Multistage Study Research Articles

Wine Pomace as Feed in Native Chicken Farming: A Revenue-Cost Analysis

Objective: This study analyzes the feasibility of using wine pomace as a feed supplement for native chickens in Bali, Indonesia, focusing on the financial benefits of this practice. Theoretical Framework: Small-scale farmers in Bali rely heavily on commercial feed for their chickens, which accounts for a significant portion of their expenses. This study explores the use of locally available grape wine pomace as a cost-effective alternative feed source. Wine pomace is rich in protein, fiber, and fat, making it a suitable ingredient for native chickens, especially KUB chickens. Method: This multi-stage study involves a survey to assess wine pomace availability, followed by fermentation and nutritional analysis. A feeding trial using a Completely Randomized Design evaluates the impact of different wine pomace percentages on chicken growth and performance. Economic analysis compares revenue and costs to determine profitability. Results and Discussion: Results show wine pomace is readily available, with nutritional value suitable for animal feed. A 5% wine pomace ration resulted in improved feed efficiency and increased profitability. Research Implications: This study highlights the potential of utilizing agro-industrial waste as a sustainable and cost-effective feed ingredient, promoting a circular economy approach in the poultry industry. Originality/Value: This research contributes to existing literature by exploring the potential of wine pomace as a feed ingredient for KUB chickens in Bali, providing valuable data on its nutritional composition and economic benefits.

Patterns, delays, and associated factors of help-seeking behaviour for lifetime mood disorders and anxiety disorders: A national representative survey

BackgroundUtilisation of health services is low and delayed among individuals with mood mental disorders and anxiety disorders, despite high disease burdens and available effective treatments. This study aims to examine patterns and delays in help-seeking and associated factors among individuals with lifetime disorder of mood disorders and/or anxiety disorders. MethodsWe used data from the China Mental Health Survey (CMHS), a nationally representative multistage clustered-area probability sample study across 31 provinces. We assessed lifetime mental disorders and help-seeking behaviour using the Composite International Diagnostic Interview (CIDI). Logistic regression analyses were used to examine sociodemographic and clinical correlates of delay to seek health care. ResultsAmong 32,552 participants, we identified 3075 patients with lifetime mood and/or anxiety disorders; 486 (15.5 % [95 % CI: 13.6–17.5 %]) have sought health care. Of these, 163 (4.8 % [95 % CI: 3.7–6.3]) ever sought specialized mental health services. The delays to initial health care were 1.0 (IQR: 0–7.1), 1.9 (0–10.0), and 10.0 (1.0–22.1) years for depressive, bipolar, and anxiety disorders. Patients with comorbidities, later age of onset, and living in urban areas showed a higher propensity for help-seeking (all p < 0.05). Older cohort was associated with longer delays in seeking health care, while a later age of onset was associated with shorter delays (all p < 0.05). LimitationsThe cross-sectional retrospective design and self-assessment approach may add bias. ConclusionsFailure and delays in help-seeking are common in China. National strategies are needed to promote health care utilisation.

Considering masculinities at forest fires: the case of the 2021 Muğla forest fires in Turkey

ABSTRACT This article investigates emerging masculinities in Turkey’s massive Muğla forest fires of 2021 and their aftermath. The findings are based on a multi-stage qualitative field study: the disaster research was conducted in Köyceğiz and Marmaris in 2021, as well as social media research and personal observations during the fires, followed by follow-up research in 2022. Following Pacholok (2013). I argue that in the unique time and terrain frame of disaster, masculinities are contested and realized. In relation to disaster and environment, four main local constructions of masculinities are observed during the fires. They are (1) the villagers who embody traditional rural masculinities, (2) the firefighters who represent working-class masculinities based on arduous physical labour without heroism, (3) the forest officers and engineers who represent masculinities with refined state-centred engineering male rationality that aim for men’s domination over nature, and (4) the celebrities and volunteers that comprise the urbanites who represent possibilities for alternative ecomasculinities with subtle gender egalitarianism. They present particular constructions of masculinities that reveal local societal norms and expectations and the gender relations that emerged as a result of the crisis environment caused by forest fires.

