Multilevel Mixed Model Analysis Research Articles

Effects of a participatory work stress prevention approach for employees in primary education: results of a quasi-experimental study.

Work stress is a serious problem for employees in primary education. This study evaluates the effects of a work stress prevention approach on emotional exhaustion and work stress determinants (job crafting behavior, quantitative and emotional demands, leadership, support, autonomy, team culture and feelings of competence), and the impact of implementation success (management commitment, employee involvement, communication during implementation) on these outcomes. A quasi-experimental study was conducted with an intervention group (4 schools, N=102 employees) and a control group (26 schools, N=656 employees) using questionnaires at baseline (T0), one-year (T1) and two-year (T2) follow-up. Multilevel mixed model analyses were performed to test effects of condition and implementation success on changes in emotional exhaustion and work stress determinants between T0 and T2 in the intervention and control group. No effect were found for emotional exhaustion. Improvement of quality of leadership between T0 and T2 was significantly larger in the intervention compared to the control group. Additionally, implementation success was associated with a decrease in unnecessary demands and an increase in quality of leadership, team culture and job crafting behavior. This study shows no direct effect of the approach on emotional exhaustion, but it does show beneficial effects on quality of leadership. Additionally, results suggest that, when successfully implemented, the approach also has beneficial effects on other work stress determinants (ie, job crafting behavior, unnecessary demands and team culture). Results indicate that - if implemented successfully - the organizational-level intervention has the potential to improve the psychosocial work context.

Unraveling the interplay between daily life fatigue and physical activity after subarachnoid hemorrhage: an ecological momentary assessment and accelerometry study

BackgroundFatigue is one of the most commonly reported symptoms after subarachnoid hemorrhage (SAH) and is indirectly associated with physical activity (PA). Associations between fatigue and PA are primarily examined based on conventional measures (i.e. a single fatigue score or average PA levels), thereby assuming that fatigue and PA do not fluctuate over time. However, levels of fatigue and PA may not be stable and may interrelate dynamically in daily life. Insight in direct relationships between fatigue and PA in daily life, could add to the development of personalized rehabilitation strategies. Therefore we aimed to examine bidirectional relationships between momentary fatigue and PA in people with SAH.MethodsPeople (n = 38) with SAH who suffer from chronic fatigue were included in an observational study using Ecological Momentary Assessment (EMA) and accelerometry. Momentary fatigue was assessed on a scale from 1 to 7 (no to extreme fatigue), assessed with 10–11 prompts per day for 7 consecutive days using EMA with a mobile phone. PA was continuously measured during this 7-day period with a thigh-worn Activ8 accelerometer and expressed as total minutes of standing, walking, running and cycling in a period of 45 min before and after a momentary fatigue prompt. Multilevel mixed model analyses including random effects were conducted.ResultsMean age was 53.2 years (SD = 13.4), 58% female, and mean time post SAH onset was 9.5 months (SD = 2.1). Multilevel analyses with only time effects to predict fatigue and PA revealed that fatigue significantly (p < 0.001) increased over the day and PA significantly (p < 0.001) decreased. In addition, more PA was significantly associated with higher subsequent fatigue (β = 0.004, p < 0.05) and higher fatigue was significantly associated with less subsequent PA (β=-0.736, p < 0.05). Moreover, these associations significantly differed between participants (p < 0.001).ConclusionsBy combining EMA measures of fatigue with accelerometer-based PA we found that fatigue and PA are bidirectionally associated. In addition, these associations differ among participants. Given these different bidirectional associations, rehabilitation aimed at reducing fatigue should comprise personalized strategies to improve both fatigue and PA simultaneously, for example by combining exercise therapy with cognitive behavioral and/or energy management therapy.

