Multiple Causal Pathways Research Articles

Discovery of interconnected causal drivers of COVID-19 vaccination intentions in the US using a causal Bayesian network

Holistic interventions to overcome COVID-19 vaccine hesitancy require a system-level understanding of the interconnected causes and mechanisms that give rise to it. However, conventional correlative analyses do not easily provide such nuanced insights. We used an unsupervised, hypothesis-free causal discovery algorithm to learn the interconnected causal pathways to vaccine intention as a causal Bayesian network (BN), using data from a COVID-19 vaccine hesitancy survey in the US in early 2021. We identified social responsibility, vaccine safety and anticipated regret as prime candidates for interventions and revealed a complex network of variables that mediate their influences. Social responsibility’s causal effect greatly exceeded that of other variables. The BN revealed that the causal impact of political affiliations was weak compared with more direct causal factors. This approach provides clearer targets for intervention than regression, suggesting it can be an effective way to explore multiple causal pathways of complex behavioural problems to inform interventions.

The Black-White Disparity in Preterm Birth: Race or Racism?

Policy Points Racism is an upstream determinant of health that influences health through many midstream and downstream factors. This Perspective traces multiple plausible causal pathways from racism to preterm birth. Although the article focuses on the Black-White disparity in preterm birth, a key population health indicator, it has implications for many other health outcomes. It is erroneous to assume by default that underlying biological differences explain racial disparities in health. Appropriate science-based policies are needed to address racial disparities in health; this will require addressing racism.

Effects of pre-service teachers’ cultural competence on their social justice and self-efficacy beliefs: a cross-cultural comparison between Turkey, South Korea and the United States

ABSTRACT This study is a comparative research investigating whether cultural competence of preservice teachers is causally related to their social justice and self-efficacy beliefs in Turkey, South Korea and the United States. The study group involved pre-service teachers from Turkey (n = 560), South Korea (n = 790) and the United States (n = 352). The model was developed in the study to discern pattern of relationships among cultural competence acting on social justice and self-efficacy beliefs via multiple causal pathways. Multisample structural equation model was performed to test the equivalence of relationships among variables in the three samples by estimating the model separately for Turkish, S. Korean, and US groups. The study results revealed that cultural competence of pre-service teachers has positive effect on their social justice and self-efficacy beliefs in all three samples. The results indicated that there is a strongest effect of pre-service teachers’ cultural competence on their social justice beliefs in S. Korea. There was a strongest effect of pre-service teachers’ cultural competence on their self-efficacy beliefs in Turkey. The implications for academic research and teacher training are discussed.

Understanding the systemic influences on maritime pilot decision-making

Maritime incidents occurring during pilotage are of international concern. Maritime pilots control most pilotage operations worldwide, yet despite the safety criticality of their role, research examining pilot decision-making processes during these complex and dynamic operations is scarce. This article describes the findings from two studies that utilised an integrated systems thinking framework to understand how pilots make decisions and what factors are perceived to influence their decisions. Interviews were held with 22 pilots (Study 1) and 17 maritime safety stakeholders (Study 2) in the New Zealand maritime context. The findings illustrate the challenges pilots face during pilotage and provide insights into their decision-making processes and the systemic factors that can be addressed to improve maritime safety. Given the multiple causal pathways to incidents occurring during pilotage identified by this research, it is suggested that multiple systems-wide interventions are needed, which is likely to require a long-term, strategic approach.

Estimating the Effect of Health Service Delivery Interventions on Patient Length of Stay: A Bayesian Survival Analysis Approach

AbstractHealth service delivery interventions include a range of hospital ‘quality improvement’ initiatives and broader health system policies. These interventions act through multiple causal pathways to affect patient outcomes and they present distinct challenges for evaluation. In this article, we propose an empirical approach to estimating the effect of service delivery interventions on patient length of stay considering three principle issues: (i) informative censoring of discharge times due to mortality; (ii) post-treatment selection bias if the intervention affects patient admission probabilities; and (iii) decomposition into direct and indirect pathways mediated by quality. We propose a Bayesian structural survival model framework in which results from a subsample in which required assumptions hold, including conditional independence of the intervention, can be applied to the whole sample. We evaluate a policy of increasing specialist intensity in hospitals at the weekend in England and Wales to inform a cost-minimisation analysis. Using data on adverse events from a case note review, we compare various specifications of a structural model that allows for observations of hospital quality. We find that the policy was not implemented as intended but would have likely been cost saving, that this conclusion is sensitive to model specification, and that the direct effect accounts for almost all of the total effect rather than any improvement in hospital quality.

