Multilevel Logistic Regression Analysis Research Articles

Continuation of education after marriage and its associated factors among young adult women: findings from the Bangladesh Demographic and Health Survey 2017–2018

ObjectiveTo identify the individual and community-level variables associated with the continuation of education among currently married young adult women in Bangladesh.DesignCross-sectional data extracted from the Bangladesh Demographic and Health Survey...

Women's Sexual Autonomy and Short Birth Interval in Sub-Saharan Africa: A Multilevel Analysis of Demographic and Health Survey Data.

Sexual autonomy is an inalienable human right to protect and maintain an informed decision over one's body, sexuality, and sexual experience. With the increased attention to women's empowerment and gender equality all over the world, it is surprising that previous research has overlooked the relationship between women's sexual autonomy and short birth intervals. This study examined the association between women's sexual autonomy and short birth intervals in sub-Saharan Africa (SSA). Data were sourced from the Demographic and Health Surveys of 29 sub-Saharan African countries conducted from 2010 to 2019. A total of 222,940 women were included in this study. Multilevel logistic regression analysis was conducted to examine the association between sexual autonomy and short birth interval. The results were presented as adjusted odds ratios (aOR) and significance level was set at p < .05. The overall proportions of sexual autonomy and short birth interval among women in SSA were 75.1% and 13.3%, respectively. Women who reported having sexual autonomy had lower odds of short birth interval [aOR = 0.94; CI = 0.91, 0.96]. The likelihood of short birth interval among women increased with increasing maternal and partner's age but reduced with increasing level of education and wealth index. Given that short birth intervals could have negative maternal and child health outcomes, public health authorities in sub-Saharan African countries should endeavor to promote health interventions and social programs to empower women with low sexual autonomy.

(Un)safe Spaces: The Relationship Between Slavery and Sexual Victimization of Black Women.

Research exploring the correlates of sexual victimization has found sexual victimization to be associated with both individual- and contextual-level factors, including age, gender, poverty, and size of the female population. However, to date, research has been limited in exploring how historical factors, such as slavery, may be associated with the contemporary prevalence of sexual victimization of women. Historical accounts have often suggested that enslaved women often experienced sexual victimization during their enslavement. Despite these accounts, research has been limited in empirically exploring the relationship between slavery and the sexual victimization of Black women. Using the 1860 U.S. Census and the 2019 National Incidence-Based Reporting System, multilevel logistic regression analyses are employed to explore whether slavery is consequential for contemporary instances of Black female sexual victimization. In line with the "legacy effect" framework, the findings from the current study suggest that Black women are significantly more likely to be sexually victimized in counties characterized by larger enslaved populations in 1860. These findings illuminate how historical institutions, despite being outlawed, have contemporary consequences, particularly for Black women. These findings, discussions, avenues for future research, and policy implications are discussed below.

Not all ‘greenness’ is equal: Influence of perceived neighborhood environments on psychological well-being in Chicago

Neighborhood greenness is of growing importance to understand the quality of urban life, including outcomes tied to health and well-being. However, all greenness may not lead to the same outcomes in racially and ethnically segregated cities. There are many factors associated with the influence of greenness, including perceptions of the physical and social environments. By using multilevel logistic regression analysis, this study investigated differences in psychological well-being associated with neighborhood greenness, park use frequency, and perceived neighborhood physical and social settings in Chicago, IL. We used individual-level health data of 4517 Chicago respondents in 77 neighborhoods, which were aggregated into three distinct regions of the city and drawn from the 2020 Healthy Chicago Survey (HCS); neighborhood greenness was measured using the Normalized Difference Vegetation Index (NDVI). Results suggest that: (1) greenness was significantly associated with psychological well-being in Chicago’s North region but not in the other regions; (2) more frequent park use was associated with psychological well-being in the North region but not in the other regions; (3) neighborhood safety was the strongest predictor of psychological well-being in all three regions of Chicago. This study offers theoretical and practical insights on the need for comprehensive assessment that can help disentangle and differentiate the levels of care and maintenance in urban green spaces. By coupling NDVI with geographic differences, researchers can better capture the complex interplay between different aspects of greenness and urban residents’ well-being.