Moderating Effect Of Bank Size On Nexus Between External Equity Capital And Financial Performance Of Lower-Tier Commercial Banks In Kenya

The commercial banks in Kenya have been recording declining performance over the recent past, with the lower-tier banks being the hardest hit. As a result, several banks in the lower-tier, such as Chase Bank, Dubai Bank of Kenya, and Imperial Bank, have been put under receivership. The collapse of banks does not give a good reflection of the sustainability of the banking system. Thus, the signals of poor financial performance need to be addressed promptly as the collapse of the banking system could also have a ripple effect on other sectors. The Kenyan banking sector is categorized into tier I, II, and III. The categorization is dependent on the size of the bank. The decline in profitability of the banking sector has affected tier II and III most. Also to note is that Tier one is made up of six giant banks that control close to half (49.9 percent) of the market, which begs the question as to whether the size of the bank has any influence on the performance of the banks. Therefore, this study sought to determine whether external financing influences Tier II and III performance and whether the bank size moderates this influence. Descriptive and explanatory research designs were employed in the study. The study population was 37 commercial banks in Tier II and III of the Central Bank's Lower-tier classification. Secondary data were adapted in the study for the years 2016 to 2020. After data cleaning, 26 banks were retained (70%) for further analysis. Data collected was analyzed by use of both descriptive and inferential analysis. Descriptive statistics included means, standard deviations, skewness, and Kurtosis, while inferential analysis included Multilevel Mixed Model Analysis and Hierarchical Multiple Linear Regression. The model coefficients show that equity has a positive and statistically significant relationship with the performance of lower-tier banks in Kenya measured using net profit margin (β=.229, p-value=.036&lt;0.05). Further, the study found that size moderates the relationship between external equity and performance as an introduction of size in the model change R2 by .035 (p-value = 0.001). The study thus concludes that external equity capital positively influences the performance of lower-tier banks in Kenya, while size moderates the same. The study recommends that a bank evaluate when to use external equity funding, although external equity funding may be costlier. As a recommendation, lower-tier banks are encouraged to use external equity as this will improve their performance. Lower-tier banks are also encouraged to increase their asset base as their size moderates the banks′ performance.

Combined Amplification and Sound Therapy for Individuals With Tinnitus and Coexisting Hearing Loss: A Retrospective Cohort Study.

Background: The heterogeneity of tinnitus perception and its impact necessitates a tailor-made management approach in everyone. The current study examined the effects of residual inhibition in combined amplification and sound therapy in individuals with tinnitus and coexisting hearing loss.Methods: A retrospective analysis was performed on patients with tinnitus and coexisting hearing loss between 2016 and 2019. A total of 72 patients provided with combined amplification and sound therapy were divided into 3 groups based on residual inhibition: (i) complete residual inhibition, (ii) partial residual inhibition, and (iii) negative residual inhibition. Tinnitus severity was measured using the Tinnitus Functional Index before treatment and 1 and 6 months after the intervention. A multilevel mixed-effects model was used to examine the treatment effects including both the main and interaction effects of time and residual inhibition on the tinnitus severity.Results: Of the 72 participants, 55 (76%) and 61 (85%) had clinically significant changes (13 points in Tinnitus Functional Index) at 1-month and 6-month postintervention, respectively. In the complete, partial, and negative residual inhibition groups, the reduction in tinnitus impact was 100%, 78%, and 74%, respectively. A multilevel mixed model analysis showed that the main effects of time and residual inhibition along with their interaction were significant.Conclusions: The study results suggest that combined amplification and sound therapy is beneficial in individuals with tinnitus and coexisting hearing loss in reducing their tinnitus severity, and this benefit was more in individuals with complete residual inhibition. However, these results need to be further confirmed by controlled trials.

Parental unemployment associated with the lack of the effectiveness of a children obesity prevention program: Results from the IDEFICS study

