good’ ratings of QOL and QCE, respectively. A longer length of stay (odd ratio [OR] = 0.70, 95% CI: 0.53–0.92 for ≥ 3 years of stay versus < 1 year of stay) and fall history (OR = 0.74, 95% CI: 0.60–0.91) were associated with lower QOL, while having a visual impairment (OR = 0.74, 95% CI: 0.55–0.99) and fall history (OR = 0.80, 95% CI: 0.64–0.99) were associated with lower QCE.ConclusionWe found high QOL and QCE across the 22 Australian RAC facilities. Enhancing residents’ leisure activities, social relationships, and addressing specific needs (e.g., visual impairment and fall history) may enhance QOL and QCE.

Air pollution, traffic noise, mental health, and cognitive development: A multi-exposure longitudinal study of London adolescents in the SCAMP cohort

BackgroundThere is increasing evidence that air pollution and noise may have detrimental psychological impacts, but there are few studies evaluating adolescents, ground-level ozone exposure, multi-exposure models, or metrics beyond outdoor residential exposure. This study aimed to address these gaps. MethodsAnnual air pollution and traffic noise exposure at home and school were modelled for adolescents in the Greater London SCAMP cohort (N=7555). Indoor, outdoor and hybrid environments were modelled for air pollution. Cognitive and mental health measures were self-completed at two timepoints (baseline aged 11–12 and follow-up aged 13–15). Associations were modelled using multi-level multivariate linear or ordinal logistic regression. ResultsThis is the first study to investigate ground-level ozone exposure in relation to adolescent executive functioning, finding that a 1 interquartile range increase in outdoor ozone corresponded to −0.06 (p < 0.001) z-score between baseline and follow-up, 38 % less improvement than average (median development + 0.16). Exposure to nitrogen dioxide (NO2), 24-hour traffic noise, and particulate matter < 10 µg/m3 (PM10) were also significantly associated with slower executive functioning development when adjusting for ozone. In two-pollutant models, particulate matter and ozone were associated with increased externalising problems. Daytime and evening noise were associated with higher anxiety symptoms, and 24-hour noise with worse speech-in-noise perception (auditory processing). Adjusting for air pollutants, 24-hour noise was also associated with higher anxiety symptoms and slower fluid intelligence development. ConclusionsOzone’s potentially detrimental effects on adolescent cognition have been overlooked in the literature. Our findings also suggest harmful impacts of other air pollutants and noise on mental health. Further research should attempt to replicate these findings and use mechanistic enquiry to enhance causal inference. Policy makers should carefully consider how to manage the public health impacts of ozone, as efforts to reduce other air pollutants such as NO2 can increase ozone levels, as will the progression of climate change.

Compliance and determinants of infection prevention and control practices among sanitary workers in public hospitals, Eastern Ethiopia: A cross-sectional study.

Best practice of infection prevention and control (IPC) is a hallmark for the patient care in health care settings, but it is a major problem in developing countries like Ethiopia where resources are limited. Ethiopia Federal Ministry of Health working to strengthen its IPC program, but still it there is no organized study conducted on assessment of performance gaps and implementation challenges of IPC practice faced by hospital staffs particularly among sanitary workers (SWs) at public hospitals inline to national and international guidelines. This study focuses on compliance and determinants of IPC among sanitary worker in public hospitals in eastern Ethiopia: A cross sectional study design. A cross-sectional study was conducted among 809 SWs and eight IPC experts in public hospitals, eastern Ethiopia, from May to August 2023. A standard questionnaire was used to collect data. Face-to-face interview was conducted. Ten (10) question pursued to answer YES/NO were prepared. The cut point for categories of IPC practice was 1: Good (16-20 scores), 2: Fair (10-15 scores), and 3: Poor (<10 scores). The cut point for compliance and noncompliance of IPC practice among hospitals was mean (500.1). Multi-level ordinal logistic regression models was applied to explore the association of dependent and independent variables at individual level (Model 1), hospital level (Model 2) and at both (Model 3). Crude odds ratio (COR) and adjusted odds ratio (AOR) at 95% confidence interval (CI) were used to report the result. The compliance of IPC practice among SWs was 36.21% (32.72, 39.82%). The Multilevel ordinal logistic regression model shows that SWs who have good knowledge of IPC trend (AOR: 4.70, 95% CI: 2.11-10.46), SWs who are not addictive with alcohol (AOR: 2.35, 95% CI: 1.15,4.78) and chew Khat (AOR: 1.62, 95% CI: 1.06,2.46) and smoke cigarette (AOR: 3.15, 95% CI: 2.35-5.41), and SWs without job stress (AOR: 1.46, 95% CI: 0.86-2.48) were more compliant to IPC practice. Similarly, those who do not have workload (AOR: 2.74, 95% CI: 1.56-4.82), work <8 h/day (AOR: 1.46, 95% CI: 0.92-2.30), and those who have good social recognition in hospitals (AOR: 6.08, 95% CI: 4.24-8.71) were more likely to increase the compliance of IPC practice among SWs. The multilevel random-effect model revealed 93.71% of the variability of compliance of IPC practice explained by both individual and hospital level factors. The overall study found that inadequate IPC practice was reported among SWs as well as by IPC experts due to poor knowledge of IPC trend and individual behaviors and working environment. Thus, the study advised that hospitals have to develop and establish IPC implementation guidelines in order to solve the concerns among these groups; national IPC office should follow its implementation across health care settings particularly at public hospitals.

