Multilevel Mixed-effects Models Research Articles

The Association of County-level Prostate-specific Antigen Screening with Metastatic Prostate Cancer and Prostate Cancer Mortality

Background and objectiveThere exists ongoing debate about the benefits and harms of prostate-specific antigen (PSA) screening for prostate cancer. This study sought to evaluate the association of county-level PSA screening rates with county-level incidence of metastatic prostate cancer and prostate cancer mortality in the USA. MethodsThis ecological study used data from the 2004–2012 Behavioral Risk Factor Surveillance System (BRFSS) to build a multilevel mixed-effect model with poststratification using US Census data to estimate county-level PSA screening rates for all 3143 US counties adjusted for age, race, ethnicity, and county-level poverty rates. The exposure of interest was average county-level PSA screening rate from 2004 to 2012, defined as the proportion of men aged 40–79 yr who underwent PSA screening within the prior 2 yr. The primary outcomes were county-level age-adjusted incidence of regional/distant prostate cancer during 2015–2019 and age-adjusted prostate cancer mortality during 2016–2020. Key findings and limitationsA total of 416221 male BRFSS respondents aged 40–79 yr met the inclusion criteria and were used in the multilevel mixed-effect model. The model was poststratified using 63.4 million men aged 40–79 yr from all 3143 counties in the 2010 Decennial Census. County-level estimated PSA screening rates exhibited geographic variability and were pooled at the state level for internal validation with direct BRFSS state-level estimates, showing a strong correlation with Pearson correlation coefficients 0.77–0.90. A 10% higher county-level probability of PSA screening in 2004–2012 was associated with a 14% lower county-level incidence of regional/distant prostate cancer in 2015–2019 (rate ratio 0.86, 95% confidence interval [CI] 0.85–0.87, p < 0.001) and 10% lower county-level prostate cancer mortality in 2016–2020 (rate ratio 0.90, 95% CI 0.89–0.91, p < 0.001). Conclusions and clinical implicationsIn this population-based ecological study of all US counties, higher PSA screening rates were associated with a lower incidence of regional/distant prostate cancer and lower prostate cancer mortality at extended follow-up. Patient summaryUS counties with higher rates of prostate-specific antigen (PSA) screening had significantly lower rates of metastatic prostate cancer and prostate cancer mortality in subsequent years. These data may inform shared decision-making regarding PSA screening for prostate cancer.

Neonatal mortality rate and determinants among births of mothers at extreme ages of reproductive life in low and middle income countries

Neonatal mortality, which refers to the death of neonates during the first 28 completed days of life, is a critical global public health concern. The neonatal period is widely recognized as one of the most precarious phases in human life. Research has indicated that maternal extreme ages during reproductive years significantly impact neonatal survival, particularly in low- and middle-income countries. Consequently, this study aims to evaluate the neonatal mortality rate and determinants among neonates born to mothers at extreme reproductive ages within these countries. A secondary analysis of demographic and health surveys conducted between 2015 and 2022 in 43 low- and middle-income countries was performed. The study included a total sample of 151,685 live births. Researchers utilized a multilevel mixed-effects model to identify determinants of neonatal mortality. The measures of association were evaluated using the adjusted odds ratio within a 95% confidence interval. The neonatal mortality rate among neonates born to mothers at extreme ages of reproductive life in low- and middle-income countries was 28.96 neonatal deaths per 1000 live births (95% CI 28.13–29.82). Factors associated with higher rates of neonatal mortality include male gender, low and high birth weight, maternal education (no or low), home deliveries, multiple births, short preceding birth intervals, lack of postnatal checkups, and countries with high fertility and low literacy rates. This study sheds light on the neonatal mortality rates among neonates born to mothers at extreme ages of reproductive life in low- and middle-income countries. Notably, we found that neonatal mortality was significantly higher in this group compared to neonatal mortality rates reported regardless of maternal ages. Male babies, low and high birth-weighted babies, those born to mothers with no or low education, delivered at home, singletons, babies born with a small preceding birth interval, and those without postnatal checkups faced elevated risks of neonatal mortality. Additionally, neonates born in countries with high fertility and low literacy rates were also vulnerable. These findings underscore the urgent need for targeted interventions tailored to mothers at extreme ages. Policymakers and healthcare providers should prioritize strategies that address specific risk factors prevalent in these vulnerable populations. By doing so, we can improve neonatal outcomes and ensure the survival of these newborns during the critical neonatal period.