AbstractThe relationship between social vulnerabilities and the effectiveness of behavioral interventions to prevent obesity in children is poorly understood. Therefore, the objective of this study is to evaluate the association between parental employment and the effectiveness of IDEFICS, a multilevel behavioral intervention aiming to prevent obesity among children (2 to 9.9 years old) in eight European countries. Data from 9,901 children and their parents was included in the analysis. We determined the Body Mass Index (BMI) z-score mean difference as the measurement of the intervention effectiveness and we calculated it as the follow-up (T1) BMI z-score mean minus baseline (T0) BMI z-score mean. Parents self-reported their employment status at T0 and T1. Children were classified, at both study times (T0 and T1), as children with employed parents (both parents employed) or as children with unemployed parents (one or both parents unemployed or receiving social assistance). We calculated unadjusted and adjusted multilevel mixed model analyses to evaluate if the employment status at T0 and the evolution of the employment status within a two-year period (from T0 to T1) predicted the BMI z-score mean difference among boys and girls. In boys, parental unemployment at T0 and throughout a two-year period (T0 to T1) predicted an increase of BMI z-score mean difference when compared to boys with employed parents (unemployment at T0: adjusted β = 0.12; p = 0.028; and unemployment from T0 to T1: adjusted β = 0.20; p = 0.031). We found no difference in the effectiveness of the IDEFICS intervention among girls with unemployed parents at T0 and from T0 to T1 when compared to girls with employed parents (unemployment at T0: adjusted β = 0.04; p = 0.337; and unemployment from T0 to T1: adjusted β = 0.10; p = 0.216, respectively). Our results suggest that the influence of parental unemployment in the IDEFICS outcome is different for boys and girls. Employment of both parents, which is related to a higher income, could contribute the families to engage healthier eating and physical activity behaviors among boys. Future multilevel interventions should include a combination of community-based and school-based components, as well as family-centered components, specifically on those families with parents out of the labor force, to address specific barriers or vulnerabilities that prevent them from improving behavior and weight status.

Expert and lay perspectives on burden, risk, tolerability, and acceptability of clinical interventions for genetic disorders

PurposeThe Clinical Genome Resource (ClinGen) Actionability Working Group (AWG) developed a semiquantitative scoring metric to rate clinical actionability of genetic disorders and associated genes in four domains: (1) severity of the outcome, (2) likelihood of the outcome, (3) effectiveness of the intervention to prevent/minimize the outcome, and (4) nature of the intervention with respect to burden, risk, tolerability, and acceptability to the patient. This study aimed to assess whether nature of the intervention scores assigned by AWG experts reflected lay perceptions of intervention burden, risk, tolerability, and acceptability given the subjectivity of this domain. MethodsIn July 2017, a general population sample of 1344 adults completed the study. Each participant was asked to read 1 of 24 plain language medical intervention synopses and answer questions related to its burden, risk, tolerability, and acceptability. We conducted three multilevel mixed model analyses predicting the perceived burden, perceived risk, and perceived overall nature of the intervention. ResultsAs AWG nature of the intervention scores increased, lay perceptions of intervention burden and risk decreased, and perceptions of tolerability and acceptability increased. ConclusionThe findings show alignment between the ClinGen actionability scoring metric and lay perceptions of the nature of the intervention.

Patient satisfaction with ball and Equator attachments for single-implant mandibular overdentures: A short-term randomised crossover clinical trial.

Retention and stabilisation of a single-implant mandibular overdenture (SIMO) are influenced by the biomechanical properties and clinical performance of the attachment system. To compare clinical and patient-reported outcomes following the use of two retention systems, a ball and a stud-type Equator attachment used for SIMO. Eighteen fully edentulous participants were treated with a SIMO opposing to a maxillary complete denture. They received two retentive attachments (ball and Equator) in alternate periods (sequences A-B and B-A) and outcomes were assessed after the 1week (initial) and 3months (final) periods. In the final assessment, patients were also asked about their preferred retention system. Compared with baseline, there was an improvement in patient satisfaction using both attachments, whilst no difference was observed between initial and final periods. Similarly, no significant differences were observed when comparing the ball and Equator at the initial (P=.330) and final (P=.08) periods. The multilevel mixed-model analysis revealed that the patients' satisfaction was predicted only by their satisfaction with dentures before implant placement. Although no significant difference was found between attachments regarding patient preference, this may be biased by the sequence of attachment use, which suggests that a learning effect might be present in this crossover study design. The use of a single midline implant to retain a mandibular overdenture significantly improves patient satisfaction irrespective of the attachment used, but patients' preference for the second treatment suggested a learning effect in this study.

Effect of Age, Sex, Stimulus Intensity, and Eccentricity on Saccadic Reaction Time in Eye Movement Perimetry.