Disability-related policies and practices and sustained employment: A survey and register data study

Abstract Background Many OECD countries implemented reforms to promote sustained employment of employees on long-term sick leave. Still, sustained employment remains low, which is worrying as it may affect the health and well-being of this vulnerable group of workers. This study aimed to examine the extent to which a firm's disability policies and practices increase the likelihood of sustained employment of long-term sick-listed employees with remaining work capacity. Methods Survey data on firms’ disability policies and practices was obtained from the Dutch Employee Insurance Agency (UWV) and linked to register data covering the employment outcomes of all employees that applied for disability benefits between 2006 and 2010 (N = 6103 employees from N = 366 employers). The dependent variable was sustained employment one year after the disability assessment. Implemented disability policies and practices were measured across seven domains: sick leave prevention, absenteeism management, reintegration management, occupational health and safety services (OHS), reintegration activities with the current/another employer, and positive workplace culture. Multilevel multiple logistic regression analyses were performed. Results Sick leave prevention policies (OR = 2.3, 95% CI 1.3-4.0), absenteeism management policies (OR = 1.8, 95% CI 1.0-3.3) and OHS (OR = 1.8, 95 CI 1.1-3.2) were positively associated with sustained employed one year after the disability assessment. No significant results were found for the other domains. Conclusions Employees with remaining work capacity in firms with the most comprehensive absence management policies, prevention policies, and OHS are about twice as likely to continue working one year after the disability assessment than firms with the least comprehensive policies. Legislation that encourages firms to invest more in absence management and prevention policies may result in better employment opportunities for this vulnerable group of employees. Key messages • Firm's prevention and absence management policies could be highly effective in fostering sustained employment of employees on long-term sick leave. • Legislation that encourages firms to invest more in disability policies and practices may result in better employment opportunities, health, and well-being of people with partial work disabilities.

A multilevel analysis model for dental caries determinants in independently-living elderly

To evaluate the prevalence of untreated caries and its association with biological, individual, and environmental variables in independently-living elderly people. Methods: This cross-sectional study included 72 elderly (≥60 years) patients of a university dental clinic in Belo Horizonte, Brazil. Sociodemographic data, systemic diseases, medications, and free sugar intake were collected. Visible plaque, Decayed, Missing, and Filled Teeth (DMFT), and Decayed and Filled Root (DFR) indexes were assessed through clinical examination. Unstimulated saliva was collected to determine salivary flow, pH, and buffering capacity. Descriptive analysis and multilevel logistic regression analysis were performed following a dental caries theoretical model (p &lt;0.05, 95% CI). Results: The mean DMFT and DFR were 24.44 (SD=4.59) and 3.21 (SD=2.93), respectively. The prevalence of untreated caries was 61.11%. In the adjusted multilevel regression model involving 1639 teeth, untreated dental caries was significantly associated with the presence of biofilm (OR = 1.84; 95% CI: 1.24–2.74), salivary buffering capacity (OR = 0.87; 95% CI: 0.77–0.99) and per capita income (OR = 0.06; 95% CI: 0.004–0.74). Conclusion: The experience of dental caries was widespread among independently-living elderly patients, and its variability was best explained by the presence of biofilm, reduced salivary buffering capacity, and low per capita income. A comprehensive assessment is needed of the biological, individual, and environmental factors related to the presence of dental caries in independently-living elderly people.

Multilevel Modeling of Gaze From Listeners With Hearing Loss Following a Realistic Conversation.

There is a need for tools to study real-world communication abilities in people with hearing loss. We outline a potential method for this that analyzes gaze and use it to answer the question of when and how much listeners with hearing loss look toward a new talker in a conversation. Twenty-two older adults with hearing loss followed a prerecorded two-person audiovisual conversation in the presence of babble noise. We compared their eye-gaze direction to the conversation in two multilevel logistic regression (MLR) analyses. First, we split the conversation into events classified by the number of active talkers within a turn or a transition, and we tested if these predicted the listener's gaze. Second, we mapped the odds that a listener gazed toward a new talker over time during a conversation transition. We found no evidence that our conversation events predicted changes in the listener's gaze, but the listener's gaze toward the new talker during a silence-transition was predicted by time: The odds of looking at the new talker increased in an s-shaped curve from at least 0.4 s before to 1 s after the onset of the new talker's speech. A comparison of models with different random effects indicated that more variance was explained by differences between individual conversation events than by differences between individual listeners. MLR modeling of eye-gaze during talker transitions is a promising approach to study a listener's perception of realistic conversation. Our experience provides insight to guide future research with this method.