The level of wasting and associated factors among children aged 6-59 months in sub-Saharan African countries: multilevel ordinal logistic regression analysis.

Despite various interventions to combat child malnutrition in sub-Saharan Africa, wasting remains a critical public health concern for children aged 6-59 months. Wasting is a significant predictor of child survival and development, with a heightened risk of mortality among children. However, there is a lack of recent comprehensive data on the prevalence, severity level, and factors contributing to wasting in this age group. To identify the severity levels of wasting and its individual and community-level factors contributing to wasting among children aged 6-59 months in Sub-Saharan African countries. This research utilized Demographic and Health Survey data from 34 Sub-Saharan African countries, spanning the period from 2007 to 2022. The study included a weighted sample of 180,317 6-59-month-old children. We employed a multilevel proportional odds model to identify factors predicting the severity of wasting. Adjusted odds ratios and 95% confidence intervals were reported to demonstrate significant relationships (p < 0.05) in the final model. In Sub-Saharan Africa, 7.09% of children aged 6-59 months experience wasting (95% CI: 6.97, 7.20%). Among these children, the prevalence of moderate wasting is 4.97% (95% CI: 4.90, 5.10%), while severe wasting affects 2.12% (95% CI: 2.0, 2.20%). Factors such as term/post-term babies, wealth, frequency of feeding, improved toilet facilities, water sources, employed and educated mothers, rural residence, high community maternal education, and community media exposure are strongly associated with a lower chance of experiencing severe form of wasting. Conversely, birth order, family size, breastfeeding, diarrhea, cough, and fever, high community poverty, female household heads, and all Sub-Saharan Africa regions are linked to higher levels of wasting. The study findings underscore the persistent challenge of wasting among Sub-Saharan Africa's children, with 7.09% affected, of which 4.97% experience moderate wasting and 2.12% severe wasting. The identified predictors of wasting highlight the complex interplay of socio-economic, environmental, and health-related determinants. To address this issue improve access to healthcare and nutrition services, enhance sanitation infrastructure, promote women's empowerment, and implement community-based education programs. Additionally, prioritize early detection through routine screening and strengthen health systems' capacity to provide timely interventions.

The effect of dietary diversity on anemia levels among children 6-23 months in sub-Saharan Africa: A multilevel ordinal logistic regression model.

