Multilevel Mixed-effects Models Research Articles

Metal and oxidative potential exposure through particle inhalation and oxidative stress biomarkers: a 2-week pilot prospective study among Parisian subway workers

ObjectiveIn this pilot study on subway workers, we explored the relationships between particle exposure and oxidative stress biomarkers in exhaled breath condensate (EBC) and urine to identify the most relevant biomarkers for a large-scale study in this field.MethodsWe constructed a comprehensive occupational exposure assessment among subway workers in three distinct jobs over 10 working days, measuring daily concentrations of particulate matter (PM), their metal content and oxidative potential (OP). Individual pre- and post-shift EBC and urine samples were collected daily. Three oxidative stress biomarkers were measured in these matrices: malondialdehyde (MDA), 8-hydroxy-2′deoxyguanosine (8-OHdG) and 8-isoprostane. The association between each effect biomarker and exposure variables was estimated by multivariable multilevel mixed-effect models with and without lag times.ResultsThe OP was positively associated with Fe and Mn, but not associated with any effect biomarkers. Concentration changes of effect biomarkers in EBC and urine were associated with transition metals in PM (Cu and Zn) and furthermore with specific metals in EBC (Ba, Co, Cr and Mn) and in urine (Ba, Cu, Co, Mo, Ni, Ti and Zn). The direction of these associations was both metal- and time-dependent. Associations between Cu or Zn and MDAEBC generally reached statistical significance after a delayed time of 12 or 24 h after exposure. Changes in metal concentrations in EBC and urine were associated with MDA and 8-OHdG concentrations the same day.ConclusionAssociations between MDA in both EBC and urine gave opposite response for subway particles containing Zn versus Cu. This diverting Zn and Cu pattern was also observed for 8-OHdG and urinary concentrations of these two metals. Overall, MDA and 8-OHdG responses were sensitive for same-day metal exposures in both matrices. We recommend MDA and 8-OHdG in large field studies to account for oxidative stress originating from metals in inhaled particulate matter.

Abstract MP04: Socioeconomic Spatial Social Polarization and Blood Pressure at Three Spatial Levels

Spatial social polarization (SSP) indices measure how a population is distributed at extremes of privilege and deprivation. The choice of spatial level for analysis impacts the results of studies of SSP, resulting in a bias known as the Modifiable Areal Unit Problem (MAUP). The objective of this study is to examine the association between participant SSP with systolic and high blood pressure among Black and White adults in the CHS and REGARDS studies across three spatial levels: ZCTA, census tract, and county. We used the Index of Concentration at the Extremes (ICE) to measure SSP across socioeconomic domains including race/ethnicity, income, joint race/ethnicity with income, and home ownership using ZCTA-, census tract-, and county-level data. We computed quintiles for each geographic level, with quintile 1 representing the most deprived area and quintile 5 representing the most privileged for each SSP domain measured. High BP was defined as a treated or untreated blood pressure >140/90 mmHg. Multilevel mixed-effects regression models were adjusted for source study and a priori defined covariates with a random intercept for spatial level. The magnitude of the association between spatial privilege and blood pressure was higher at more local levels. We found that study participants who resided in the most polarized and disadvantaged quintile for race/ethnicity had an odds ratio of 1.01 (95% CI: 0.87, 1.16), 1.20 (95% CI: 1.06, 1.35), and 1.24 (95% CI: 1.09, 1.40) at the county, ZCTA, and tract level respectively for high blood pressure compared to those in the most polarized privileged groups for race/ethnicity. Similar results were found for systolic blood pressure, though results varied by the ICE domain examined. These varying effects as a result of MAUP may be functions of the larger area units not capturing the underlying granular SSP distributions of deprivation and privilege and washing out the total effects of spatial polarization on blood pressure.

Assessing health determinants worldwide: Econometric analysis of the Global Burden of Diseases Study 2000-18 - Highlighting impactful factors on DALY, YLL, and YLD indicators.