Patient factors associated with conveyance decision-making by Emergency Medical Services professionals in patients with a syncope: a cross-sectional factorial survey design

BackgroundThe clinical decision-making of non-conveyance is perceived as complex and difficult by emergency medical services (EMS) professionals. Patients with a transient loss of consciousness (TLOC) based on syncope constitute a significant part of the non-conveyance population. Risk stratification is the basis of the clinical decision-making process by EMS professionals. This risk stratification is based on various patient factors. This study aimed to explore patient factors significantly associated with conveyance decision-making by EMS professionals in patients with a TLOC based on syncope.MethodsA cross-sectional vignette study with a factorial survey design was conducted. Patient factors were derived from the “National Protocol Ambulance Care”, and all possible combinations of these factors and underlying categories were combined, resulting in 256 unique vignettes (2*4*4*4*2 = 256). Patient factors presented either low-risk or high-risk factors for adverse events. Data were collected through an online questionnaire, in which participants received a random sample of 15 vignettes. For each vignette, the respondent indicated whether the patient would need to be conveyed to the emergency department or not. A multilevel logistic regression analysis with stepwise backward elimination was performed to analyse factors significantly associated with conveyance decision-making. In the logistic model, we modelled the probability of non-conveyance.Results110 respondents were included, with 1646 vignettes being assessed. Mean age 45.5 (SD 9.3), male gender 63.6%, and years of experience 13.2 (SD 8.9). Multilevel analysis showed two patient factors contributing significantly to conveyance decision-making: ‘red flags’ and ‘prehospital electrocardiogram (ECG)’. Of these patient factors, three underlying categories were significantly associated with non-conveyance: ‘sudden cardiac death < 40 years of age in family history’ (OR 0.33, 95% CI 0.22–0.50; p < 0.001), ‘cardiovascular abnormalities, pulmonary embolism or pulmonary hypertension in the medical history’ (OR 0.62, 95% CI 0.43–0.91; p = 0.01), and ‘abnormal prehospital ECG’ (OR 0.54, 95% CI 0.41–0.72; p < 0.001).ConclusionSudden cardiac death < 40 years of age in family history, medical history, and abnormal ECG are significantly negatively associated with non-conveyance decision-making by EMS professionals in patients with a TLOC based on syncope. Low-risk factors do not play a significant role in conveyance decision-making.

Ending violence against women: Help-seeking behaviour of women exposed to intimate partner violence in sub-Saharan Africa.

Intimate partner violence is a serious public health problem that transcends cultural boundaries in sub-Saharan Africa. Studies have reported that violence characteristics and perception are strong predictors of help-seeking among women. We assessed the prevalence and factors associated with help-seeking among female survivors of intimate partner violence in sub-Saharan Africa. We pooled data from the most recent Demographic and Health Surveys (DHS) of eighteen sub-Saharan African countries. The data were extracted from the women's files in countries with datasets from 2014 to 2021. A weighted sample of 33,837 women in sexual relationships: married or cohabiting who had ever experienced intimate partner violence within the five years preceding the survey were included in the analysis. Percentages with 95% confidence interval (CI) were used to present the results of the prevalence of help-seeking for intimate partner violence. We used a multilevel binary logistic regression analysis to examine the factors associated with help-seeking among survivors of intimate partner violence. The results were presented using adjusted odds ratio (AOR) with their respective 95% CI. Statistical significance was set at p<0.05. Out of the 33,837 women who had ever experienced intimate partner violence in sub-Saharan Africa, only 38.77% (95% CI = 38.26-39.28) of them sought help. Ethiopia had the lowest prevalence of women who sought help after experiencing intimate partner violence (19.75%; 95% CI = 17.58-21.92) and Tanzania had the highest prevalence (57.56%; 95% CI = 55.86-59.26). Marital status, educational level, current working status, parity, exposure to interparental violence, women's autonomy in household decision-making, mass media exposure, intimate partner violence justification, wealth index, and place of residence were associated with help-seeking behaviour of intimate partner violence survivors. The low prevalence of help seeking among women who have experienced intimate partner violence in sub-Saharan Africa calls for the intensification of formal and informal sources of assistance. Education can play a critical role in empowering girls, which may increase future help-seeking rates. Through media efforts aimed at parental awareness, the long-term benefits of females enrolling in school could be achieved. However, concentrating solely on individual measures to strengthen women's empowerment may not bring a significant rise in help-seeking as far as patriarchal attitudes that permit violence continue to exist. Consequently, it is critical to address intimate partner violence from the dimensions of both the individual and violence-related norms and attitudes. Based on the findings, there should be public awareness creation on the consequences of intimate partner violence. Respective governments must increase their coverage of formal support services to intimate partner violence survivors especially those in rural communities.