Anemia is the most common hematologic disorder of children worldwide. Since dietary diversity is a main requirement of children is to get all the essential nutrients, it can thus use as one of the basic indicator when assessing the child's anemia. Although dietary diversity plays a major role in anemia among children in sub-Saharan Africa, there is little evidence of an association between the dietary diversity and anemia level to identified potential strategies for prevention of anemia level in sub-Saharan Africa. To examine the association between dietary diversity and anemia levels among children aged 6-23 months in sub-Saharan Africa. The most recent Demographic and Health Surveys from 32 countries in SSA were considered for this study, which used pooled data from those surveys. In this study, a total weighted sample of 52,180 children aged 6-23 months was included. The diversity of the diet given to children was assessed using the minimum dietary diversity (MDD), which considers only four of the seven food groups. A multilevel ordinal logistic regression model was applied due to the DHS data's hierarchical structure and the ordinal nature of anemia. With a p-value of 0.08, the Brant test found that the proportional odds assumption was satisfied. In addition, model comparisons were done using deviance. In the bi-variable analysis, variables having a p-value ≤0.2 were taken into account for multivariable analysis. The Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was presented for potential determinants of levels of anemia in the multivariable multilevel proportional odds model. The overall prevalence of minimum dietary diversity and anemia among children aged 6-23 months were 43% [95% CI: 42.6%, 43.4%] and 72.0% [95% CI: 70.9%, 72.9%] respectively. Of which, 26.2% had mild anemia, 43.4% had moderate anemia, and 2.4% had severe anemia. MDD, being female child, being 18-23 months age, born from mothers aged ≥25, taking drugs for the intestinal parasite, higher level of maternal education, number of ANC visits, middle and richer household wealth status, distance of health facility and being born in Central and Southern Africa were significantly associated with the lower odds of levels of anemia. Contrarily, being 9-11- and 12-17-months age, size of child, having fever and diarrhea in the last two weeks, higher birth order, stunting, wasting, and underweight and being in West Africa were significantly associated with higher odds of levels of anemia. Anemia was a significant public health issue among children aged 6-23 months in sub-Saharan Africa. Minimum dietary diversity intake is associated with reduced anemia in children aged 6 to 23 months in sub-Saharan Africa. Children should be fed a variety of foods to improve their anemia status. Reducing anemia in children aged 6-23 months can be achieved by raising mother education levels, treating febrile illnesses, and improve the family's financial situation. Finally, iron fortification or vitamin supplementation could help to better reduce the risk of anemia and raise children's hemoglobin levels in order to treat anemia.

The Intersection of a Child's Demographics and Household Socioeconomic Status in the Multimorbidity of Malaria, Anaemia, and Malnutrition among Children Aged 6-59 Months in Nigeria.

Multimorbidity of malaria, anemia, and malnutrition (MAMM) is a condition in which an individual has two or more of these health conditions, and is becoming an emergent public health concern in sub-Saharan African countries. The independent associations of a child's demographic variables and household socioeconomic (HSE) disparities with a child's health outcomes have been established in the literature. However, the effects of the intersection of these factors on MAMM, while accounting for other covariates, have not been studied. Therefore, this study aimed to determine how children's sex, age, and household socioeconomic status interact to explain the variations in MAMM among children aged 6-59 months in Nigeria. Data from the 2018 Nigeria Demographic and Health Survey and the 2018 National Human Development Report (NHDR) were used. This study included weighted samples of 10,184 children aged 6-59 months in Nigeria. A three-level multilevel mixed effect ordinal logistic regression model was used, such that individual characteristics at level 1 were nested in communities at level 2 and nested in states at level 3. Subsequently, predictive probability charts and average adjusted probability tables were used to interpret the intersectional effects. Five models were created in this scenario. Model 1 is the interaction between the child's sex and household wealth status; model 2 is the interaction between the child's sex and age; model 3 is the interaction between the child's age and household wealth status; model 4 has the three two-way interactions of the child's sex, age, and household wealth status; and model 5 includes model 4 and the three-way interactions between a child's sex, age, and household wealth quintiles; while accounting for other covariates in each of the models. The prevalence of children with a 'none of the three diseases' outcome was 17.3% (1767/10,184), while 34.4% (3499/10,184) had 'only one of the diseases', and 48.3% (4918/10,184) had 'two or more' MAMMs. However, in the multivariate analyses, model 3 was the best fit compared with other models, so the two-way interaction effects of a child's age and household wealth status are significant predictors in the model. Children aged 36-47 months living in the poorest households had a probability of 0.11, 0.18, and 0.32 of existing with MAMM above the probability of children of the same age who live in the middle class, more prosperous, and richest households, respectively, while all other covariates were held constant. Thus, the variation in the prevalence of MAMM in children of different ages differs depending on the household wealth quintile. In other words, in older children, the variations in MAMM become more evident between the richer and the poorer household quintiles. Therefore, it is recommended that policies that are geared toward economic redistribution will help bridge the disparities observed in the prevalence of multiple diseases among children aged 6-59 months in Nigeria.