As the health status of a population is influenced by a variety of health determinants, we sought to assess their impact on health outcomes, both at the global and regional levels. This ecological study encompassed all 194 member countries of the World Health Organization (WHO) from 2000 to 2018. We first identified all health determinants and then retrieved the related data from various global databases. We additionally considered three indicators - disability-adjusted life years (DALYs), years of life lost (YLL), and years lived with disability (YLD) - in evaluating health outcomes; we extracted their data from the Global Burden of Disease (GBD) 2019 study. We then applied econometric analyses using a multilevel mixed-effects linear regression model. The analysis using the DALY indicator showed that the variables of sexually transmitted infections, injuries prevalence, and urbanisation had the highest effect size or regression coefficients (β) for health outcomes. The variables of sexually transmitted infection (β = 0.75, P < 0.001) in the African region; drinking water (β = -0.60, P < 0.001), alcohol use (β = 0.20, P < 0.001), and drug use (β = 0.05, P = 0.036) in the Americas region; urbanisation (β = -0.34, P < 0.001) in the Eastern Mediterranean region; current health expenditure (β = -0.21, P < 0.001) in the Europe region; injuries (β = 0.65, P < 0.001), air pollution (β = 0.29, P < 0.001), and obesity (β = 0.92, P < 0.001) in the South-East Asia region; and gross domestic product (β = -0.25, P < 0.001), education (β = -0.90, P < 0.001), and smoking (β = 0.28, P < 0.001) in the Western Pacific region had the most significant role in explaining global health outcomes. Except for the drug use variable in regional findings, the role of other variables in explaining the YLL indicator was greater than that of the YLD indicator. To address global health disparities and optimise resource allocation, global and interregional policymakers should focus on determinants that had the highest β with health outcomes in each region compared to other regions. These determinants likely have a higher marginal health product, and investing in them is likely to be more cost-effective.

Adolescent Mental Health and Resilience Before and During the COVID-19 Pandemic

PurposeWe aimed to assess levels of depression, anxiety, and resilience factors before and during the COVID-19 pandemic in a school sample of adolescents. We also aimed to examine the compensatory and protective effects of individual, family, and school resilience factors on adolescent mental health. MethodsWe used fall 2019 and fall 2020 survey responses from a cluster randomized controlled trial implemented in 20 schools in a Midwestern county. The sample consisted of 3,085 responses from students in grades 5 and 6. Multilevel mixed-effects models with cluster robust standard errors were used to investigate the associations between exposure to the COVID-19 pandemic, mental health (anxiety, depression), and resilience factors (future orientation, family engagement, and having a caring school adult). ResultsAnxiety, but not depression, was higher in fall 2020 compared to fall 2019. Family engagement increased during the pandemic, while future orientation of the student body was lower during that time and the prevalence of having a caring adult at school was unchanged. A positive future orientation was associated with lower levels of anxiety and depression, while having a caring school adult was associated with lower depression. Adolescents with less positive future orientations, low family engagement, and no caring school adults experienced the greatest increases in anxiety. DiscussionPositive future orientations, family engagement, and supportive nonparental adult relationships had compensatory and protective effects on adolescent mental health during the COVID-19 pandemic. Adding these measures to the inventory of modifiable resilience factors during natural disasters may promote healthy adaptation among adolescents.

IMproving psYchosocial adjustment to Traumatic Brain Injury from acute to chronic injury through development and evaluation of the myTBI online psychoeducation platform: protocol for a mixed-methods study

IntroductionThis protocol describes the myTBI study which aims to: (1) develop an online psychoeducation platform for people with traumatic brain injury (TBI), their family members/caregivers, and healthcare staff to improve...

The Fleeting Allure of Dark Campaigns: Backlash from Negative and Uncivil Campaigning in the Presence of (Better) Alternatives

ABSTRACT More aggressive campaigning styles focusing on criticizing opponents (negativity) or using inappropriate language to vilify opponents (incivility) tend to be disliked by voters, and remain thus risky for parties facing off in competitive elections. Backlashes against attackers often cancel out any dent the attacks may leave in the support for the targets. Yet, research on the conditions under which these backlashes are more likely to happen remains fragmentary. In this article, we argue that the nature of the electoral competition – specifically, the presence of viable alternative parties for voters to choose from – matters. Voters could be more likely to withdraw political support from the attacker when such alternatives exist. We test whether the availability and ideological attractiveness of alternatives intervene to explain the backlash effect associated with negativity and incivility, at the election, party, and voter levels. We do so comparatively in the context of the 2019 European Parliament elections in 27 EU countries, by linking a cross-sectional post-election survey (N = 18,790) with an expert survey covering the campaigning strategies of 175 parties that participated in the election across the continent. Estimating mixed effects multi-level models, we find support for the moderating effect of alternatives at the voter-level; voters who have at least equally attractive alternatives available to them are less likely to support parties that go negative than voters to whom the attacking party is the most viable option. Alternatives do not seem to play a major role, however, at the party and election levels.