Effectiveness of silver diamine fluoride versus sodium fluoride varnish combined with mother’s motivational interviewing for arresting early childhood caries: a randomized clinical trial

BackgroundSilver Diamine Fluoride (SDF) has gained attention as one of the minimally invasive modalities to manage ECC although it causes black staining of treated carious lesions. A possible affordable alternative may be Sodium Fluoride (NaF) varnish combined with good oral hygiene promoted by parental Motivational Interviewing (MI). The study compared the effectiveness of 38% SDF solution and 5% NaF varnish supported by parental MI in arresting ECC.Materials and methodsChildren aged ≤ 4 years old with at least one active carious lesion (ICDAS score ≥ 3) were randomly assigned to treatment by a single application of 38% SDF solution or a single application of 5% NaF varnish supported by two MI sessions for mothers at baseline and after three months. Chi-Squared test was used to compare groups and multilevel logistic regression analysis was used to assess the effect of the interventions on ECC arrest adjusting for confounders. The interaction between the type of intervention and baseline lesion severity, moderate (ICDAS 3/4) or advanced (ICDAS 5/6), was also assessed.ResultsThe study included 165 children with 949 active lesions. After 6 months, there were no significant differences between SDF and NaF/MI groups in overall caries arrest (63.7% and 58.1%, p = 0.08), and in moderate lesions (72.9% and 69.6%, p = 0.52). However, in advanced lesions, the arrest rate was significantly higher in the SDF than the NaF/ MI group (60.3% and 50.0%, P = 0.01). Multilevel multiple logistic regression showed no significant differences between the interventions (AOR = 1.56, P = 0.27) with significant interaction between the intervention and baseline lesion severity (p < 0.001). Moderate lesions treated with SDF (AOR = 3.69, P = 0.008) or NaF/MI (AOR = 3.32, P < 0.001) had significantly higher odds of arrest than advanced lesions treated with NaF/ MI with no difference between advanced lesions treated with SDF or NaF/ MI (AOR = 1.85, P = 0.155) in arrest rate.ConclusionNaF/ MI can be an alternative to SDF in arresting advanced and moderate ECC lesions without staining with stronger effect on moderate lesions (ICDAS 3/4).Trial registrationThe trial was retrospectively registered at clinicaltrial.gov registry (#NCT05761041) on 9/3/2023.

Spirometric patterns in young and middle-aged adults: a 20-year European study

BackgroundUnderstanding the natural history of abnormal spirometric patterns at different stages of life is critical to identify and optimise preventive strategies. We aimed to describe characteristics and risk factors of...

Evaluating Knowledge, Attitudes, and Behaviors toward HPV Infection and Vaccination among University Students in Italy.

This survey investigated the knowledge, attitudes, and behaviors towards HPV preventive measures among university students in Italy and their associated factors. The cross-sectional survey was conducted between November 2022 and April 2023. Only 41.7% knew about HPV infection and the main preventive measures. Multilevel mixed-effects logistic regression analysis showed that females, those aged 25-30 years, those who have had oral sex, those who had received information about HPV infection and preventive measures from physicians, and those who needed additional information about HPV infection and preventive measures were more knowledgeable. Only 39.1% have received at least one HPV vaccination dose, whereas 29.2% and 31.7% had not been vaccinated or did not remember. Multilevel mixed-effects logistic regression analysis identified that female students enrolled in the field of health sciences, those who did not report a prior history of a sexually transmitted infection, and those with a higher knowledge about HPV infection and preventive measures were more willing to receive the HPV vaccination. Despite some limitations, this was the first detailed survey on this topic conducted in the post-acute phase of COVID-19 among university students in Italy. The survey underlined the need to develop and to implement comprehensive educational programs and health interventions among students, to enhance their knowledge and modify their attitudes and improve the HPV vaccine uptake.