Determinants of nutritional status of children aged 6–59 months in the case of Itang special woreda, Gambella, Ethiopia

Nutritional status is one of the most important causes of improper physical and mental development in children. The study attempts to assess the factors affecting the severity status of children aged 6–59 months’ malnutrition based on the weight-for-age anthropometric index (z-score) and examine between-kebeles-level differences in determinants of the nutritional status of children. A community-based, cross-sectional study design was conducted from October 12 to November 12, 2022. A sample of 397 children aged 6–59 months primary data by applying multi–stage clustered sampling technique was used by considering their heterogeneity. The data were entered by SPSS and analyzed by using R version 3.4.0 and STATA 14.2 statistical software package using a multilevel ordinal logistic regression model and inferences were conducted at a 5% significance level. The results show that birth interval ≥ 24 months (OR = 1.431253, 95% CI 1.221337 1.6763421, P-value = 0.008), economic status of households medium (OR = 16.21466, 95% CI 1.221403 1.423929, P-value = 0.000), economic status of households rich (OR = 223.2856, 95% CI 1.34295 2.582325, P-value = 0.000), employment status of the mother unemployed (OR = 0.2291348, 95% CI 0.0529511 0.9966281, P-value = 0.049), No toilet facility (bush field) (OR = 0.3163329, 95% CI 0.1825356 0.5481975, P-value = 0.000), number of household members (OR = 0.9100682, 95% CI 0.8313481 0.9967315, P-value = 0.042), breastfeeding < 12 months (OR = 0.53803, 95% CI 0.322315 0.898135, P-value = 0.018), educational level of father Primary (OR = 4.601687, 95% CI 1.758009 2.22053, P-value = 0.000), educational level of father Secondary above (OR = 99.65229, 95% CI 2.533502 4.788896, P-value = 0.000) and geographical area (kebeles) were found to be important factors that affect a child's nutritional status between 6 and 59 months. 15% of the overall variation is attributable to the Kebeles level, according to two-level multilevel ordinal logistic regressions with estimates of the variation attributable to the Kebeles level equal to 0.569 and an intraclass correlation coefficient of 0.15. Due to the nature of the response variable random intercept model with random coefficients fitted the data adequately in predicting the severity status of children aged 6–59 months’ malnutrition for the multilevel ordinal logistic regression model analysis. So, the researcher recommended that implementing primary health care and nutrition programs that would fit each kebeles’ features in Itang Special Woreda to safeguard children from nutritional deficiency.

177 Modulation of fecal microbiome by phytogenics, a postbiotic, and mix of organic acids with essential oils in weaned pigs subjected to F18 Escherichia coli challenge