PurposeIn eye movement perimetry (EMP), the extent of the visual field is tested by assessing the saccades using an eye tracker. The aim of the present study was to determine the effects of age and sex of the subjects, the eccentricity and intensity of the peripheral stimuli on saccadic reaction time (SRT), and the interaction between these parameters in healthy participants.MethodsHealthy participants aged between 20 to 70 years underwent a complete ophthalmic examination and an EMP test. SRT was determined from detected peripheral stimuli of four intensity levels. A multilevel mixed-model analysis was used to verify the influence of subject and stimulus characteristics on SRT within the tested visual field.ResultsNinety-five subjects (mean age 43.0 [15.0] years) were included. Age, stimulus intensity, and eccentricity had a statistically significant effect on SRT, not sex. SRTs were significantly faster with increasing stimulus intensity and decreasing eccentricity (P < 0.001). At the lowest stimulus intensity of 192 cd/m2, a significant interaction was found between age and eccentricity.ConclusionsThe current study demonstrated significant SRT dependence across the visual field measured up to 27°, irrespective of sex. The presented SRT values may serve as a first normative guide for EMP.Translational RelevanceThis report of SRT interaction can aid in refining its use as a measure of visual field responsiveness.

Staff Food-Related Behaviors and Children’s Tastes of Food Groups during Lunch at Child Care in Oklahoma

BackgroundYoung children should consume a variety of nutrient-dense foods to support growth, while limiting added fat and sugar. A majority of children between the ages of 3 and 5 years attend child care in the United States, which makes this environment and the child-care staff influential at meals. ObjectiveThe aim was to determine the association between best-practice food-related behaviors and young children’s tastes of fruit, vegetable, low-fat dairy, and high-fat/high-sugar foods at child care. DesignThis was a cross-sectional study. ParticipantsA community-based study with 201 children ages 3 to 5 years from 25 early care and education centers, including 11 tribally affiliated centers and two Head Start programs across Oklahoma. Data collection occurred from fall 2011 to spring 2014. Main outcome measuresClassroom observations used the Environmental Policy Assessment Observation tool to measure the staff behaviors and environment. Staff behavior was compared at three different levels: the composite score of staff nutrition behavior, each constituent staff behavior, and staff behaviors grouped into broader feeding behaviors. Tasted food was measured through the Dietary Observation in Child Care method. The children’s meals were categorized into the following food groups: fruit, vegetable, low-fat dairy, fried vegetable, fried meat, high-fat meat, and high-fat/high-sugar food. Statistical analysis performedDescriptive statistics were calculated for relevant variables. Relationships between the constituent staff behaviors and food groups that children tasted were compared using multilevel mixed-model analysis. ResultsThe mean number of tasted fruit or vegetable items was higher and the mean number of tasted high-fat/high-sugar food items was lower when staff: 1) determined fullness before plate removal when less than half of food was eaten, 2) ate with the children, 3) and talked about healthy food. ConclusionsThe utilization of the three staff behaviors and their association with higher mean tastes of nutrient-dense items and lower mean tastes of high-fat/high-sugar food items among exposed children demonstrated support for the use of the best practices in early care and education centers.

Longitudinal changes in linguistic complexity among professional football players

Reductions in spoken language complexity have been associated with the onset of various neurological disorders. The objective of this study is to analyze whether similar trends are found in professional football players who are at risk for chronic traumatic encephalopathy. We compare changes in linguistic complexity (as indexed by the type-to-token ratio and lexical density) measured from the interview transcripts of players in the National Football League (NFL) to those measured from interview transcripts of coaches and/or front-office NFL executives who have never played professional football. A multilevel mixed model analysis reveals that exposure to the high-impact sport (vs no exposure) was associated with an overall decline in language complexity scores over time. This trend persists even after controlling for age as a potential confound. The results set the stage for a prospective study to test the hypothesis that language complexity decline is a harbinger of chronic traumatic encephalopathy.

Time course of threat responding in panic disorder and depression

Heightened sensitivity to threat is a characteristic feature of panic disorder (PD). It is also a factor that is considered to be central to PD but not major depressive disorder (MDD) — a related disorder that commonly co-occurs with PD. However, sensitivity to threat is a broad construct and it is unclear whether individuals with PD exhibit heightened initial threat reactivity, impairments in modulating their threat responding over time, or both. It is also unclear how these different facets of threat responding apply to predictable and/or unpredictable threat. The aim of the current study was to examine whether there are differences in initial threat reactivity and the time course of threat responding during predictable and unpredictable threat-of-shock in 186 adults with: 1) current PD and no history of depression (i.e., PD-only), 2) current MDD and no history of an anxiety disorder (i.e., MDD-only), 3) current comorbid PD and MDD, or 4) no lifetime history of psychopathology (i.e., controls). Threat responding was assessed using an electromyography startle paradigm. Relative to controls, individuals in the three psychopathology groups exhibited heightened initial threat reactivity to predictable and unpredictable threat and did not differ from each other. Multilevel mixed model analyses indicated that those with PD evidenced less of a decline over time in startle responding during unpredictable threat relative to those without PD. Those with MDD displayed a greater slope of decline in startle responding during predictable threat compared with those without MDD. The pattern of results suggests that there may be conceptual differences between measures of initial threat reactivity and time course of threat responding. Moreover, time course of threat responding, not initial threat reactivity, may differentiate PD from MDD.