Improving Pinus densata Carbon Stock Estimations through Remote Sensing in Shangri-La: A Nonlinear Mixed-Effects Model Integrating Soil Thickness and Topographic Variables

Forest carbon sinks are vital in mitigating climate change, making it crucial to have highly accurate estimates of forest carbon stocks. A method that accounts for the spatial characteristics of inventory samples is necessary for the long-term estimation of above-ground forest carbon stocks due to the spatial heterogeneity of bottom-up methods. In this study, we developed a method for analyzing space-sensing data that estimates and predicts long time series of forest carbon stock changes in an alpine region by considering the sample’s spatial characteristics. We employed a nonlinear mixed-effects model and improved the model’s accuracy by considering both static and dynamic aspects. We utilized ground sample point data from the National Forest Inventory (NFI) taken every five years, including tree and soil information. Additionally, we extracted spectral and texture information from Landsat and combined it with DEM data to obtain topographic information for the sample plots. Using static data and change data at various annual intervals, we built estimation models. We tested three non-parametric models (Random Forest, Gradient-Boosted Regression Tree, and K-Nearest Neighbor) and two parametric models (linear mixed-effects and non-linear mixed-effects) and selected the most accurate model to estimate Pinus densata’s above-ground carbon stock. The results showed the following: (1) The texture information had a significant correlation with static and dynamic above-ground carbon stock changes. The highest correlation was for large-window mean, entropy, and variance. (2) The dynamic above-ground carbon stock model outperformed the static model. Additionally, the dynamic non-parametric models and parametric models experienced improvements in prediction accuracy. (3) In the multilevel nonlinear mixed-effects models, the highest accuracy was achieved with fixed effects for aspect and two-level nested random effects for the soil and elevation categories. (4) This study found that Pinus densata’s above-ground carbon stock in Shangri-La followed a decreasing, and then, increasing trend from 1987 to 2017. The mean carbon density increased overall, from 19.575 t·hm−2 to 25.313 t·hm−2. We concluded that a dynamic model based on variability accurately reflects Pinus densata’s above-ground carbon stock changes over time. Our approach can enhance time-series estimates of above-ground carbon stocks, particularly in complex topographies, by incorporating topographic factors and soil thickness into mixed-effects models.

Hospital-level variation in hospitalization costs for spinal fusion in the United States.

With a growing emphasis on value of care, understanding factors associated with rising healthcare costs is increasingly important. In this national study, we evaluated the degree of center-level variation in the cost of spinal fusion. All adults undergoing elective spinal fusion were identified in the 2016 to 2020 National Inpatient Sample. Multilevel mixed-effect models were used to rank hospitals based on risk-adjusted costs. The interclass coefficient (ICC) was utilized to tabulate the amount of variation attributable to hospital-level characteristics. The association of high cost-hospital (HCH) status with in-hospital mortality, perioperative complications, and overall resource utilization was analyzed. Predictors of increased costs were secondarily explored. An estimated 1,541,740 patients underwent spinal fusion, and HCH performed an average of 9.5% of annual cases. HCH were more likely to be small (36.8 vs 30.5%, p<0.001), rural (10.1 vs 8.8%, p<0.001), and located in the Western geographic region (49.9 vs 16.7%, p<0.001). The ICC demonstrated 32% of variation in cost was attributable to the hospital, independent of patient-level characteristics. Patients who received a spinal fusion at a HCH faced similar odds of mortality (0.74 [0.48-1.15], p = 0.18) and perioperative complications (1.04 [0.93-1.16], p = 0.52), but increased odds of non-home discharge (1.30 [1.17-1.45], p<0.001) and prolonged length of stay (β 0.34 [0.26-0.42] days, p = 0.18). Patient factors such as gender, race, and income quartile significantly impacted costs. The present analysis identified 32% of the observed variation to be attributable to hospital-level characteristics. HCH status was not associated with increased mortality or perioperative complications.

Advanced imaging use and delays among inpatients with psychiatric comorbidity.