Failure to rescue following emergency general surgery: A national analysis

BackgroundFailure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event. MethodsAll adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016–2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR. ResultsAmong 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23–1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17–1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI. ConclusionOur findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.

Relationship between chlorhexidine gluconate concentration and microbial colonization of patients' skin.

To characterize the relationship between chlorhexidine gluconate (CHG) skin concentration and skin microbial colonization. Serial cross-sectional study. Adult patients in medical intensive care units (ICUs) from 7 hospitals; from 1 hospital, additional patients colonized with carbapenemase-producing Enterobacterales (CPE) from both ICU and non-ICU settings. All hospitals performed routine CHG bathing in the ICU. Skin swab samples were collected from adjacent areas of the neck, axilla, and inguinal region for microbial culture and CHG skin concentration measurement using a semiquantitative colorimetric assay. We used linear mixed effects multilevel models to analyze the relationship between CHG concentration and microbial detection. We explored threshold effects using additional models. We collected samples from 736 of 759 (97%) eligible ICU patients and 68 patients colonized with CPE. On skin, gram-positive bacteria were cultured most frequently (93% of patients), followed by Candida species (26%) and gram-negative bacteria (20%). The adjusted odds of microbial recovery for every twofold increase in CHG skin concentration were 0.84 (95% CI, 0.80-0.87; P < .001) for gram-positive bacteria, 0.93 (95% CI, 0.89-0.98; P = .008) for Candida species, 0.96 (95% CI, 0.91-1.02; P = .17) for gram-negative bacteria, and 0.94 (95% CI, 0.84-1.06; P = .33) for CPE. A threshold CHG skin concentration for reduced microbial detection was not observed. On a cross-sectional basis, higher CHG skin concentrations were associated with less detection of gram-positive bacteria and Candida species on the skin, but not gram-negative bacteria, including CPE. For infection prevention, targeting higher CHG skin concentrations may improve control of certain pathogens.

Comparison between total weight loss and other metrics after bariatric surgery using a multilevel mixed-effects linear regression model.

Several tools are used to assess postoperative weight loss after bariatric surgery, including the percentage of excess body weight loss (%EWL), percentage of total weight loss (%TWL), and percentage of excess body mass index (BMI) loss (%EBMIL). A repeated series of measurements should be considered to assess weight loss as accurately as possible. This study aimed to test weight loss metrics. Data were obtained from a prospective database of patients with obesity who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between 2016 and 2017 in a French tertiary referral bariatric center. A multilevel mixed-effects linear regression model with repeated measures was used to analyze repeated weight measurements over time. A total of 435 patients underwent LRYGB (n = 266) or LSG (n = 169). At 2years, the average %EWL, %EBMIL, and %TWL were 56.8%, 61.3%, and 26.6%, respectively. Patients who underwent LSG experienced lower weight loss (β: -4233 in %TWL model, β: -6437 in %EWL model, and β: -6989 in %EBMIL model) than those who underwent LRYGB. In multivariate mixed analysis, preoperative BMI was not significantly associated with %TWL at 2years (β, -0.09 [-0.22-0.03] p = 0.1). Preoperative BMI was negatively associated with both %EWL (β, -1.61 [-1.84--1.38] p < 0.0001) and %EBMIL (β, -1.91 [-2.16--1.66] p < 0.0001). This is the first study to assess %TWL use for postoperative weight measurement, using a multilevel mixed-effects linear regression model %TWL is the measure of choice to assess weight loss following bariatric surgery.

Determinants of tobacco use among pregnant women in sub-Saharan Africa. A multilevel mixed-effect logistic regression model.