Determinants of institutional delivery service utilization in Nepal.

Maternal mortality continues to be a pressing concern in global health, presenting an enduring and unmet challenge for healthcare systems worldwide. Utilization of institutional delivery services has been established as a proven intervention to mitigate life-threatening risks for both mothers and newborns. Exploring the determinants of institutional delivery is crucial to improve and enhance maternal and newborn safety. This study aimed to assess the contextual and individual factors associated with institutional delivery in Nepal. This study utilized that data form Nepal Multiple Indicator Survey 2019, which included a sample of 1,932 women who had given birth within the two years prior to the survey. A multilevel logistic regression analysis was performed to determine the significant external environment, contextual and individual predictors of institutional delivery. The women from Madhesh province [Adjusted Odds Ratio (aOR): 0.32, 95% Confidence Interval (CI): 0.17-0.61], as compared to Bagmati province, women from rural areas (aOR: 0.55, 95% CI: 0.39-0.78) as compared to urban areas, and women from a relatively less-advantaged ethnic groups (aOR: 0.52, 95% CI: 0.35-0.76) as compared to the relatively advantaged ethnic groups were less likely to deliver in health institutions. Similarly, women from the poorest (aOR: 0.09, 95% CI: 0.04-0.22) and second wealth groups (aOR: 0.29, 95% CI: 0.13-0.64) were less likely to attend institute for delivery compared to women from the richest household. Women with formal education (aOR: 1.65, 95% CI: 1.16-2.35) were more likely to deliver in an institution over uneducated women. Moreover, the uptake of institutional delivery increased by 59% (aOR: 1.59, 95% CI: 1.43-1.75) for each additional ANC visit. The findings highlight the importance of stepping up efforts to achieve universal health care from the standpoint of long-term government investment, focusing particularly on illiterate women in rural areas, poorer households, and socially disadvantaged groups. Expanding the benefits of maternal benefit schemes targeting the women from the poorest households in the communities is recommended.

School Racial Composition as a Moderator of the Effect of Discrimination on Mental Health and Substance use Among American Indian Adolescents

PurposeTo examine the relationships between individual-level perceived racial/ethnic discrimination and mental health and substance use outcomes by school-level racial composition among American Indian (AI) adolescents. MethodSelf-reported survey data on individual-level variables come from a sample of AI adolescents (n = 510) living in or near the Cherokee Nation during the fall of 2021. School-level data come from publicly available databases. Multilevel linear and logistic regression analyses were performed to test for and examine the interaction between perceived racial/ethnic discrimination and school racial composition in relation to symptoms of anxiety and depression, past 30-day use of alcohol and marijuana, and misuse of prescription opioids. ResultsAdjusted analyses showed a significant interaction effect between discrimination and racial composition on anxiety symptoms, such that the effect of discrimination was more pronounced at lower % AI (10th percentile) than at more equivalently mixed (50th percentile) or higher % AI (90th percentile) school settings. No significant interactions were observed with depressive symptoms or substance use outcomes. DiscussionSchool racial compositions of higher percentage AI may buffer the adverse effect of racial/ethnic discrimination on anxiety symptoms among AI adolescents.