Abstract This study evaluated the effects of bioactive feed ingredients on fecal microbiome of weaned pigs subjected to F18 enterotoxigenic Escherichia coli (ETEC) challenge. Two blocks of weaned pigs [n = 72; Yorkshire/Landrace/Duroc; initial body weight (BW) = 6.62 ± 1.37 kg] were balanced by gender and litter and randomly allocated to one of the six treatments with 12 pens/block and 6 pigs/pen. Treatments included: 1) basal diet (NC), 2) NC + 0.1% phytogenic (Fresta Protect, Delacon, Austria; PFP), 3) NC + 0.2% postbiotic (Dia-V Nursery, Diamond V, IA; PB), 4) NC + 0.2% new phytogenic prototype (Delacon, Austria; NPP), 5) NC + 0.2% organic acid and essential oil blend (OA+EO), and 6) NC + 0.1% phytogenic (Fresta Protect) + 0.2% postbiotic (Dia-V Nursery; PFP+PB). The trial lasted 15 d, with a 7-d pre-challenge and 8-d post-challenge periods. Pigs were orally inoculated with 5 x 1010 CFU/mL of F18 ETEC (O147:H2, LT:STb:STa:Stx2:F18) on d 8 and 9 of study after 5-h fasting. Fecal swabs were collected before challenge (d 8) and 3- and 8-d post-challenge (d 10 and 15 of study) and subjected to shotgun metagenomics. Diarrhea score and E. coli shedding (CFU/mL) were monitored daily and analyzed using a multi-level mixed effect ordinal logistic regression with block and pen as random effects. Microbiome data were center-log-ratio transformed and analyzed for diversity, abundance, and interaction networks. At 3-d post-challenge, the OA+EO, PFP+PB and NPP supplemented pigs had reduced (P &amp;lt; 0.001) E. coli shedding compared with NC. Diarrhea score tended to be less (P = 0.054) in PFP+PB fed pigs 5-d post-challenge and was less (P = 0.02) in PFP+PB, OA+EO, and NPP 6-d post-challenge than NC. Alpha-diversity declined (P &amp;lt; 0.01) 3-d post-challenge with most reduction in PFP and OA+EO but recovered 8-d post-challenge except for PFP and OA+EO (P &amp;lt; 0.01). At the baseline and 8-d post-challenge, the largest number of differentially abundant taxa (P &amp;lt; 0.05) were observed in PFP+PB compared with NC. The PFP+PB reduced the abundances of Escherichia.sp000208585 and Campylobacter.P585 which were negatively correlated (P &amp;lt; 0.01) with average daily gain (ADG) and BW, and positively correlated (P &amp;lt; 0.01) with diarrhea score and E. coli shedding. The PFP+PB increased beneficial species including Prevotella.sp900543585, Mitsuokella jalaludinii, and Faecalibacterium prausnitzii with the first two positively correlated (P &amp;lt; 0.01) with ADG and BW, and negatively correlated (P &amp;lt; 0.01) with diarrhea score and E. coli shedding. By d-8 post-challenge, PFP+PB microbial network had the highest degree of negative connections suggestive of a more competitive microbial ecosystem against opportunistic microorganisms compared with NC. In conclusion, co-supplementation of Fresta Protect phytogenic and postbiotic promoted a microbiome with greater beneficial and reduced detrimental bacteria resulting in low diarrhea score post-challenge.

Determinants of severity levels of anemia among pregnant women in Sub-Saharan Africa: multilevel analysis.

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

Longitudinal associations between food parenting practices and dietary intake in preschool children: The ToyBox Study

IntroductionFood Parenting Practices (FPPs) include the practices parents use in the act of feeding their children, which may further influence their health. ObjectivesTo assess associations between changes in FPPs (permissiveness, food availability, guided choices, water encouragement, rules and limits and the use of food as reward) over 1 year and dietary intake (water, energy-dense/nutrient-poor and nutrient-dense foods) at follow-up in 4- to 6-year-old preschool-aged children. MethodsLongitudinal data from the control group of the ToyBox study, a cluster-randomized controlled intervention study, was used (NCT02116296). Multilevel ordinal logistic regression analyses including FPP as the independent variables and dietary intake as outcome. ResultsNine hundred sixty-four parent-child dyads (50.5% boys and 95.0% mothers) were included. Limited changes on the use of FPPs were observed over time. Nevertheless, in boys, often having F&V at home was associated with higher F&V consumption (OR = 6.92 [1.58; 30.38]), and increasing home availability of F&V was directly associated with higher water consumption (OR = 7.62 [1.63; 35.62]). Also, not having sweets or salty snacks available at home was associated with lower consumption of desserts (OR = 4.34 [1.75; 10.75]). In girls, having F&V availability was associated with higher F&V consumption (OR = 6.72 [1.52; 29.70]) and lower salty snack consumption (OR = 3.26 [1.50; 7.10]) and never having soft drinks at home was associated with lower consumption of sweets (OR = 7.89 [6.32; 9.86]). Also, never being permissive about soft drink consumption was associated with lower soft drink consumption (OR = 4.09 [2.44; 6.85]). ConclusionUsing favorable FPPs and avoiding the negative ones is prospectively associated with healthier dietary intake, especially of F&V, and less intake of soft drinks, desserts, and salty snacks.

Socio-economic disparities and predictors of fertility among adolescents aged 15 to 19 in Zambia: Evidence from the Zambia Demographic and Health Survey (2018).