Although it is known that maternal tobacco use during pregnancy substantially declined in higher-income countries, information on the magnitude and determinants of tobacco use among pregnant women in sub-Saharan Africa (SSA) remains limited. Establishing evidence on maternal tobacco during pregnancy is crucial for guiding targeted interventions in SSA. This study aimed to determine the overall prevalence of tobacco use and its determinants among pregnant women in SSA countries. The study used data from Demographic and Health Surveys conducted in 33 countries across SSA from 2010 and 2021. Our analysis included a total weighted sample of 40,291 pregnant women. A multilevel logistic regression model was used to identify factors associated with maternal tobacco use during pregnancy. The measure of association between explanatory variables and the outcome was reported using adjusted odds ratios (AORs) with 95% confidence intervals (CIs). The pooled prevalence of tobacco use among pregnant women in SSA was 1.76% (95% CI: 1.41, 2.12). Our findings showed that pregnant women in the age groups of 25-34 years (AOR 1.44; 95% CI: 1.14, 1.82) and 35+ years (AOR 2.18; 95% CI: 1.68, 2.83) had higher odds of tobacco use during pregnancy. Pregnant women who attained primary education (AOR 0.57; 95% CI: 0.46, 0.70) and secondary or higher education (AOR 0.39; 95% CI: 0.30, 0.53) were associated with lower odds of tobacco use. Similarly, pregnant women who resided in households with a high wealth index (AOR 0.36; 95% CI: 0.55 0.90) and those with media exposure (AOR 0.81; 95% CI: 0.67, 0.99) were less likely to use tobacco during pregnancy. This study revealed that the overall prevalence of maternal tobacco use during pregnancy was relatively low in SSA, but some countries exhibited higher estimates. To address this, it is crucial to implement targeted smoking prevention and cessation strategies, particularly for young pregnant women, those facing socioeconomic disadvantages, and those with lower educational status.

Assessing the impact of CHARM2, a family planning program on gender attitudes, intimate partner violence, reproductive coercion, and marital quality in India.

Using a two-armed cluster randomised controlled trial, CHARM2 (Counselling Husbands to Achieve Reproductive health and Marital equity), a 5-session gender equity and family planning intervention for couples in rural India, showed an impact on family planning outcomes in primary trial analyses. This study examines its effects on gender-equitable attitudes, intimate partner violence, reproductive coercion, and marital quality. We used multilevel mixed-effects models to assess the intervention impact on each outcome. Both male (aIRR at 9 months: 0.64, C.I.: 0.45,0.90; aIRR at 18 months: 0.25, C.I.: 0.18,0.39) and female (aIRR at 9 months: 0.57, C.I.: 0.46,0.71; aIRR at 18 months: 0.38, C.I.: 0.23,0.61) intervention participants were less likely than corresponding control participants to endorse attitudes accepting physical IPV at 9- and 18-month follow-ups. Men in the intervention, compared to those in the control condition, reported more gender-equitable attitudes at 9- and 18 months (ß at 9 months: 0.13, C.I.: 0.06,0.20; ß at 18 months: 0.26, C.I.: 0.19,0.34) and higher marital quality at the 18-month follow-up (ß: 0.03, C.I.: 0.01,0.05). However, we found no effects on women's experiences of IPV, reproductive coercion, or marital quality. CHARM2 shows promise in improving men's and women's attitudes towards gender equality and male perceptions of marital quality. Still, IPV and reproductive coercion reductions may require more intensive programming than that provided within this 5-session model focused on family planning.

Sleep hygiene measures combined with mindfulness meditation in the management of sleep bruxism in children: A randomized controlled clinical trial.

Sleep hygiene measures and meditation may reduce stress and improve sleep quality, but their effect on the occurrence of sleep bruxism in children has not yet been investigated. To explore the effects of sleep hygiene measures combined with mindfulness meditation (relaxation audio) in the management of probable sleep bruxism (SB) in children. This clinical trial (no. NCT04501237) randomized 36 children with 3-8 years of age. Probable SB detection was performed according to the criteria established by the International Consensus on The Assessment of Bruxism-2018. Intervention group was instructed to practice sleep hygiene measures and mindfulness meditation (i.e., the use of a digital app to broadcast audio relaxation) each night before bedtime for 5 weeks; control group did not receive guidance for therapies. Parents completed a bruxism diary for 5 weeks, and the outcome was the number of SB episodes-day reported in the week (ranging from 0 to 7) in each period. A multilevel mixed-effects Poisson regression model was performed. A total of 32 children (mean age: 6.1 years) completed the study. The children who received the therapies related to sleep hygiene measures and mindfulness meditation had a reduction in the SB incidence rate ratio (IRR)of 46% (IRR = 0.54 [Confidence Interval 95%, 0.45-0.65]) during a 5-week observation period. The sensitivity analyses did not show relevant changes in the measure of the effect. Sleep hygiene measures combined with mindfulness meditation reduced the SB in children.