Predictors of change in quality of life in older adults with generalized anxiety disorder.

Quality of life (QOL) is lower in older adults with generalized anxiety disorder (GAD). QOL generally improves following cognitive-behavioral treatment for GAD. Little is known, however, about additional variables predicting changes in QOL in older adults with GAD. This study examined predictors of change in QOL among older participants in a randomized clinical trial of cognitive behavioral therapy (CBT) for GAD, relative to enhanced usual care (EUC). Hierarchical multilevel mixed-model analyses were used to examine inter-individual and intra-individual factors that predicted QOL over time. Predictors were categorized into treatment, personal and clinical characteristics. QOL improved over time, and there was significant variability between participants in change in QOL. Controlling for treatment condition, baseline general self-efficacy, baseline social support, within-person variation in worry and depression and average levels of depression across different time points predicted changes in QOL. QOL has increasingly been used as an outcome measure in treatment outcome studies to focus on overall improvement in functioning. Attention to improvement in symptoms of depression and worry, along with psychosocial variables, such as social support and self-efficacy, may help improve QOL in older adults with GAD. This study was a secondary study of data from a randomized clinical trial (NCT00308724) registered with clinical.trials.gov.

Long-Term Renal Function of Living Kidney Donors- A Prospective Cohort Study.

Introduction and Aims: The long-term medical risks after living kidney donation are uncertain. This study aimed to determine the factors that predict long-term post-donation decline in renal function amongst living kidney donors. Methods: A longitudinal analysis was undertaken within a prospective cohort of living donors (n=357, aged above 22.2 years) donated in a single centre between January 2000 and December 2013. The change in estimated glomerular filtration rate (eGFR) between baseline (pre-donation), one, five and ten years was analysed using multilevel mixed model analyses. The glomerular filtration rate was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Results: Of the 357 living donors, 338 (94.7%) completed follow-up at the first year. A total of 138 (out of 237, 58.2%) and 48 (out of 88, 54.5%) were followed at five and ten years, respectively. The mean eGFR at baseline, one, five and ten years were 94 ml/min/1.73m2 (SD: 13.97), 61 (SD: 12.45), 58 (SD: 12.81) and 56 (SD: 12.67). Overall, eGFR declined by 32.7 (SD: 10.7) ml/min/1.73m2 between baseline and one year in participants who had repeated measures of serum creatinine (323 out of 357, 90.5%). The decline in eGFR stabilised between 1-5 and 5-10 years after donation, with a median reduction in eGFR of 0.47 (SD: 6.1) ml/min/1.73m2 and 0.81 (SD: 3.1) ml/min/1.73m2, respectively. Multivariate linear mixed modelling suggested that older age and higher body mass index (BMI) at the time of donation were associated with the greatest annual decline in eGFR post-nephrectomy (p values <0.001 and 0.02 respectively). There was a 0.57 ml/min/1.73m2 per year reduction in eGFR for every year increase in age at the time of donation. For every 1 kg/m2 increase in BMI at the time of donation, there was a 0.70 ml/min/1.73m2 reduction in eGFR annually over the 10-year follow-up. There was an insufficient number of donors with pre-existing hypertension and/or albuminuria to assess an effect on eGFR. Conclusion: Older age and higher BMI at the time of donation are independent predictors of decline in renal function over time amongst living kidney donors. However, the absolute decrement of renal function appeared to remain stable with aging.