Globally, 12 million girls aged 15-19 give birth each year, and Africa hosts 19% of youth aged 15-24. In Zambia, 29% of adolescents experience childbirth, with variations by age. Projections suggest a continued rise in these trends by 2030. Zambia came up with Adolescent Health Strategic Plan 2011-2015 among the specific policies being advocated for was Adolescent-Friendly Health Services (ADFHS) in order to mitigate among others adolescent fertility. The study aims to investigate socio-economic disparities and predictors of fertility in Zambian adolescents aged 15 to 19. The study used a cross-sectional study design utilized the 2018 Zambia Demographic Health Survey (ZDHS). The variable of interest in this study is "total number of children ever born" among adolescents aged 15 to 19 years. The explanatory variables that were used in the study were demographic, socio-economic, behavioral and community level factors. The Rao-Scott Chi-square test was used to test for association between categorical variables. Determinants of adolescent fertility were identified through a multilevel ordinal logistic regression conducted at a significance level of 5%. Analysis in the study was carried out using Stata version 14.2. A total of 3,000 adolescents were involved in the study, revealing that 75.88% had not given birth, 21.14% had one child, and 2.98% had at least two children. The findings revealed that education played a protective role, with adjusted odds ratios (AOR) of 0.47 (95% CI, 0.23-0.97), 0.21 (95% CI, 0.10-0.47), and 0.03 (95% CI, 0.00-0.54) for primary, secondary, and tertiary education, respectively. On the other hand, certain factors were associated with an elevated risk of fertility. These included the age of adolescents, educational attainment, marital status, wealth index, contraceptive use, exposure to family planning (FP) messages, being educated about FP at health facilities, and age at first sexual encounter. Among contextual factors, only community age at first birth was identified as a predictor of fertility, AOR, 1.59 (95% CI, 1.01-2.52). The study highlights sociodemographic disparities in adolescent fertility, emphasizing the need for targeted sexual reproductive health policies. Education protects against having more than one child, while marital status significantly influences fertility, particularly for married adolescents. The research provides valuable insights into the complex factors shaping adolescent fertility in Zambia, offering guidance for interventions and policies to support this vulnerable demographic.

Invasive Fungal Infections in Inpatient Solid Organ Transplant Recipients With COVID-19: A Multicenter Retrospective Cohort.

The prevalence and outcomes of COVID-19-associated invasive fungal infections (CAIFIs) in solid organ transplant recipients (SOTRs) remain poorly understood. A retrospective cohort study of SOTRs with COVID-19 admitted to 5 hospitals within Johns Hopkins Medicine was performed between March 2020 and March 2022. Cox regression multilevel mixed-effects ordinal logistic regression was used. In the cohort of 276 SOTRs, 22 (8%) developed IFIs. The prevalence of CAIFIs was highest in lung transplant recipients (20%), followed by recipients of heart (2/28; 7.1%), liver (3/46; 6.5%), and kidney (7/149; 4.7%) transplants. In the overall cohort, only 42 of 276 SOTRs (15.2%) required mechanical ventilation; these included 11 of 22 SOTRs (50%) of the CAIFI group and 31 of 254 SOTRs (12.2%) of the no-CAIFI group. Compared with those without IFIs, SOTs with IFIs had worse outcomes and required more advanced life support (high-flow oxygen, vasopressor, and dialysis). SOTRs with CAIFIs had higher 1-y death-censored allograft failure (hazard ratio 1.6 5.1 16.4 , P = 0.006) and 1-y mortality adjusting for oxygen requirement (adjusted hazard ratio 1.1 2.4 5.1 , P < 0.001), compared with SOTRs without CAIFIs. The prevalence of CAIFIs in inpatient SOTRs with COVID-19 is substantial. Clinicians should be alert to the possibility of CAIFIs in SOTRs with COVID-19, particularly those requiring supplemental oxygen, regardless of their intubation status.