The impact of COVID-19 on police officer wellness

ABSTRACT Disaster policing requires considerably more effort than working under normal conditions, thereby exacerbating existing threats to employee wellness. Research suggests that such working conditions may be harmful to physical and mental health outcomes, including increasing absenteeism. This study relies on personnel records from 3,398 police officers across 12 police services to determine the extent to which the COVID-19 pandemic impacted police officer work attendance and absenteeism, controlling for officer – and community-level characteristics. Results indicate that compared to the previous time-period, work attendance decreased during the COVID-19 pandemic and absenteeism increased. Data shows that a greater proportion of officers worked fewer days during the pandemic compared to the time-period before, and a smaller proportion worked a greater number of days. Multilevel mixed effects models indicate that COVID-19 largely contributed to decreasing attendance and increasing absenteeism beyond the effects of community conditions and officer demographics.

Association between Child Mortality and Healthcare Facility Level Factors: Evidence from Nationally Representative Survey

Child mortality is an important indicator of child health and overall national development. Under-five mortality is unacceptably high in Low- and Middle-Income Countries (LMICs) including Bangladesh. Increased availability and access to the healthcare services can play a significant role to reduce under-five mortality. The aim of this study was to explore the associations of several forms of child mortality with health facility level factors. Data were extracted from the 2017-18 Bangladesh Demographic and Health Survey data and 2017 Bangladesh Health Facility Survey data. Three outcome variables were considered: neonatal mortality, infant mortality, and under-five mortality in this study. Health facility level factors were considered as major explanatory variables. They were the availability of the child healthcare services at the nearest healthcare facility, readiness of the nearest healthcare facility to provide child healthcare services and the average distance of the nearest healthcare facility providing child healthcare services. Multilevel mixed-effect logistic regression model was used to determine the associations between the outcome variables and explanatory variables adjusted for covariates. We reported under-five, infant and neonatal mortality were 40, 37, and 30 per 1000 live births, respectively. The likelihood of neonatal and infant mortality was found to be declined for one-unit increase on the availability and readiness of the mothers’ homes nearest healthcare facilities to provide child healthcare services. On contrary, for every kilometre increased distance between mothers’ homes and their nearest healthcare facility was found to be associated with increased in the likelihoods of neonatal, infant and under-five mortality. The availability of health facilities providing child healthcare services close to residence and their improved management, infrastructure, and readiness to provide child healthcare services play a significant role in reducing under-five mortality in Bangladesh. Policies and programs should prioritize to increase the availability and accessibility of health facilities that provide child healthcare services.

Recommended homemade fluid utilization for the treatment of diarrhea and associated factors among children under five in sub-Saharan African countries: a multilevel analysis of the recent demographic and health survey