To determine whether presence of a psychiatric comorbidity impacts use of inpatient imaging tests and subsequent wait times. This was a retrospective cohort study of all patients admitted to General Internal Medicine (GIM) at five academic hospitals in Toronto, Ontario from 2010 to 2019. Exposure was presence of a coded psychiatric comorbidity on admission. Primary outcome was time to test, as calculated from the time of test ordering to time of test completion, for computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, or peripherally inserted central catheter (PICC) insertion. Multilevel mixed-effects models were used to identify predictors of time to test, and marginal effects were used to calculate differences in absolute units (h). Secondary outcome was the rate of each type of test included. Subgroup analyses were performed according to type of psychiatric comorbidity: psychotic, mood/anxiety, or substance use disorder. There were 196,819 GIM admissions from 2010to 2019.In 77,562 admissions, ≥1 advanced imaging test was performed. After adjusting for all covariates, presence of any psychiatric comorbidity was associated with increased time to test for MRI (adjusted difference: 5.3h, 95% confidence interval [CI]: 3.9-6.8), PICC (adjusted difference: 3.7h, 95% CI: 1.6-5.8), and ultrasound (adjusted difference: 3.0h, 95% CI: 2.3-3.8), but not for CT (adjusted difference: 0.1h, 95% CI: -0.3 to 0.5). Presence of any psychiatric comorbidity was associated with lower rate of ordering for all test types (adjusted difference: -17.2 tests per 100days hospitalization, interquartile range: -18.0 to -16.3). There was a lower rate of ordering of advanced imaging among patients with psychiatric comorbidity. Once ordered, time to test completion was longer for MRI, ultrasound, and PICC. Further exploration, such as quantifying rates of cancelled tests and qualitative studies evaluating hospital, provider, and patient barriers to timely advanced imaging, will be helpful in elucidating causes for these disparities.

Household environment associated with anaemia among children aged 6–59 months in Ethiopia: a multilevel analysis of Ethiopia demographic and health survey (2005–2016)

BackgroundAnaemia continues to be a major public health challenge globally, including in Ethiopia. Previous studies have suggested that improved household environmental conditions may reduce anaemia prevalence; however, population-level evidence of this link is lacking in low-income countries. Therefore, this study aimed to examine the association between environmental factors and childhood anaemia in Ethiopia.MethodsIn this study, we conducted an analysis of the data from the Ethiopian Demographic and Health Survey (EDHS), a nationally representative population-based survey conducted in Ethiopia between 2005 and 2016. The study included a total of 21,918 children aged 6–59 months. Children were considered anemic if their hemoglobin (Hb) concentration was less than 11.0 g/dl. To examine the association between environmental factors and anemia, we used multilevel mixed-effect models. These models allowed us to control for various confounding factors including: child, maternal, household and community-level variables. The study findings have been reported as adjusted odds ratios (AORs) along with 95% confidence intervals (CIs) at a significance level of p < 0.05.ResultsThe study found the overall prevalence of childhood anaemia to be 49.3% (95%CI: 48.7–49.9) between 2005 and 2016 in Ethiopia. The prevalence was 47.6% (95%CI: 46.1–49.1) in 2005, 42.8% (95%CI: 41.8–43.8) in 2011, and increased to 57.4% (95%CI: 56.3–58.4) in 2016. The pooled data showed that children from households practising open defecation were more likely to be anaemic (AOR: 1.19, 95% CI: 1.05–1.36). In our survey specify analysis, the odds of anaemia were higher among children from households practising open defecation (AOR: 1.33, 95% CI: 1.12–1.58) in the EDHS-2011 and EDHS-2016 (AOR: 1.49, 95% CI: 1.13–1.90). In contrast, neither household water sources nor the time to obtain water was associated with anaemia after controlling for potential confounders. The other variables significantly associated with childhood anaemia include: the child’s age (6–35 months), not fully vaccinated (AOR: 1.14, 95%CI: 1.05–1.24), children not dewormed in the last 6 months (AOR: 1.11, 95%CI: 1.01–1.24), children born to mothers not working (AOR: 1.10, 95%CI: 1.02–1.19), children from poor households (AOR: 1.18: 95%CI: 1.06–1.31), and rural residence (AOR: 1.23, 95%CI: 1.06–1.42).ConclusionIn Ethiopia, about fifty percent of children suffer from childhood anemia, making it a serious public health issue. Open defecation is a major contributing factor to this scourge. To address this issue effectively, it is recommended to strengthen initiatives aimed at eliminating open defecation that involve various approaches, including sanitation infrastructure development, behavior change campaigns, and policy interventions. In addition, to reduce the burden of anemia in children, a multi-faceted approach is necessary, involving both prevention and treatment strategies.