Iron-rich food consumption and associated factors among children aged 6–23 months in Sierra Leone: multi-level logistic regression analysis

BackgroundIron deficiency is the most common micronutrient deficiency worldwide. Also, iron deficiency is a significant public health problem in low- and middle-income countries. Thus, this study aimed to assess iron-rich food consumption and associated factors among children aged 6–23 months in Sierra Leone.MethodThis study is a cross-sectional study based on data from the Sierra Leone Demographic and Health Survey dataset with a total weighted sample of 2622 children aged 6–23 months. Data cleaning, coding, and labeling were done using STATA version 14 software. A multilevel logistic regression model was employed to identify associated factors.ResultAlmost half (53.38%) of children aged between 6–23 months consumed iron-rich foods. The odds of iron rich food consumption were high among children in the age group of 12–17 months (AOR = 4.81, 95% CI: 3.67, 6.31) and 18–23 months (AOR = 9.3, 95% CI: 6.55, 13.2), and who fed minimum acceptable diet (AOR = 22.5, 95% CI: 11.65, 43.46). Moreover, a child from a mother who had work (AOR = 1.49, 95% CI: 1.08, 2.06), and with a mother who had more than four ANC visits during her pregnancy of the most recent live birth (AOR = 1.87; 95%CI: 1.36—2.55) had higher odds of iron-rich food consumption compared to their counterparts. On the other hand, children who were breastfeeding (AOR = 0.72, 95% CI: 0.53, 0.97), and mothers aged 15–19 (AOR = 0.48, 95% CI: 0.27, 0.85) decreased the odds of iron rich food consumption.ConclusionConsumption of iron-rich food is low among children aged 6–23 months in Sierra Leone. Iron-rich food consumption among children was significantly associated with maternal occupation, child’s age, child’s breastfeeding status, taking drugs for intestinal parasites, minimum acceptable diet, frequency, and timing of ANC, and region. Thus, special emphasis should be given to those children aged between 6–11 months, currently breastfeeding, children who did not get the minimum acceptable diet, and children from women who did not have work.

Women's autonomy in refusing risky sex in sub-Saharan Africa: Evidence from 30 countries.

Understanding the factors associated with women's autonomy to refuse risky sex is imperative to inform the development of policies and interventions to reduce the risk of unintended pregnancies, sexually transmitted infections, unsafe abortion, and maternal mortality. This study sought to examine the prevalence and factors associated with women's autonomy to refuse risky sex in sub-Saharan Africa (SSA). Data for the study were extracted from the most recent Demographic and Health Surveys (DHS) of thirty countries in SSA conducted from 2010 to 2020. We included a weighted sample of 260,025 women who were married or cohabiting in the final analysis. Percentages were used to present the results of the prevalence of women's ability to refuse risky sex. We used a multilevel logistic regression analysis to examine the factors associated with women's ability to refuse risky sex. Stata software version 16.0 was used for the analysis. We found that 61.69% (95% confidence interval [CI]: 56.22-67.15) of the women were autonomous to refuse sex if their partners have other women, and this was highest in Namibia (91.44% [95% CI: 90.77-92.18]) and lowest in Mali (22.25% [95% CI: 21.24-23.26]). The odds of autonomy in refusing risky sex was higher among women with higher education (adjusted odds ratio [aOR] = 1.88; 95% CI = 1.78-1.46) compared to those with no formal education. Employment status was also a significant predictor, with working women having higher odds of sex refusal compared to non-working women (aOR = 1.16; 95% CI = 1.13-1.18). Advocacy to improve women's autonomy to refuse risky sex must leverage the mass media as it emerged as a significant factor. Policies and intervention to enhance women's autonomy must also target high-risk sub-populations which constitutes adolescent girls, those with no formal education, and those without employment.

Women empowerment domains and unmet need for contraception among married and cohabiting fecund women in Sub-Saharan Africa: A multilevel analysis based on gender role framework.