IntroductionDiarrhea is a common public health problem and the third leading cause of death in the world among children under the age of five years. An estimated 2 billion cases and 1.9 million deaths are recorded among children under the age of five years every year. It causes body fluid loss and electrolyte imbalance. Even though, early initiation of recommended homemade fluid is a simple and effective approach to prevent diarrhea-related complications and mortality of children, recommended homemade fluid utilization for the treatment of diarrhea is still low in sub-Saharan African countries. Therefore, this study aimed to assess the magnitude of recommended homemade fluid utilization for the treatment of diarrhea and associated factors among children under five in sub-Saharan African countries.MethodThe most recent Demographic and Health Survey dataset of 21 sub-Saharan African countries from 2015 to 2022 was used for data analysis. A total of 33,341 participants were included in this study as a weighted sample. Associated factors were determined using a multilevel mixed-effects logistic regression model. Significant factors in the multilevel mixed-effect logistic regression model were declared significant at p-values < 0.05. The adjusted odds ratio (AOR) and confidence interval (CI) were used to interpret the results.ResultThe overall recommended homemade fluid utilization for the treatment of diarrhea among children under five in sub-Saharan African countries was 19.08% (95% CI = 18.66, 19.51), which ranged from 4.34% in Burundi to 72.53% in South Africa. In the multivariable analysis, being an educated mother/caregiver (primary and secondary level) (AOR = 1.15, 95% CI: 1.04, 1.27) and (AOR = 1.30, 95% CI: 1.15, 1.1.47), the primary and secondary level of fathers education (AOR = 1.53, 95% CI: 1.37, 1.71) and (AOR = 1.41, 95% CI: 1.19, 1.1.68), having antenatal care follow-up (AOR = 1.16, 95% CI: 1.01, 1.33), having multiple children (AOR = 1.17, 95% CI: 1.07, 1.28), and being an urban dweller (AOR = 1.15, 95% CI: 1.04, 1.27) were factors associated with recommended homemade fluid utilization.ConclusionThe overall recommended homemade fluid utilization for the treatment of diarrhea was low. Individual and community-level variables were associated with recommended homemade fluid utilization for the treatment of diarrhea. Therefore, special consideration should be given to rural dwellers and caregivers who have three and below children. Furthermore, better to strengthen the antenatal care service, mother/caregiver education, and father’s education to enhance recommended homemade fluid utilization for the treatment of diarrhea.

The magnitude of stunting and its determinants among late adolescent girls in East Africa: Multilevel binary logistics regression analysis.

Stunting poses a significant health risk to adolescent girls aged 15-19 in low- and middle-income countries, leading to lower education levels, reduced productivity, increased disease vulnerability, and intergenerational malnutrition. Despite the inclusion of adolescent nutrition services in the Sustainable Development Goals, little progress has been made in addressing malnutrition among adolescent girls in several African nations. Limited evidence exists in East Africa due to small sample sizes and methodological limitations. To overcome these constraints, this study utilizes the latest Demographic and Health Survey data to estimate the prevalence and factors influencing stunting among late adolescent girls in ten East African countries. This study utilized the most recent Demographic and Health Survey (DHS) data from 10 East African countries, including a total sample weight of 22,504 late-adolescent girls. A multilevel mixed-effect binary logistic regression model with cluster-level random effects was employed to identify factors associated with stunting among these girls. The odds ratio, along with the 95% confidence interval, was calculated to determine individual and community-level factors related to stunting. A p-value less than 0.05 was considered statistically significant in determining the factors influencing stunting among late-adolescent girls. The prevalence of stunting among late adolescent girls in East Africa was found to be 13.90% (95% CI: 0.13-0.14). Religion, relationship to the head, presence of under-five children in the household, lactating adolescent, marital status, Time to get water source, and country of residence were significantly associated with Stunting. This study highlights the complexity of stunting in East Africa and identifies key factors that need attention to reduce its prevalence. Interventions should focus on improving water access, supporting lactating girls, addressing socioeconomic disparities, promoting optimal care practices, and implementing country-specific interventions to combat stunting and improve adolescent girls' nutrition.

Agroecosystem-based analysis of household dietary diversity and its linkage with agricultural production diversification in the Upper Blue Nile Basin, Ethiopia: Multilevel analysis approach

Even though the UN's Sustainable Development Goals emphasize improving dietary diversity and overall nutritional status globally by promoting sustainable agriculture, inadequately diversified dietary intake remains a public health problem in many low-income countries, including in Sub-Saharan Africa. The main objective of this study was to gather relevant information to gain an improved understanding of household dietary diversity and explore the role that production diversification could play within household diets and nutrition so that appropriate interventions could be implemented with the goal of enhancing nutrition-sensitive agriculture while also considering the varied features across the agroecosystems. Agroecosystem-based cross-sectional study design was employed. Data were collected predominantly through semi-structured questionnaires and analyzed by descriptive and inferential statistics, and a multilevel mixed-effect model. Results showed that the usual dietary intake of households has a monotonous pattern dominated by starchy staple foods, and consumption of fruits, vegetables, and animal-sourced foods was very limited. One out of five households had inadequate dietary diversity but varied significantly across agroecosystems. About 26% of the heterogeneity in dietary diversity was attributed due to agroecosystem level factors. In the fixed-effect part of the model, production diversification, wealth status, number of meals per day, market access, and annual mean rainfall were significantly associated with household dietary diversity status. The findings of our research contribute to give insights on the linkage between dietary diversity and production diversification among subsistence rural farmers across contrasting agroecosystem zones. Therefore, understanding agroecosystem variations and local context in the rural subsistence farming setup is a key point in designing nutrition-sensitive agriculture.