Secondary multilevel mixed-effects modelling of seroprevalence trends of Crimean-Congo haemorrhagic fever.

Some review papers and meta-analyses have investigated seroprevalence and fatality trends of the Crimean-Congo hemorrhagic fever (CCHF), but it is not clear if its seroprevalence is increasing. To investigate the trend in the seroprevalence of CCHF. We conducted a secondary analysis of the results of a meta-analysis of the seroprevalence of CCHF published in 2019. We used a multilevel mixed effects Poisson regression to find the predictors of seropositivity. To explain the magnitude effect, we reported an incidence rate ratio (IRR) with a 95% confidence interval (CI). We conducted multilevel modeling using Stata 14 for data analysis. In the fixed effects model, time was significantly associated with increased seropositivity (IRR = 1.025, 95% CI = 1.021-1.030), and no significant association was found for local sampling (IRR = 1.026, 95% CI = 0.988-1.065). In the mixed effects model, random intercepts of the country and parallel of latitude were applied as 3 levels of the model (prevalence rate of each study, nested within countries and latitude parallel). Accordingly, time was significantly associated with a reduction of seropositivity (IRR = 0.899, 95% CI = 0.891-0.907), and local sampling was significantly associated with increased seropositivity (IRR = 2.477, 95% CI = 2.316-2.649). Despite reporting increasing trends for seroprevalence of CCHF in previous reviews and the fixed effects model of the present study, the secondary mixed effects modeling showed a decreasing trend. The multilevel generalized model is recommended for such temporal and spatial designs in the future.

Modern contraceptive utilization and its associated factors in East Africa: Findings from multi-country demographic and health surveys.

The use of modern contraceptives has been low in most Sub-Saharan African countries despite high population growth and a sluggish economy. This study aimed to identify the prevalence and determinants of modern contraceptive use among married reproductive-age women in East Africa. For this study, the Demographic and health survey (DHS) data from nine countries in East Africa were analyzed, yielding a weighted sample of 32,925 married women. A multilevel mixed-effect logistic regression model was used to identify characteristics associated with the utilization of modern contraceptives at a p-value less than 0.05. For model comparison, we used the Akaike and Bayesian Information Criteria (AIC and BIC). For assessing variation (random effects), we used community-level variance with standard deviation and intra-cluster correlation coefficient (ICC). The overall prevalence of modern contraceptive use was 45.68%, 95% CI (45.15, 46.21). Women's age, maternal education level, husband education level, media exposure, wealth status, occupation, religion, the total number of children ever born, distance to health facilities, history of termination of pregnancy, couple's desire for children, women's participation in decision making, living country and place of residence were significantly associated with modern contraceptive use in Eastern Africa. Conferring to this study, utilization of modern contraceptives is low in East Africa. Interventions to improve the use of modern contraceptives should encompass disseminating awareness through mass media, enrolment of males in family planning, giving maternal education, building health facilities in remote areas, and encouraging family planning programs in rural areas.

Trends in social determinants of inequality in child undernutrition from the Ethiopian Demographic and Health Surveys, 2005-2016.

While child undernutrition has been eliminated in some middle-income countries, it remains highly prevalent in sub-Sahara African (SSA) and South Asian regions, and is disproportionately concentrated among the poor. In this study, we estimated trends in child undernutrition by social determinants and related risks from wealth inequality in Ethiopia, from 2005 to 2016. We analyzed data from three consecutive surveys (2005, 2011, and 2016) from the Ethiopian Demographic and Health Survey. First, we estimated trends in the prevalence of childhood undernutrition variables (stunting, underweight, and wasting) and social determinants (household wealth status, education level, place of residence, and administrative regions). Then we assessed evidence of undernutrition by wealth-related inequality with concentration curves (visual) and concentration indeces (quantitative). A multilevel mixed-effect Poisson regression model was used to identify predictors of undernutrition variables expressed as covariate-adjusted rate ratios, with 95% confidence intervals (RRs, 95%CI). A total of 23,934 mother-child pairs were obtained from the three surveys. The average prevalence decreased by 12.4 percentage points for stunting (from 50.8 to 38.4%, P<0.01), 9.5 percentage points for underweight (33.2% to23.7%, P<0.01), and 2.1 percentage points for wasting (12.2% to10.1%, P<0.01). There was persistent and statistically evidence of wealth inequality in stunting, underweight, and wasting (concentration indeces of -0.2 to -0.04, all P values <0.05). Stunting, underweight, and wasting variables were associated with male sex of the child (RR 0.94, 0.95, 0.85, all P-values <0.01) recent diarrhea (RR 1.18, 1.27, 1.37, all P-values <0.01), secondary education status of the mother (RR 0.66, 0.57, 0.61, all P-values < 0.057), increasing wealth index (richest) (RR 0.73, 0.70, 0.50, all P-values < 0.05), and having no toilet facility (RR 1.16, 1.22, 1.18, all P-values < 0.05). Despite the decreased burden of stunting and underweight, the prevalence of wasting remained relatively unchanged in Ethiopia from 2005 to 2016. Moreover, wealth-related inequality in child undernutrition increased for most of the child undernutrition indicators during this period. Social determinants of child undernutrition warrant urgent implementation of strategies to reduce their health impacts in SSA.