An Econometric Analysis to Explore the Temporal Variability of the Factors Affecting Crash Severity Due to COVID-19

This study utilizes multilevel ordinal logistic regression (M-OLR), an approach that accounts for spatial heterogeneity, to assess the dynamics of crash severity in Virginia, USA, over the years 2018 to 2023. This period was notably influenced by the COVID-19 pandemic and its associated stay-at-home orders, which significantly altered traffic behaviors and crash severity patterns. This study aims to evaluate the pandemic’s impact on crash severity and examine the consequent changes in driver behaviors. Despite a reduction in total crashes, a worrying increase in the proportion of severe injuries is observed, suggesting that less congested roads during the pandemic led to riskier driving behaviors, notably increased speed violations. This research also highlights heightened risks for vulnerable road users such as pedestrians, cyclists, and motorcyclists, with changes in transportation habits during the pandemic leading to more severe crashes involving these groups. Additionally, this study emphasizes the consistent influence of environmental and roadway features, like weather conditions and traffic signals, in determining crash outcomes. These findings offer vital insights for road safety policymakers and urban planners, indicating the necessity of adaptive road safety strategies in response to changing societal norms and behaviors. The research underscores the critical role of individual behaviors and mental states in traffic safety management and advocates for holistic approaches to ensure road safety in a rapidly evolving post-pandemic landscape.

The Impact of Patient Race, Patient Socioeconomic Status, and Cognitive Load of Physician Residents and Fellows on Chronic Pain Care Decisions

Social stereotypes are more likely to influence decision-making under conditions of high cognitive load (ie, mental workload), such as in medical settings. We examined how patient race, patient socioeconomic status (SES), physician cognitive load, and physician implicit beliefs about race and SES differences in pain tolerance impacted physicians’ pain treatment decisions. Physician residents and fellows (N = 120) made treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the physicians were randomized to be interrupted during the decision task to make hypertension medication conversion calculations (high cognitive load group), while the other half completed the task without interruptions (low cognitive load group). Both groups were given equal time to make pain care decisions (2.5 minutes/patient). Results of multilevel ordinal logistic regression analyses indicated that physicians prescribed weaker analgesics to patients with high vs. low SES (odds ratio = .68, 95% confidence interval [.48, .97], P = .03). There was also a patient SES-by-cognitive load interaction (odds ratio = .56, 95% confidence interval [.31, 1.01], P = .05) that is theoretically and potentially practically meaningful but was not statistically significant at P < .05. These findings shed light on physician cognitive load as a clinically-relevant factor in the context of pain care quality and equity. PerspectiveThese findings highlight the clinical relevance of physician cognitive load (eg, mental workload) when providing pain care for diverse patients. This line of work can support the development of interventions to manage physician cognitive load and its impact on pain care, which may ultimately help reduce pain disparities.

Determinants and spatial factors of anemia in women of reproductive age in Democratic Republic of Congo (drc): a Bayesian multilevel ordinal logistic regression model approach

BackgroundAs a global public health problem, anemia affects more than 400 million women of reproductive age worldwide, mostly in Africa and India. In the DRC, the prevalence of anemia has decreased slightly from 52.9% in 2007, to 46.4% in 2012 and 42.4% in 2019. However, there is considerable regional variation in its distribution. The aim of this study is to determine the factors contributing to anemia in women of reproductive age and to explore its spatial distribution in the DRC.MethodsBased on the Bayesian Multilevel Spatial Ordinal Logistic Regression Model, we used the 2013 Democratic Republic of Congo Demographic and Health Survey (DHS-DRC II) data to investigate individual and environmental characteristics contributing to the development of anemia in women of reproductive age and the mapping of anemia in terms of residual spatial effects.ResultsAge, pregnancy status, body mass index, education level, current breastfeeding, current marital status, contraceptive and insecticide-treated net use, source of drinking water supply and toilet/latrine use including the province of residence were the factors contributing to anemia in women of reproductive age in DRC. With Global Moran's I = -0.00279, p-value ≥ 0.05, the spatial distribution of anemia in women of reproductive age in DRC results from random spatial processes. Thus, the observed spatial pattern is completely random.ConclusionThe Bayesian Multilevel Spatial Ordinal Logistic Regression statistical model is able to adjust for risk and spatial factors of anemia in women of reproductive age in DRC highlighting the combined role of individual and environmental factors in the development of anemia in DRC.

Skill Specificity on High-Skill Online Gig Platforms: Same as in Traditional Labour Markets?