Targeting Impaired Antimicrobial Immunity in the Brain for the Treatment of Alzheimer's Disease.

Alzheimer’s disease (AD) is the most common form of dementia and aging is the most common risk factor for developing the disease. The etiology of AD is not known but AD may be considered as a clinical syndrome with multiple causal pathways contributing to it. The amyloid cascade hypothesis, claiming that excess production or reduced clearance of amyloid-beta (Aβ) and its aggregation into amyloid plaques, was accepted for a long time as the main cause of AD. However, many studies showed that Aβ is a frequent consequence of many challenges/pathologic processes occurring in the brain for decades. A key factor, sustained by experimental data, is that low-grade infection leading to production and deposition of Aβ, which has antimicrobial activity, precedes the development of clinically apparent AD. This infection is chronic, low grade, largely clinically silent for decades because of a nearly efficient antimicrobial immune response in the brain. A chronic inflammatory state is induced that results in neurodegeneration. Interventions that appear to prevent, retard or mitigate the development of AD also appear to modify the disease. In this review, we conceptualize further that the changes in the brain antimicrobial immune response during aging and especially in AD sufferers serve as a foundation that could lead to improved treatment strategies for preventing or decreasing the progression of AD in a disease-modifying treatment.

Specialty Certification: A Path To Improving Outcomes.

Specialty Certification: A Path To Improving Outcomes.

Upstream Factors in Population Health: A Concept Analysis to Advance Nursing Theory.

The assessment of upstream factors is important in population-based nursing practice. The aim of this concept analysis is to enhance understanding of upstream factors and articulate a definition linked to the Conceptual Model for Nursing and Population Health. Upstream factors are thus defined as established conditions related to economic, social, and physical environments that occur outside the health care system, in the communities where people live, and contribute indirectly to the health outcomes for groups of individuals through multiple causal pathways. This concept analysis highlights the need for middle-range theory to guide nursing assessment and contributes to conceptual model evaluation.

Using Structural Equation Modelling to Untangle Pathways of Factors Associated with Type 2 Diabetes

Abstract Background Risk factors for type 2 diabetes (T2D) are multi-facet and interrelated. We aimed to apply structural equation modelling to examine and quantify pathways of modifiable risk factors related to incident type 2 diabetes. Methods Analysis was based on 68 649 participants (35-80 years, without diabetes at baseline) from the Lifelines cohort study. We proposed a conceptual model that illustrates the pathways of risk factors related to incident type 2 diabetes: socio-economic status (income and education) → lifestyle behaviors (diet quality, physical activity, TV watching, and smoking) → clinical markers (blood lipids and obesity status) → incident type 2 diabetes. Structural equation modeling was performed to test this proposed model. Results After a median follow-up of 41 months, 1124 new cases of type 2 diabetes were identified. The best-fitting model indicated that among all modifiable risk factors included, waist circumference had the biggest direct effect on type 2 diabetes (β: 0.213 ), followed by HDL-cholesterol (β: -0.141). Less TV watching and more physical activity were found to play an important role in improving clinical markers that were directly associated with type 2 diabetes. Education had the biggest direct effects on all lifestyle behaviors. Conclusions Using this innovative approach, our analysis provides a more nuanced assessment of the interplay of type 2 diabetes risk factors, compared to traditional risk estimates. Our results indicated that reducing large waist circumference may be prioritized as the main target for the prevention of type 2 diabetes, and lifestyle interventions are urgently warranted with additional support for those with a low education. Key messages Our study elucidated the multiple causal pathways to type 2 diabetes in a prospective setting. Our results identified the most critical targets for future prevention strategies for type 2 diabetes.

Practices Derived from the Evidence Base for Depression Predict Disruptive Behavior Progress in Adolescent Community Mental Health Care.