Appropriate feeding practices and associated factors during diarrheal disease among children aged 6 to 23 months in Sub-Saharan Africa: a multilevel analysis of the recent demographic and health survey

BackgroundDiarrhea is the second leading cause of morbidity and mortality for under-five children which cause about 525,000 deaths annually. Even though diarrheal diseases have decreased substantially at the global level, low-income countries are still faced with a huge number of diarrheal diseases. Thus, our aim was to assess the child feeding practices during diarrheal diseases and associated factors among children aged 6 to 23 months in Sub-Saharan African countries using the recent demographic and health survey.MethodsThe appended and most recent demographic and health survey (DHS) dataset of 19 Sub-Saharan African countries from 2015 to 2020 was used for data analysis. A total of 64,628 living children aged 6–23 months with diarrhea were used as a weighted sample. The determinants of appropriate feeding practice were determined using a multilevel mixed-effects logistic regression model. Significant factors associated with appropriate feeding practice 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 prevalence of appropriate child feeding practice during diarrhea in this study was 6.24% (95% CI: 6.06, 6.43). Maternal age (15 to 19 years and 20 to 35 years) (AOR = 1.32, 95%CI: 1.12, 1.55 and AOR = 1.14, 95%CI: 1.03, 1.27), mothers education (primary and secondary level) (AOR = 1.23, 95%CI: 1.12, 1.35 and AOR = 1.28, 95%CI: 1.15, 1.43), having media exposure(AOR = 1.36, 95%CI: 1.26, 1.46), being married (AOR = 1.18, 95%CI: 1.01, 1.38), currently working (AOR = 1.08, 95%CI:1.00, 1.15), vaccinated for Rotavirus (AOR = 1.30, 95%CI:1.19, 1.43) and living in Central and eastern African countries (AOR = 1.82, 95%CI: 1.12, 2.97) and (AOR = 2.23, 95%CI: 1.37, 3.61) respectively were significantly associated with appropriate feeding practice.ConclusionThe prevalence of appropriate feeding practice during child diarrheal disease aged 6–23 months of age was strictly low which implies that child diarrhea and appropriate feeding practice is still a great issue in in Sub-Saharan African countries. Enhancing maternal education, strengthening media exposure and vaccination for rotavirus, and designing interventions that address the mother’s marital status, mother’s work status, and country category are recommended to enhance appropriate feeding practices. Furthermore, special consideration should be given to older mothers to increase appropriate feeding practices during diarrheal disease.

Choice and Opportunity: Housing Relocation, Neighborhood Change, and Family Well-Being in the South City Choice Neighborhoods Initiative (CNI) in Memphis, TN

Mixed-income development initiatives target distressed public housing for redevelopment and provide support to low-income families. These initiatives involve an involuntary move for families living in the sites targeted for redevelopment. The objectives of this study were to examine housing relocation, neighborhood change, and family well-being among families (n = 383) affected by the South City Choice Neighborhoods Initiative (CNI) in Memphis, Tennessee, using longitudinal administrative records merged with census data. Regression analysis and multilevel mixed-effects modeling were utilized to examine quality of life outcomes (e.g., perceived home safety, neighborhood safety, stress). Families who moved out of the CNI zip code improved their neighborhood quality compared to families who stayed. All families experienced improvements to home safety and neighborhood safety, but also experienced increased stress irrespective of decisions to leave or stay in the CNI zip code. Implications for policy and practice are discussed.