Low women empowerment, is a known contributing factor to unmet needs for contraception by limiting access to health services through negative cultural beliefs and practices. However, little is known about the association between unmet needs and domains of women empowerment in Sub-Saharan African (SSA) countries. Hence, this study aimed at assessing the influence of women empowerment domains on the unmet need for contraception in the region using the most recent Demographic and Health Survey (DHS) data (2016-2021). The data for the study was derived from the appended women's (IR) file of eighteen SSA countries. A weighted sample of 128,939 married women was analyzed by STATA version 16. The Harvard Institute's Gender Roles Framework, which comprised of influencer, resource, and decision-making domains was employed to identify and categorize the covariates across three levels. The effects of each predictor on the unmet need for spacing and limiting were examined using a multivariable multilevel mixed-effect multinomial logistic regression analysis. Adjusted relative risk ratio (aRRR) with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables. The pooled prevalence of unmet needs for contraception was 26.36% (95% CI: 24.83-30.40) in the region, with unmet needs for spacing and limiting being 16.74% (95% CI: 16.55, 17.02) and 9.62% (95% CI: 9.45, 12.78), respectively. Among variables in the influencer domain, educational level, family size of more than five, parity, number of children, attitude towards wife beating, and media exposure were substantially linked with an unmet need for spacing and limiting. Being in the poorest wealth quintile and enrollment in health insurance schemes, on the other hand, were the two variables in the resource domain that had a significant influence on unmet needs. The overall decision-making capacity of women was found to be the sole significant predictor of unmet needs among the covariates in the decision-making domain. Unmet needs for contraception in SSA countries were found to be high. Reproductive health program planners and contraceptive service providers should place due emphasis on women who lack formal education, are from low-income families, and have large family sizes. Governments should collaborate with insurance providers to increase health insurance coverage alongside incorporating family planning within the service package to minimize out-of-pocket costs. NGOs, government bodies, and program planners should collaborate across sectors to pool resources, advocate for policies, share best practices, and coordinate initiatives to maximize the capacity of women's decision-making autonomy.

Impact of family involvement and an advance directive to not hospitalize on hospital transfers of residents in long-term care facilities

ObjectiveWith the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia. MethodUsing the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan. ResultsOf the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77–1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28–0.89) among the LTCF residents. ConclusionsAlthough ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care.

PUNCTATE INNER PACHYCHOROIDOPATHY: Demographic and Clinical Features of Inner Choroidal Inflammation in Eyes with Pachychoroid Disease.

To perform an unsupervised machine learning clustering of patients with punctate inner choroidopathy (PIC) and provide new insights into the significance of pachychoroid disease features in PIC eyes. Retrospective multicenter study, including 102 eyes from 82 patients diagnosed with PIC. Demographics, clinical data, and multimodal imaging, including fundus photography, optical coherence tomography, and indocyanine green angiography, were collected. Clusters of eyes were identified, and multilevel logistic regression analysis was performed to compare between-group differences. Using 17 clinical features, two distinct clusters of patients with PIC were identified. Cluster 1 patients were characterized by older age, high myopia, myopic maculopathy features, thin choroids, multiple lesions, and a higher likelihood of developing patchy chorioretinal atrophy. Cluster 2 consisted of younger age, emmetropia or low myopia, thick choroids, choroidal vascular hyperpermeability on late-phase indocyanine green angiography, and high prevalence of focal choroidal excavation. These features exhibited significant differences ( P < 0.05) between the two clusters. While PIC typically affects young myopic female patients with thin choroids, a subset of patients with PIC exhibits features associated with pachychoroid disease. Considering the potential influence of choroidal venous insufficiency on PIC manifestations and secondary complications, we propose the term "punctate inner pachychoroidopathy" to characterize this distinct subtype of PIC.

EU consumer awareness of food safety and healthy diets: Are there synergies to benefit a sustainable protein transition?

This paper aims to gain more insight into potential synergies between food safety and healthy diets with a sustainable protein transition (i.e., reducing protein over-consumption and replacing animal protein with plant protein) in the EU. The paper is based on a systematic analysis of the survey on food safety, organized by the European Food Safety Authority (EFSA) as part of Eurobarometer wave 97.2 (Spring 2022). Consumers responded somewhat differently to the survey items on chemical contaminants in food than to those on biological hazards in food, plant health and animal health and welfare. They were somewhat more aware of and concerned about the former than the latter. They also had different ideas on the most important healthy diet items. Cluster analysis identified five clusters who, inter alia, focused on conventional options (e.g., eating fewer calories) or the protein replacement options. Multilevel logistic regression analysis showed that food safety awareness and concern variables, explicitly including farm animal welfare, were somewhat stronger associated with the protein replacement cluster than with the conventional cluster. Hence, synergies between food safety and healthy diet issues may stimulate the replacement (not reduction) aspects of a sustainable protein transition. The Discussion suggests that further research should investigate how improving the quality of a week menu with a high diversity of protein sources can help to promote the reduction of over-consumption.