Disruptive behavior problems develop along multiple causal pathways and are associated with a wide variety of co-occurring problems, including mood disorders. In usual care, effective treatment practices for youth disruptive behavior might differ from what the efficacy research suggests, given treatment setting and population demographic differences. The current study examined whether practices derived from the evidence base for disruptive behavior and/or depressed mood predicted progress on disruptive behavior problems in an adolescent usual care sample. Monthly clinical data, including therapeutic practices, treatment targets, and progress on selected treatment targets, for 1210 youth ages 13-17 who received intensive in-home services and were treated for disruptive behavior problems were examined utilizing multilevel modeling techniques. Practices derived from the evidence base for only depressed mood and practices derived from both disruptive behavior and depressed mood literatures predicted disruptive behavior progress, while practices derived from only the disruptive behavior evidence-based literature did not. All five practice elements exclusive to depressed mood treatment predicted positive disruptive behavior progress, while two of eleven disruptive behavior practices and four of seven practices derived from both problem areas predicted positive progress. Findings held when other predictors were included as covariates, including youth age and functional impairment. Although directionality remains unclear and further research is vital, usual care settings might present barriers to disruptive behavior treatment as prescribed by the evidence base, and youth-focused treatments based on depressed mood treatments merit further examination as a potentially promising route to effective treatment in such settings.

Amyloid, Vascular, and Resilience Pathways Associated with Cognitive Aging.

ObjectiveTo investigate the multifactorial processes underlying cognitive aging based on the hypothesis that multiple causal pathways and mechanisms (amyloid, vascular, and resilience) influence longitudinal cognitive decline in each individual through worsening brain health.MethodsWe identified 1,230 elderly subjects (aged ≥50 years) with an average of 4.9 years of clinical follow‐up and with amyloid positron emission tomography, diffusion tensor imaging, and structural magnetic resonance imaging scans from the population‐based Mayo Clinic Study of Aging. We examined imaging markers of amyloid and brain health (white matter microstructural integrity and cortical thinning), systemic vascular health preceding the imaging markers, and early to midlife intellectual enrichment to predict longitudinal cognitive trajectories. We used latent growth curve models for modeling longitudinal cognitive decline.ResultsAll the pathways (amyloid, vascular, resilience) converged through their effects on cortical thinning and worsening cognition and together explained patterns in cognitive decline. Resilience and vascular pathways (aging process, sex differences, education/occupation, and systemic vascular health) had significant impact on white matter microstructural integrity. Education/occupation levels contributed to white matter integrity through systemic vascular health. Worsening white matter integrity contributed to significant cortical thinning and subsequently longitudinal cognitive decline. Baseline amyloidosis contributed to a significant proportion of cognitive decline that accelerated with longer follow‐up times, and its primary impact was through cortical thinning.InterpretationWe developed an integrated framework to help explain the dynamic and complex process of cognitive aging by considering key causal pathways. Such an approach is important for both better comprehension of cognitive aging processes and will aid in the development of successful intervention strategies. ANN NEUROL 2019;86:866–877

Sexual initiation among Canadian youth: A model comparison approach of evolutionary hypotheses shows greatest support for extrinsic mortality cues, intergenerational conflict, and early life psychosocial stressors

Abstract Early life factors are associated with the timing of reproductive events in adolescence, but a variety of hypotheses (such as psychosocial acceleration theory, paternal investment theory, extrinsic mortality, internal prediction, and intergenerational conflict) propose different explanations for why this may occur. To compare between these theories, we use the National Longitudinal Survey of Children and Youth, an extensive, longitudinal survey of Canadian male and female youth (aged 14-15 in last wave) to identify variables that uniquely support these different models (n≈1200). We identify the best predictors of sexual initiation for each hypothesis and then use a model selection procedure to determine which set of variables has the most support. Results show that variables representing extrinsic mortality cues, intergenerational conflict, early life psychosocial stressors, and prenatal factors are included in the top models, while variables representing social support and unpredictability are represented in some of the top models. Variables representing the paternal investment theory were not included in any of the top models, suggesting limited support for this hypothesis. These results support many of the hypotheses that have been previously presented in the literature, suggesting that timing of sexual initiation may have multiple causal pathways.