The transition from cigarette smoking to the exclusive or partial use of e-cigarettes: A multi-stage mixed methods study among French university students

BackgroundFew studies have estimated the frequency of e-cigarette use by smoking status among French young adults, and how those who smoke tobacco start and continue to use e-cigarettes. Our aim was to describe e-cigarette use among students who smoked tobacco. MethodsA multi-stage, mixed methods study was conducted at the University of Bordeaux between September 2018 and March 2020. The study consisted of three different sub-studies: 1) a cross-sectional study across five campuses (n = 211), 2) a qualitative study (n = 30), and 3) an online cross-sectional study (n = 415). These were combined to form an explanatory sequential design (stage 1) and then a convergent parallel design (stage 2). ResultsAlthough 41 % of students had tried e-cigarettes at least once in their lifetime, only 7 % were current users. Both e-cigarette experimentation and current use (i.e. occasional or daily use) were mainly found among current and former smokers. Student smokers started using e-cigarettes out of curiosity, with other vapers. Two main factors were identified as intervening in the transition from smoking to sustained vaping: the perception of smoking as problematic and personal commitment to e-cigarette use (i.e. by buying their own device, acquiring technical skills, and increasing the frequency of use). Among current vapers, exclusive vapers and dual users differed in terms of their smoking goals, the role they attributed to e-cigarettes, their identity development and their perceived social or personal benefits. ConclusionThis study highlighted the complexity of the decision-making process for transitioning from smoking to sustained vaping among university students. This required a socially supportive environment and some intrinsic factors, of which the problematization of smoking and personal commitment to vaping were key factors.

Prevalence and risk factors associated with psychological distress among children in Penang, Malaysia: A stratified multistage cluster study

Mental health is a state of mind influences one thinking, feeling and acting from inside and outside that are vital for children's normal growth and development. Psychological distress may results in serious mental health problem if left untreated. Hence, early diagnosis can largely improve the condition from being deteriorating. This study determined the prevalence of psychological distress and its associated risk factors among children in Penang, Malaysia. The study applied stratified multistage cluster sampling for the recruitment of children, and their socio-demographics background, health and lifestyle practices, and the prevalence and risk factors of psychological distress were succinctly studied. The study provides a fundamental platform for informing parents and policy makers about psychological distress, and the need to strategize potential health intervention for achieving optimum human well-being.•Stratified multistage cluster sampling was useful to study the prevalence and risk factors of psychological distress in a children population.•DASS-Y is robust for brief dimensional measure of depression, anxiety and stress among children.

Co-producing an advocacy video on e-cigarette advertising with adolescents in Scotland: a multi-stage qualitative study

BackgroundResearchers, advocacy workers, and adolescents have raised concerns about the uptake of e-cigarettes (‘vapes’) among adolescents. Currently, vaping is not part of NHS Scotland's smoking cessation resources. This study investigated adolescents’ exposure to and perceptions of e-cigarette advertising to co-produce an advocacy video. This focus on e-cigarette marketing and adolescents is timely as policymakers in the UK are actively shaping new regulations in response to these concerns, such as banning disposable e-cigarettes. MethodsBetween March and September, 2023, a four-phase project was conducted with adolescents aged 11–16 years from the central belt of Scotland. The phases included 1) three workshops with 33 adolescents (10–12 per workshop) about their experiences with e-cigarette marketing; 2) photographs from 28 adolescents depicting examples of marketing in their local areas and online; 3) six focus groups (a total of 28 adolescents, 2–6 per group) to discuss the photographs and 4) co-production of an advocacy video with a video production company, including one additional workshop with six adolescents. Workshops were not recorded; however, researchers took field notes, and the materials produced were kept for analysis. Focus group transcripts were thematically analysed. FindingsThis study explored adolescents’ exposure to and views on e-cigarette advertising to co-produce an advocacy video aimed at reducing such exposure. Our qualitative thematic analysis of the workshop and focus group data revealed adolescents’ concerns about e-cigarettes’ potential health effects, pervasive advertising targeting adolescents, and peer usage, which became the focus of the final video. Although none of our participants were current e-cigarette users, some had encountered targeted online advertisements, despite being under 18, or had seen friends of public figures using e-cigarettes on social media. The advocacy video, produced in collaboration with the adolescents, effectively integrated their insights and experiences, highlighting their collective concerns about e-cigarette advertising. InterpretationOur findings show adolescents are highly exposed to e-cigarette advertising, feel uncertain about their harms, and are aware of marketing tactics like vibrant colours and flavour variations. This highlights the need for advocacy work which focuses on promoting stronger marketing legislation to protect them. Our advocacy video, is one such example of this which is being used by advocacy groups to raise awareness about e-cigarette advertisements. FundingCancer Research UK.