Appropriate Antibiotic Use for Patients With Urinary Tract Infections Reduces Length of Hospital Stay

To define appropriate antibiotic use for patients with a complicated urinary tract infection (UTI), we developed in a previous study a key set of 4 valid, guideline-based quality indicators (QIs). In the current study, we evaluated the association between appropriate antibiotic use for patients with a complicated UTI, as defined by these QIs, and length of hospital stay (LOS). A retrospective, observational multicenter study included 1252 patients with a complicated UTI, hospitalized at internal medicine and urology departments of 19 university and nonuniversity Dutch hospitals. Data from the patients' medical charts were used to calculate QI performance scores. Multilevel mixed-model analyses were performed to relate LOS to QI performance (appropriate use or not). We controlled for the potential confounders sex, age, (urological) comorbidity, febrile UTI, and intensive care unit admission <24 hours. Prescribing therapy in accordance with local hospital guidelines was associated with a shorter LOS (7.3 days vs 8.7 days; P = .02), as was early intravenous-oral switching (4.8 days vs 9.1 days; P < .001). There was an inverse relationship between the proportion of appropriate use in a patient (QI sum score/number of applicable QIs) and LOS (9.3 days for lower tertile vs 7.2 days for upper tertile; overall P < .05). Appropriate antibiotic use in patients with a complicated UTI seems to reduce length of hospital stay and therefore favors patient outcome and healthcare costs. In particular, adherence to the total set of QIs showed a significant dose-response relationship with a shorter LOS.

Effectiveness of supervised implementation of an oral health care guideline in care homes; a single-blinded cluster randomized controlled trial

The objective of this study was to assess the effectiveness of a supervised implementation of the "Oral health care Guideline for Older people in Long-term care Institutions" (OGOLI) in The Netherlands. A sample of 12 care homes in the Netherlands was allocated randomly to an intervention or control group. While the residents in the control group received oral health care as before, the intervention consisted of a supervised implementation of the OGOLI. At baseline, the overall random sample comprised 342 residents, 52 % in the intervention group and 48 % in the control group. At 6 months, significant differences were observed between the intervention and the control group for mean dental as well as denture plaque, with a beneficial effect for the intervention group. The multilevel mixed-model analyses conducted with the plaque scores at 6 months as outcome variables showed that the reduction by the intervention was only significant for denture plaque. Supervised implementation of the OGOLI was more effective than non-supervised implementation in terms of reducing mean plaque scores at 6 months. However, the multilevel mixed-model analysis could not exclusively explain the reduction of mean dental plaque scores by the intervention. A supervised implementation of an oral health care guideline improves oral health of care home residents.

Determinants of emergency response willingness in the local public health workforce by jurisdictional and scenario patterns: a cross-sectional survey

BackgroundThe all-hazards willingness to respond (WTR) of local public health personnel is critical to emergency preparedness. This study applied a threat-and efficacy-centered framework to characterize these workers' scenario and jurisdictional response willingness patterns toward a range of naturally-occurring and terrorism-related emergency scenarios.MethodsEight geographically diverse local health department (LHD) clusters (four urban and four rural) across the U.S. were recruited and administered an online survey about response willingness and related attitudes/beliefs toward four different public health emergency scenarios between April 2009 and June 2010 (66% response rate). Responses were dichotomized and analyzed using generalized linear multilevel mixed model analyses that also account for within-cluster and within-LHD correlations.ResultsComparisons of rural to urban LHD workers showed statistically significant odds ratios (ORs) for WTR context across scenarios ranging from 1.5 to 2.4. When employees over 40 years old were compared to their younger counterparts, the ORs of WTR ranged from 1.27 to 1.58, and when females were compared to males, the ORs of WTR ranged from 0.57 to 0.61. Across the eight clusters, the percentage of workers indicating they would be unwilling to respond regardless of severity ranged from 14-28% for a weather event; 9-27% for pandemic influenza; 30-56% for a radiological 'dirty' bomb event; and 22-48% for an inhalational anthrax bioterrorism event. Efficacy was consistently identified as an important independent predictor of WTR.ConclusionsResponse willingness deficits in the local public health workforce pose a threat to all-hazards response capacity and health security. Local public health agencies and their stakeholders may incorporate key findings, including identified scenario-based willingness gaps and the importance of efficacy, as targets of preparedness curriculum development efforts and policies for enhancing response willingness. Reasons for an increased willingness in rural cohorts compared to urban cohorts should be further investigated in order to understand and develop methods for improving their overall response.