Introducing regional self-governments in Central and Eastern Europe: Paths to success and failure

ABSTRACT Only over half of the new EU member states in Eastern Europe have introduced regional self-governments. This article explores the factors that have contributed to the success or failure of regionalization. The novel contribution of the article is as follows: first, if previous studies have mainly concentrated on larger countries that have successfully regionalized, the current study explores those factors that have contributed to the failure. Second, earlier studies have been too focused on EU conditionality, whereas the current study, in applying QCA (Qualitative Comparative Analysis), outlines the multiple causal pathways that have lead to successful regionalization (or failure). The results of the analysis reveal that there are two pathways for successful regionalization: (1) EU-induced regionalization, or (2) the semi-regionalist pathway. Pathways leading to failure also comprise two options: (3) ‘small-size-blocked’ pathway, or (4) the ‘lack of external pressure and tradition’ pathway.

Environmental enteric dysfunction and child stunting.

In 2017, an estimated 1 in every 4 (23%) children aged < 5 years were stunted worldwide. With slow progress in stunting reduction in many regions and the realization that a large proportion of stunting is not due to insufficient diet or diarrhea alone, it remains that other factors must explain continued growth faltering. Environmental enteric dysfunction (EED), a subclinical state of intestinal inflammation, can occur in infants across the developing world and is proposed as an immediate causal factor connecting poor sanitation and stunting. A result of chronic pathogen exposure, EED presents multiple causal pathways, and as such the scope and sensitivity of traditional water, sanitation, and hygiene (WASH) interventions have possibly been unsubstantial. Although the definite pathogenesis of EED and the mechanism by which stunting occurs are yet to be defined, this paper reviews the existing literature surrounding the proposed pathology and transmission of EED in infants and considerations for nutrition and WASH interventions to improve linear growth worldwide.

Secular changes in body height predict global rates of caesarean section.

The massive global variation in caesarean-section (C-section) rate is usually attributed to socio-economic, medical and cultural heterogeneity. Here, we show that a third of the global variance in current national C-section rate can be explained by the trends of adult body height from the 1970s to the 1990s. In many countries, living conditions have continually improved during the last century, which has led to an increase in both fetal and adult average body size. As the fetus is one generation ahead of the mother, the fetus is likely to experience better environmental conditions during development than the mother did, causing a disproportionately large fetus and an increased risk of obstructed labour. A structural equation model revealed that socio-economic development and access to healthcare affect C-section rate via multiple causal pathways, but the strongest direct effect on C-section rate was body height change. These results indicate that the historical trajectory of socio-economic development affects-via its influence on pre- and postnatal growth-the intergenerational relationship between maternal and fetal dimensions and thus the difficulty of labour. This sheds new light on historic and prehistoric transitions of childbirth and questions the World Health Organization (WHO) suggestion for a global 'ideal' C-section rate.

An Embodied Neurocomputational Framework for Organically Integrating Biopsychosocial Processes: An Application to the Role of Social Support in Health and Disease.

Two distinct perspectives-typically referred to as the biopsychosocial and biomedical models-currently guide clinical practice. Although the role of psychosocial factors in contributing to physical and mental health outcomes is widely recognized, the biomedical model remains dominant. This is due in part to (a) the largely nonmechanistic focus of biopsychosocial research and (b) the lack of specificity it currently offers in guiding clinicians to focus on social, psychological, and/or biological factors in individual cases. In this article, our objective is to provide an evidence-based and theoretically sophisticated mechanistic model capable of organically integrating biopsychosocial processes. To construct this model, we provide a narrative review of recent advances in embodied cognition and predictive processing within computational neuroscience, which offer mechanisms for understanding individual differences in social perceptions, visceral responses, health-related behaviors, and their interactions. We also review current evidence for bidirectional influences between social support and health as a detailed illustration of the novel conceptual resources offered by our model. When integrated, these advances highlight multiple mechanistic causal pathways between psychosocial and biological variables. By highlighting these pathways, the resulting model has important implications motivating a more psychologically sophisticated, person-specific approach to future research and clinical application in the biopsychosocial domain. It also highlights the potential for quantitative computational modeling and the design of novel interventions. Finally, it should aid in guiding future research in a manner capable of addressing the current criticisms/limitations of the biopsychosocial model and may therefore represent an important step in bridging the gap between it and the biomedical perspective.