Malaria risk factors amongst forest going populations in Mondulkiri Province and Kampong Speu Province, Cambodia: a large cross-sectional survey.

Cambodia strives to eliminate all species of human malaria by 2025, requiring that foci among forest-exposed populations in remote settings be addressed. This study explores malaria risk factors amongst forest-exposed groups in Mondulkiri and Kampong Speu Provinces, Cambodia as part of a multi-stage study on novel bite prevention tools (Project BITE). A serial cross-sectional survey explored the demographics, housing structure openness, mosquito bite prevention habits, and gaps in protection amongst three target groups: forest goers who work in the forest, forest dwellers who live in the forest, and forest rangers who patrol forested regions. Malaria prevalence data was collected at three time points using rapid diagnostic tests (RDTs) for febrile individuals and qPCR for all participants. Infection locations and travel patterns of P. falciparum-infected individuals were analyzed for clustering and the potential movement of infections. 2,935 participants were enrolled between October 2022 and February 2023, consisting of 1,093 (37%) forest goers and 1,787 (61%) forest dwellers across both provinces, and 55 (5%) forest rangers in Mondulkiri province. Most worked outdoors as farmers, day laborers, and forest collectors, and reported going to the forest five to seven days a week. For housing, 29% and 39% of participants reported living in partially open primary and secondary structures, respectively. The main methods of mosquito bite protection used were insecticide-treated nets, wearing long sleeves, and burning mosquito coils, with gaps in protection during the daytime and outside at night. All febrile individuals had negative RDT test results. For qPCR, 24 P. falciparum infections (<1%) were detected among forest goers and dwellers, clustered in Pu Trom and Pu Nhav villages in Mondulkiri Province, and Banteay Roka and Banteay Roka Kirisenchey (M) villages in Kampong Speu Province. P. vivax cases were detected (216 cases, 5%) across all enrolled villages. Only two infections were found in forest rangers. Malaria elimination strategies for forest-exposed populations in Cambodia should focus on vector intervention strategies that offer protection during the day and outside at night, and the use of drug-based strategies to clear subpatent infections, targeting forest goers and dwellers in villages where cases are detected.

Identification of novel pQTL-SNPs associated with lung adenocarcinoma risk: A multi-stage study.

To explore the association between protein quantitative trait loci (pQTL-SNPs) and the risk of LUAD. "Blood +" high depth blood proteomics analysis was performed on plasma from female LUAD patients and female healthy controls, and combined with proteomics data from tumors and adjacent non-tumor tissues of female LUAD patients to screen proteins uniformly expressed in plasma and tissues. pQTL-SNPs were then screened through multiple databases and subjected to multilevel screening. The associations between selected pQTL-SNPs and LUAD risk were evaluated by Female Lung Cancer Consortium in Asia GWAS (FLCCA GWAS). Enzyme linked immunosorbent assay (ELISA) is used to determine the levels of candidate protein. A total of 7 pQTL-SNPs were significantly associated with altered LUAD risk (p < 0.05). Meanwhile, the expression of their corresponding target proteins were all decreased in both plasma and tumor tissues of LUAD cases, which may play a role of tumor suppressor proteins. After mutation of 3 pQTL-SNPs (rs7683000, rs73224660, and rs2776937), the expression of corresponding target proteins BST1 and NRP1 decreased, and as potential tumor suppressor proteins, which may promote tumorigenesis and further increasing the risk of developing LUAD (OR >1, p < 0.05); while after mutation the other pQTL-SNP rs62069916, the corresponding target protein APOH expression was increased, while as a potential tumor suppressor protein, which may inhibit tumorigenesis and further reduced the risk of developing LUAD (OR <1, p < 0.05). In addition, the expression of NRP1 and APOH were significant decreased in LUAD cell lines and validated in plasma of LUAD patients. A total of 4 pQTL-SNPs (rs7683000, rs73224660, rs2776937, and rs62069916) may associate with altered LUAD risk by regulating the expression of target proteins (BST1, NRP1, and APOH) after mutation.