Urban-rural differences in seasonal malaria chemoprevention coverage and characteristics of target populations in nine states of Nigeria: a comparative cross-sectional study.

Differences between urban and rural contexts in terms of sociodemographic characteristics, geographical features and risk perceptions may lead to disparities in coverage and related outcomes of community-based preventive interventions, such as seasonal malaria chemoprevention (SMC). This study investigated urban-rural differences in SMC coverage and other programme outcomes, as well as child and caregiver characteristics of target populations in nine implementing states in Nigeria during the 2022 SMC round. This is a comparative cross-sectional study based on comprehensive end-of-round household surveys conducted in nine states where SMC was delivered in Nigeria in 2022. Data of 11,880 caregiver-child pairs were included in the analysis. Rural-urban differences in SMC outcomes and child and caregiver characteristics were assessed, first by using Pearsons' chi-square test for independence for categorical variables. Univariate multilevel mixed-effect logistic regression models, with random intercepts for cluster units, were used to quantify the strength of association between location and each SMC coverage and related outcomes. Significant urban-rural differences were observed in caregivers' sociodemographic characteristics, such as age, gender, level of education, occupation status and health-seeking behaviour for febrile childhood illnesses. Disparities were also seen in terms of SMC coverage and related outcomes, with lower odds of the receipt of Day 1 dose direct observation of the administration of Day 1 dose by community distributors, receipt of the full three-day course of SMC medicines and receipt of SMC in all cycles of the annual round among children residing in urban areas, compared with those residing in rural areas. Similarly, urban-dwelling caregivers had lower odds of being knowledgeable of SMC and believing in the protective effect of SMC than rural-dwelling caregivers. Findings highlight observable urban-rural disparities in SMC programme delivery and related outcomes, as well as target population characteristics, underscoring the need for context-specific strategies to ensure optimal delivery of SMC and improve programme implementation outcomes in urban settings.

Human Factors on the Road: Truck Drivers’ Heterogeneity in Distribution

While human factors in warehousing have received considerable attention in recent years, they remain largely underexamined in transportation. This is surprising, given that truck driver shortage and load space scarcity are recent key challenges in the logistics industry that significantly hamper the growth potential of European economies. While increasing demand for loadspace meets a decreasing availability of professional truck drivers, managers across all industries need to think about how scarce human resources can be deployed more efficiently. Therefore, the goal of this study is to quantify truck drivers’ heterogeneity in retail distribution. We formulate and apply a mixed-effect multilevel regression model where delivery routes are nested within truck drivers. The model is applied to a unique empirical dataset, including N = 51,164 routes performed by 218 truck drivers in a six-month time frame in 2021, obtained in collaboration with a German brick-and-mortar grocery retailer. We find that truck drivers’ heterogeneity accounts for 29.9% of the total route duration time variation. This impact is significantly higher compared to existing empirical research on the quantification of heterogeneity for warehouse workers and proposes a higher potential for transport managers to increase efficiency in collection and distribution by taking into account driver heterogeneity in tour planning and allocation.

Married Women Decision-Making Autonomy on Contraceptive Use in East Africa: A Multilevel Analysis of Recent Demographic and Health Survey

The utilization of contraceptives depends on women’s autonomy in making decisions. Limited and inconclusive information is available on women’s decision-making autonomy to use contraceptives in East Africa. Therefore, the main objective of this study was to assess married women’s decision-making autonomy on contraceptive use and associated factors in East African countries. The most recent Demographic and Health Surveys were used for this study. The study included a total weighted sample of 41,893 married reproductive-age women. A multilevel mixed-effect binary logistic regression model was fitted. The prevalence of married women’s decision-making autonomy on contraceptive use was 18.91% (95% CI: 18.54, 19.29). Respondents who are employed (AOR = 1.24; 95% CI: 1.03, 1.44), having more than two alive children (AOR = 1.38; 95% CI: 1.13, 1.67), and visited a health facility in the last 12 months (AOR = 1.22; 95% CI: 1.05, 1.45), urban residency (AOR = 1.39; 95% CI: 1.27, 1.50), lower middle-income level 1.37 (AOR = 1.37; 95% CI: 1.17, 1.60), and community media exposure to family planning message (AOR = 1.25; 95% CI: 1.04, 1.45) were significantly associated with women’s decision making autonomy on contraceptive use. Despite the fact that every woman has the right to participate in her own healthcare decisions, less than one-fifth of married women in East Africa have contraceptive decision-making autonomy. Hence, Women’s decision-making autonomy on contraceptives should be promoted through mass media as an essential part of sexual and reproductive rights, with particular attention paid to rural women, women with no children, and women living in low-income households.