Risky sexual behavior and associated factors among reproductive age women in eastern African countries: a multilevel analysis of the recent demographic and health survey

IntroductionRisky sexual behavior exposes an individual to the risk of contracting sexually transmitted infections including human immunodeficiency virus (HIV). Even though risky sexual behavior is a devastating problem in low- and middle-income countries, studies on risky sexual behavior and associated factors among reproductive-age women in Eastern African countries are limited. Therefore, this study aimed to assess the magnitude of risky sexual behavior and associated factors among reproductive-age women in Eastern African countries that help to target high-risk groups and set appropriate intervention.MethodThe appended and recent Demographic and Health Survey dataset of 10 Eastern African countries from 2012 to 2022 was used for data analysis. A total of 111,895 participants were included in this study as a weighted sample. Associated factors were determined using a multilevel mixed-effects logistic regression model. Significant factors in the multilevel mixed-effect logistic regression model were declared significant at p-values < 0.05. The adjusted odds ratio (AOR) and confidence interval (CI) were used to interpret the results.ResultThe overall magnitude of risky sexual behavior among reproductive-age women in Eastern African countries was 28.16% (95% CI 27.90%, 28.43%), which ranged from 3.80% in Ethiopia to 67.13% in Kenya. In the multivariable analysis, being a younger woman, being an educated woman, being tested for human immunodeficiency virus, having work, drinking alcohol, and being an urban dweller were factors that were significantly associated with higher odds of risky sexual behavior.ConclusionThe overall magnitude of risky sexual behavior among reproductive-age women in Eastern African countries was high. Individual-level (being a younger woman, being an educated woman, being tested for human immunodeficiency virus, having work, and drinking alcohol) and community-level (being an urban dweller) variables were associated with higher odds of risky sexual behavior. Therefore, policymakers and other stakeholders should give special consideration to urban dwellers, educated, worker and younger women. Better to improve the healthy behavior of women by minimizing alcohol consumption and strengthening HIV testing and counseling services to reduce the magnitude of risky sexual behavior.

Prevalence of childhood stunting and determinants in low and lower-middle income African countries: Evidence from standard demographic and health survey.

Undernutrition poses a significant global public health challenge, adversely affecting childhood cognitive and physical development while increasing the risk of disease and mortality. Stunting, characterized by impaired growth and development in children due to insufficient psychological stimulation, frequent infections, and inadequate nutrition, remains a critical issue. Although economic growth alone cannot fully address the prevalence of stunting, there exists a robust correlation between a country's income level and childhood stunting rates. Countries with higher incomes tend to have lower rates of childhood stunting. Notably, while childhood stunting is declining worldwide, it remains persistent in Africa. Consequently, this study aims to assess the prevalence of childhood stunting and its determinants in low- and lower-middle-income African countries. This study conducted a secondary analysis of standard demographic and health surveys in low- and lower-middle-income African countries spanning the period from 2010 to 2022. The analysis included a total sample of 204,214 weighted children under the age of five years. To identify the determinants of stunting, we employed a multilevel mixed-effect model, considering the three levels of variables. The measures of association (fixed effect) were determined using the adjusted odds ratio at a 95% confidence interval. Significance was declared when the association between the outcome variable and the explanatory variable had a p-value less than 0.05. In low and lower-middle-income African countries, 31.28% of children under five years old experience stunting, with a 95% confidence interval ranging from 31.08% to 31.48%. The results from a multilevel mixed-effect analysis revealed that 24 months or more of age of child, male gender, low and high birth weight, low and high maternal BMI, no and low maternal education, low household wealth index, multiple (twin or triplet) births, rural residence, and low income of countries were significantly associated with childhood stunting. Stunting among children under five years of age in low- and lower-middle-income African countries was relatively high. Individual, community, and country-level factors were statistically associated with childhood stunting. Equally importantly, with child, maternal, and community factors of stunting, the income of countries needs to be considered in providing nutritional interventions to mitigate childhood stunting in Africa.