Virtual Coaching for Home Rehabilitation - Evidence of an Empirical Study.

Older individuals often face disabilities or diseases that lower their quality of life (QoL). While inpatient rehabilitation can initially enhance QoL, there is often a lack of continuation at home. Virtual coaches (VCs) as specific embodied conversational agents promise appropriate support for home rehabilitation. They emerge as complementary digital aids to ensure care continuity. This paper presents the results of implementing a full-featured VC for older patients' home rehabilitation in a multi-stage study, summarizing the main results regarding QoL outcomes and user experience tests. The study confirms the intervention as an engaging means for rehabilitation (mostly above user experience thresholds) and improvements of QoL (>10% between experimental and control groups).

Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study

IntroductionAt least 10% of hospital admissions in high-income countries, including Australia, are associated with patient safety incidents, which contribute to patient harm (‘adverse events’). When a patient is seriously harmed,...

The relationship between occupant behaviour and indoor air quality in Malaysian hospital outpatient departments: A multistage cross-sectional study

IntroductionPoor indoor air quality (IAQ) in healthcare settings may adversely impact occupants’ well-being and promote transmission of infectious respiratory disease. However, evidence on its potentially modifiable determinants, including occupant behaviour, remains scarce. This study aims to determine the relationship between occupant behaviour and IAQ in Malaysian hospital outpatient departments (OPDs). MethodsA multistage cross-sectional study of six randomly selected Malaysian public hospital OPDs was conducted. In stage one, IAQ parameters, including temperature, relative humidity (RH), air velocity (AV), carbon dioxide (CO2), total bacterial count (TBC), and total fungal count (TFC) were measured. In stage two, an observation form based on the Korsavi and Montazami tool for measuring adaptive behaviour was used to examine occupant density, activities, and operation of building envelopes and appliances. Simple correlation, partial correlation, and linear regression analyses were performed to examine the relationship between occupant behaviour and IAQ parameters. ResultsThe IAQ of selected hospital OPDs complied with established standards, except for temperature and AV. Occupant density was positively correlated with temperature and CO2. Meanwhile, occupants' activities including slow walking and brisk walking were positively correlated with temperature, AV, CO2, TBC and TFC. Conversely, occupants' opening of windows and doors were positively correlated with temperature and AV but negatively correlated with CO2, TBC and TFC. Finally, turning on fans was positively correlated with AV but negatively correlated with TBC, whereas turning on air conditioner was positively correlated with CO2. Among occupants’ behaviour, opening of windows and doors contributed the most to variation in IAQ parameters. ConclusionsThe study findings suggest that IAQ in hospital OPDs are influenced by occupant density, activities, and operation of doors, windows, and appliances. Prospective hospital IAQ guidelines should incorporate policies and measures targeting these factors to ensure occupants’ best practices in maintaining healthy hospital indoor air environments.

Spatiotemporal heterogeneity of the association between short-term exposure to carbon monoxide and COVID-19 incidence: A multistage time-series study in the continental United States