Ecological and life history traits are associated with Ross River virus infection among sylvatic mammals in Australia

BackgroundRoss River virus (RRV) is Australia’s most important arbovirus given its annual burden of disease and the relatively large number of Australians at risk for infection. This mosquito-borne arbovirus is also a zoonosis, making its epidemiology and infection ecology complex and cryptic. Our grasp of enzootic, epizootic, and zoonotic RRV transmission dynamics is imprecise largely due to a poor understanding of the role of wild mammalian hosts in the RRV system.MethodsThe current study applied a piecewise structural equation model (PSEM) toward an interspecific comparison of sylvatic Australian mammals to characterize the ecological and life history profile of species with a history of RRV infection relative to those species with no such history among all wild mammalian species surveyed for RRV infection. The effects of species traits were assessed through multiple causal pathways within the PSEM framework.ResultsSylvatic mammalian species with a history of RRV infection tended to express dietary specialization and smaller population density. These species were also characterized by a longer gestation length.ConclusionsThis study provides the first interspecific comparison of wild mammals for RRV infection and identifies some potential targets for future wildlife surveys into the infection ecology of this important arbovirus. An applied RRV macroecology may prove invaluable to the epidemiological modeling of RRV epidemics across diverse sylvatic landscapes, as well as to the development of human and animal health surveillance systems.

Conceptualizing Ecological Responses to Dam Removal: If You Remove It, What's to Come?

One of the desired outcomes of dam decommissioning and removal is the recovery of aquatic and riparian ecosystems. To investigate this common objective, we synthesized information from empirical studies and ecological theory into conceptual models that depict key physical and biological links driving ecological responses to removing dams. We define models for three distinct spatial domains: upstream of the former reservoir, within the reservoir, and downstream of the removed dam. Emerging from these models are response trajectories that clarify potential pathways of ecological transitions in each domain. We illustrate that the responses are controlled by multiple causal pathways and feedback loops among physical and biological components of the ecosystem, creating recovery trajectories that are dynamic and nonlinear. In most cases, short-term effects are typically followed by longer-term responses that bring ecosystems to new and frequently predictable ecological condition, which may or may not be similar to what existed prior to impoundment.

Introduction: Bringing Institutions Back in the Study of Global Value Chains.

The article introduces and summarizes the key questions and findings of this special issue of Global Policy on the role of domestic and international institutions in the study of Global Value Chains (GVCs). The article starts by briefly introducing the concept of GVCs and the state-of-the-art of the existing literature focusing on the political implications of these landmark changes in the global economy. Then we make a case for grounding this emerging literature more strongly into an "institutionalist" perspective. More specifically, we argue that while a great deal of attention has been paid to intra-chain governance modes - i.e. the different ways in which firms organize their cross-border production arrangements - the role external institutional forces play in structuring chain dynamics remains surprisingly under-researched. These observations invite an analytical perspective that brings institutions back into the study of GVCs. The contributions to the special issue focus on multiple causal pathways linking GVCs and various types of domestic- and international institutions. Altogether, these contributions underscore that the politics engendered by GVCs, as well as how they evolve, can only be fully understood by paying attention to the external institutional context in which they are embedded.

Leaf phosphorus content of Quercus wutaishanica increases with total soil potassium in the Loess Plateau.

Phosphorus (P) is arguably more limiting than nitrogen for forest ecosystems being free of disturbances for lengthy time periods. The elucidation of multivariate relationships between foliar P and its primary drivers for dominant species is an urgent issue and formidable challenge for ecologists. Our goal was to evaluate the effects of primary drivers on foliar P of Quercus wutaishanica, the dominant species in broadleaved deciduous forest at the Loess Plateau, China. We sampled the leaves of 90 Q. wutaishanica individuals across broad climate and soil nutrient gradients at the Loess Plateau, China, and employed structural equation models (SEM) to evaluate multiple causal pathways and the relative importance of the drivers for foliar P per unit mass (Pmass) and per unit area (Parea). Our SEMs explained 73% and 81% of the variations in Pmass and Parea, respectively. Pmass was negatively correlated to leaf mass per area, positively correlated to leaf area, and increased with mean annual precipitation and total soil potassium. Parea was positively correlated to leaf mass per area, leaf dry weight, and increased significantly with total soil potassium. Our results demonstrated that leaf P content of Q. wutaishanica increased with total soil potassium in the Loess Plateau accordingly.