A longitudinal cohort study on the use of health and care services by older adults living at home with/without dementia before and during the COVID-19 pandemic: the HUNT study.

Older adults and people with dementia were anticipated to be particularly unable to use health and care services during the lockdown period following the COVID-19 pandemic. To better prepare for future pandemics, we aimed to investigate whether the use of health and care services changed during the pandemic and whether those at older ages and/or dementia experienced a higher degree of change than that observed by their counterparts. Data from the Norwegian Trøndelag Health Study (HUNT4 70 + , 2017-2019) were linked to two national health registries that have individual-level data on the use of primary and specialist health and care services. A multilevel mixed-effects linear regression model was used to calculate changes in the use of services from 18months before the lockdown, (12 March 2020) to 18months after the lockdown. The study sample included 10,607 participants, 54% were women and 11% had dementia. The mean age was 76years (SD: 5.7, range: 68-102years). A decrease in primary health and care service use, except for contact with general practitioners (GPs), was observed during the lockdown period for people with dementia (p < 0.001) and those aged ≥ 80years without dementia (p = 0.006), compared to the 6-month period before the lockdown. The use of specialist health services decreased during the lockdown period for all groups (p ≤ 0.011), except for those aged < 80years with dementia. Service use reached levels comparable to pre-pandemic data within one year after the lockdown. Older adults experienced an immediate reduction in the use of health and care services, other than GP contacts, during the first wave of the COVID-19 pandemic. Within primary care services, people with dementia demonstrated a more pronounced reduction than that observed in people without dementia; otherwise, the variations related to age and dementia status were small. Both groups returned to services levels similar to those during the pre-pandemic period within one year after the lockdown. The increase in GP contacts may indicate a need to reallocate resources to primary health services during future pandemics. The study is registered at ClinicalTrials.gov, with the identification number NCT04792086.

Examining the scale effect of nearby residential green space on residents’ BMI: A case study of Guangzhou, China

Green spaces are closely related to the quality of the urban environment and public health. However, studies have rarely paid attention to nearby residential green space which is more closely connected to residents’ daily lives. Does nearby residential green space have a scale effect on the body mass index (BMI) of residents? What type of green space has a more significant effect? Does this effect differ for residents living in central urban areas and suburban areas? To answer these questions, this study first measured three scales of nearby residential green space accessibility of 1398 samples of 18 neighborhoods’ survey data in Guangzhou, China, combined with the application of the TIQS (Travel O-D point Intelligent Query System). And then, multilevel mixed-effects models were developed to examine the scale effect of nearby residential green space accessibility on residents’ BMI. The results show that nearby residential green space has a scale effect on individual BMI and the effect of the 10-minute walking scale is the most significant. Within a 10-minute walking distance from the residence, the larger the green space and the more accessible it is, the lower the individual’s BMI. Parks are the green spaces that are most correlated to residents’ BMI, but their effect is somewhat different between the central urban areas and suburban areas. These findings give us a better understanding of the association between nearby residential green space and public health, as well as providing implications for the improvement of the urban green space system and policy development for healthy cities.

Effects of a work schedule with abated quick returns on insomnia, sleepiness and work-related fatigue: Results from a large-scale cluster randomized controlled trial.