Abstract Political economists and labour sociologists alike have studied how the skill specificity of workers can be explained, as it significantly affects workers’ performance. However, the emergence of the gig economy may substantially change skill hiring and specificity in online labour markets because gig workers do not need formal educational credentials to offer their services. Instead, skills are “unbundled” from occupations, and platforms provide alternative ways to signal competencies, for example, via their rating and review systems. To shed light on the applicability of existing theories to explain the skill profiles of gig workers, we examine what predicts the skills hired in the online gig economy. Based on multilevel ordinal logistic regression analyses of 2336 gig worker profiles, we show that—as in traditional labour markets—gig workers with a vocational degree and longer online work experience are hired for more specific skills. However, national labour market institutions and educational systems affect the gig workers’ skill specificity in the opposite direction than in traditional labour markets. Our findings thus suggest that online gig platforms allow workers to overcome restrictions imposed by national institutions as they are hired for those skills in the online gig economy that are institutionally less facilitated in their home labour markets.

Levels of stunting associated factors among under-five children in Ethiopia: A multi-level ordinal logistic regression analysis.

Stunting is a major public health problem affecting more than one-third of under five year's old children in Ethiopia. It has short and long (irreversible) consequences, including stunted growth, never reaching physical and cognitive potential, struggles in school, and increased morbidity and mortality due to infections. Though stunting is the leading cause of child mortality in Ethiopia, evidence is scarce on the prevalence and predictors of stunting among under-five years old children in Ethiopia. Therefore, this study aimed to estimate the prevalence and predictors of stunting severity among under-5 children in Ethiopia. This study was based on 2019 Mini-Ethiopian Demographic and Health Survey (EDHS) data. A weighted total sample of 4972 under-five years old children was included in the study. Height measurement was collected for each child. Anthropometric indicator, height-for-age was determined for children using World Health Organization growth standards (Z-scores for Height-for-Age (HAZ)) to asses stunting level. Given the ordinal nature of stunting and the hierarchical nature of EDHS data, a multilevel ordinal logistic regression model was applied. Brant test was used to check the proportional odds assumption, which was satisfied (P-value ≥0.05). Moreover, deviance was used for model comparison. For the multivariable analysis, variables with a p-value ≤0.2 in the bivariable analysis were considered. The Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was reported as associated factor to the severity levels of stunting in the multivariable multilevel proportional odds model. The overall prevalence of stunting among under-5 children in Ethiopia was 35.7% [95% CI: 34.4%, 37.1%]. Of these, 12.1% were severely stunted, and 24.9% were moderately stunted. Being male [AOR = 0.83, 95% CI: 0.74, 0.93], children aged 6-23 months [AOR = 2.38, 95% CI: 1.84, 3.07], ≥ 24 months [AOR = 4.15, 95% CI: 3.26, 5.28], children whose maternal age 15-24 years [AOR = 0.73, 95% CI: 0.58, 0.92], children from the poorest, poorer, middle, and richer household wealth were [AOR = 1.84, 95% CI: 1.32, 2.57], [AOR = 1.66, 95% CI: 1.20, 2.31], [AOR = 1.78, 95% CI: 1.29, 2.44], and [AOR = 1.62, 95% CI: 1.20, 2.17], children whose maternal educational status of no formal education and primary education had [AOR = 1.90, 95% CI: 1.28, 2.82], [AOR = 1.78, 95% CI: 1.22, 2.60], Tigray [AOR = 2.95, 95% CI: 1.78, 4.86], Afar [AOR = 1.85, 95% CI: 1.11, 3.10], Amhara [AOR = 1.90, 95% CI: 1.14, 3.14] and Harari [AOR = 1.97, 95% CI: 1.20, 3.25]regions, low community maternal education [AOR = 0.76, 95% CI: 0.62, 0.92] were significantly associated with stunting severity levelling. Stunting among children under five years of old in Ethiopia remains a major public health issue. Improving access to maternal education is related to appropriate child feeding practices and health, particularly in younger and uneducated mothers. Strengthening the family's wealth status is also recommended to reduce stunting. In addition, it is better to support strategies of preconception care for mothers during pregnancy to reduce stunting in the long term.