Factors associated with sexual violence against reproductive-age women in Ghana: A multilevel mixed-effects analysis.

Sexual violence against women is a pervasive public health challenge and human rights violation, with global prevalence rates of approximately one in three women affected, notably prevalent in African countries. Understanding its multifaceted determinants is crucial for developing targeted intervention strategies. Thus, this study aimed to investigate factors associated with sexual violence against reproductive-age ever-married women in Ghana. A weighted sample of 3,816 reproductive-age ever-married women from the 2022 Ghana Demographic and Health Survey (DHS) was included. To accommodate the hierarchical nature of the DHS data and the binary outcome variable 'sexual violence', a multilevel mixed-effect logistic regression model was employed. The deviance value was utilized for selecting the best-fitted model. In the multivariable multilevel binary logistic regression analysis, adjusted odds ratios (AORs) along with their respective 95% confidence intervals (CIs) were utilized to gauge the association strength, with statistical significance set at a p-value < 0.05. The prevalence of sexual violence was found to be 8.80% (95% CI: 7.94-9.74). Factors positively associated with sexual violence included women's decision-making autonomy (AOR = 1.39, 95% CI: 1.08-1.74), husband/partner's alcohol consumption (AOR = 3.88, 95% CI: 2.98-5.06), sex of household head (AOR = 1.31, 95% CI: 1.02-1.68), and justification of beating (AOR = 1.35, 95% CI: 1.01-1.81). Conversely, women's age showed a negative association with sexual violence (AOR = 0.68, 95% CI: 0.48-0.98). In conclusion, prioritizing initiatives that empower women in decision-making roles, provide support for those struggling with alcohol consumption, and raise awareness about its impact on interpersonal relationships and the risk of sexual violence is essential. Furthermore, addressing harmful gender norms, particularly those justifying violence, and considering demographic characteristics are vital components of comprehensive strategies to prevent and mitigate sexual violence.

Changes in unmet need for family planning among married women of reproductive age in Nigeria: A multilevel analysis of a ten-year DHS wave.

Unmet need for family planning [UNFP] remains a serious public health concern in Nigeria. Evidence suggests that UNFP remains high over the last fifteen years despite numerous policies and programmes aimed at generating demand for family planning. This study used three Demographic and Health Survey (DHS) conducted over a ten-year period (2008-2018) to assess the changes in unmet need for family planning and associated contextual determinants. Understanding changes in unmet need for family planning among women and its associated contextual factors is crucial for designing appropriate interventions. We analysed datasets the Nigeria Demographic and Health Surveys of 2008, 2013 and 2018 to assess changes and contextual determinants of unmet need for family planning. Data were analysed using frequency distribution, chi-square statistical test and multilevel binary logistic regression models. Due to the hierarchical structure of the data in which individuals are nested within households, multilevel mixed-effect logistic regression models were constructed. We used a multilevel binary logistic regression model after adjusting for variables not significant at the bivariate level. An adjusted odds ratio with 95% confidence interval was reported, with a p-value less than 0.05 declared to be significant predictors of unmet need for family planning. Unmet need for family planning decreased from 20.21% to 16.10% between 2008 and 2013 but subsequently rose later from 16.10% to 18.89% between 2013 and 2018. The pattern of changes in unmet need for either limiting or spacing was consistently high over the 10-year period, with the highest rate of each of the indicators of unmet need for family planning occurring in 2018 while the lowest rate was in 2008, thus indicating an increase in the proportion of respondents having unmet need for family planning over the referenced period. Age of respondents, educational level, wealth status, religious affiliation, parity, sex of head of household, partner educational level, region of residence, and community socioeconomic status were significant factors associated with the unmet need for family planning across the different data waves in Nigeria (p < 0.05). An intraclass correlation (ICC) of 4.9% showed that the individual and household level factors had a greater influence on the variation in the unmet need for family planning than did community factors in Nigeria. The overall prevalence of unmet need for family planning was consistently high over the ten-year period and community-level factors had lowest influence on the variation in unmet need for family planning compared to household and individual-level factors in Nigeria. Policies and interventions should focus on improving women's socio-economic and demographic characteristics at individual, household, and community levels to improve unmet need for family planning.