To investigate the effect of a work schedule with abated quick returns (i.e., >11 hours between two shifts) on insomnia, daytime sleepiness, and work-related fatigue compared to a shift schedule maintaining the usual number of quick returns. A two-armed cluster randomized controlled trial including 66 units was conducted at a university hospital in Norway. Units with healthcare workers on rotating shift schedules were randomly assigned to a shift schedule with abated quick returns (intervention) or to continue with a schedule including quick returns as usual (control) for six months. Questionnaires assessed symptoms of insomnia (Bergen Insomnia Scale), daytime sleepiness (Epworth Sleepiness Scale), and work-related fatigue (Revised Swedish Occupational Fatigue Inventory) at baseline and towards the end of the intervention. Data was analyzed using multilevel linear mixed-effects models, and Cohen's d was used to calculate the effect size between groups. Overall, 1314 healthcare workers (85.2% female) completed the baseline questionnaire (response rate 49.1%), and 552 completed the follow-up questionnaire. The intervention reduced quick returns from an average of 13.2 (SD=8.7) to 6.7 (SD=6.0), while the control group's average remained relatively unchanged from 13.2 (SD=8.7) to 12.0 (SD=9.3). Results showed a small improvement in symptoms of insomnia (BIS; d=-0.13, p=0.022) and daytime sleepiness (ESS; d=-0.14, p=0.013) in favor of the intervention. No effects were observed on work-related fatigue. Reducing the number of quick returns resulted in improvements in insomnia and daytime sleepiness. The findings highlight the importance of sufficient rest time in the work schedule of healthcare workers.

Cycling speed variation: a multilevel model of characteristics of cyclists, trips and route tracking points

AbstractSmooth cycling can improve the competitiveness of bicycles. Understanding cycling speed variation during a trip reveals the infrastructure or situations which promote or prevent smooth cycling. However, research on this topic is still limited. This study analyses speed variation based on data collected in the Netherlands, using GPS-based devices, continuously recording geographical positions and thus the variation in speeds during trips. Linking GPS data to spatial data sources adds features that vary during the trip. Multilevel mixed-effects models were estimated to test the influence of factors at cyclist, trip and tracking point levels. Results show that individuals who prefer a high speed have a higher average personal speed. Longer trips and trips made by conventional electric bicycles and sport bicycles have a higher average trip speed. Tracking point level variables explain intra-trip cycling speed variations. Light-medium precipitation and tailwind increase cycling speed, while both uphill and downhill cycling is relatively slow. Cycling in natural and industrial areas is relatively fast. Intersections, turns and their adjacent roads decrease cycling speed. The higher the speed, the stronger the influence of infrastructure on speed. Separate bicycle infrastructure, such as bike tracks, streets and lanes, increase speed. These findings are useful in the areas of cycling safety, mode choice models and bicycle accessibility analysis. Furthermore, these findings provide additional evidence for smooth cycling infrastructure construction.

Availability and readiness of healthcare facilities and their effects on antenatal care services uptake in Bangladesh

BackgroundSustainable Development Goal (SDG) 3.7 aims to ensure universal access to sexual and reproductive healthcare services, where antenatal care (ANC) is a core component. This study aimed to examine the influence of health facility availability and readiness on the uptake of four or more ANC visits in Bangladesh.MethodsThe 2017/18 Bangladesh Demographic and Health Survey data were linked with the 2017 Health Facility Survey and analyzed in this study. The associations of health facility-level factors with the recommended number of ANC uptakes were determined. A multilevel mixed-effect logistic regression model was used to determine the association, adjusting for potential confounders.ResultsNearly 44% of mothers reported four or more ANC uptakes, with significant variations across several areas in Bangladesh. The average distance of mothers' homes from the nearest health facilities was 6.36 km, higher in Sylhet division (8.25 km) and lower in Dhaka division (4.45 km). The overall uptake of the recommended number of ANC visits was positively associated with higher scores for the management (adjusted odds ratio (aOR) 1.85; 95% CI, 1.16–2.82) and infrastructure (aOR, 1.59; 95% CI, 1.09–2.19) of health facilities closest to mothers' homes. The odds of using the recommended number of ANC in mothers increased by 3.02 (95% CI, 2.01–4.19) and 2.36 (95% CI, 2.09–3.16) folds for each unit increase in the availability and readiness scores to provide ANC services at the closest health facilities, respectively. Every kilometer increase in the average regional-level distance between mothers' homes and the nearest health facilities reduced the likelihood of receiving the recommended number of ANC visits by nearly 42% (aOR, 0.58, 95% CI, 0.42–0.74).ConclusionThe availability of healthcare facilities close to residence, as well as their improved management, infrastructure, and readiness to provide ANC, plays a crucial role in increasing ANC services uptake. Policies and programs should prioritize increasing the availability, accessibility, and readiness of health facilities to provide ANC services.