BackgroundPrevious research has established carbon monoxide (CO) as a significant air pollutant contributing to coronavirus disease 2019 (COVID-19) transmission. The spatiotemporal heterogeneity in the relationship between short-duration CO exposure and COVID-19 incidence remain underexplored. Investigating such heterogeneity plays a crucial role in designing region-specific cost-effective public health policies, exploring the reasons for heterogeneity, and understanding the temporal trends in the association between CO and an emerging infectious disease such as COVID-19. MethodsThe 49 states of the continental United States (U.S.) were examined in this study. Initially, we developed time-series generalized additive models (GAMs) for each state to assess the preliminary correlation between daily COVID-19 cases and short-term CO exposure from April 1, 2020, to December 31, 2021. Subsequently, the correlations were compiled utilizing Leroux-prior-based conditional autoregression (LCAR) to achieve a smoothed spatial distribution. Finally, we integrated a time-varying component into the GAM and LCAR to analyze temporal correlations and illuminate the factors contributing to spatiotemporal heterogeneity. ResultsOur analysis revealed that, across the 49 states, a 10-ppb increase in CO concentration was associated with a 1.33 % (95%CI: 0.86%–1.81 %) increase in COVID-19 cases on average. Furthermore, spatial variability was noted, with weaker correlations observed in the central and southeastern regions, stronger associations in the northeastern regions, and negligible associations in the western regions. Temporally, the correlation was not significant from April 2020 to June 2021, but began to increase steadily thereafter until the end of 2021. Additionally, vaccination and temperature were determined to be potential causes contributing to the heterogeneity, indicating stronger positive associations in areas with higher vaccination rates and temperatures. ConclusionThe findings of this study underscore the importance of monitoring CO pollution in the central and northeastern US, especially in the aftermath of the pandemic.

African American Preschoolers' Performance on Norm-Referenced Language Assessments: Examining the Effect of Dialect Density and the Use of Scoring Modifications.

We investigated and compared the outcomes from two standardized, norm-referenced screening assessments of language (i.e., Clinical Evaluation of Language Fundamentals Preschool-Second Edition [CELFP-2], Diagnostic Evaluation of Language Variation-Screening Test [DELV-ST]) with African American preschoolers whose spoken dialect differed from that of General American English (GAE). We (a) described preschoolers' performance on the CELFP-2 Core Language Index (CLI) and its subtests with consideration of degree of dialect variation (DVAR) observed, (b) investigated how the application of dialect-sensitive scoring modifications to the expressive morphology and syntax Word Structure (WS) subtest affected CELFP-2 CLI scores, and (c) evaluated the screening classification agreement rates between the DELV-ST and the CELFP-2 CLI. African American preschoolers (N = 284) completed the CELFP-2 CLI subtests (i.e., Sentence Structure, WS, Expressive Vocabulary) and the DELV-ST. Density of spoken dialect use was estimated with the DELV-ST Part I Language Variation Status, and percentage of DVAR was calculated. The CELFP-2 WS subtest was scored with and without dialect-sensitive scoring modifications. Planned comparisons of CELFP-2 CLI performance indicated statistically significant differences in performance based on DELV-ST-determined degree of language variation groupings. Scoring modifications applied to the WS subtest increased subtest scaled scores and CLI composite standard scores. However, preschoolers who demonstrated strong variation from GAE continued to demonstrate significantly lower performance than preschoolers who demonstrated little to no language variation. Affected-status agreement rates between assessments (modified and unmodified CELFP-2 CLI scores and DELV-ST Part II Diagnostic Risk Status) were extremely low. The application of dialect-specific scoring modifications to standardized, norm-referenced assessments of language must be simultaneously viewed through the lenses of equity, practicality, and psychometry. The results of our multistage study reiterate the need for reliable methods of identifying risk for developmental language disorder within children who speak American English dialects other than GAE. https://doi.org/10.23641/asha.26017978.

Developing application software to quickly detect the adolescent's risky behaviour to prevent teen pregnancy.

To develop a software application for early detection of adolescent's risky behaviour, and promotion of safe reproductive health. The multi-stage study was conducted from September 20, 2018, to April 3, 2019, at Rumbai District Pekanbaru, Riau-Indonesia. The planned software application was developed using the waterfall design model which is a sequential process. Every progress was acknowledged to be flowing downwards, like a waterfall, by going through the phases of requirements, design, implementation, verification and maintenance. The application software was pilot-tested on a group of adolescents after it was first tested for validity. The adolescents were given a questionnaire at baseline and 2 weeks after the intervention to assess the application's effectiveness. The data was analyzed using SPSS version 21. Validation of the tool was confirmed by Aiken's V values >0.85, with sensitivity 84.8% and specificity 75%. Of the 45 adolescents tested, majority respondens were girls 38(84,4%), early adolescent 18(40%), middle adolescent 16(35,5%) and late adolescent 11(24,4%). About 5(11.1%) were found to be positive, and 28(62.2%)were truly positive, while 3(6.7%) were found negative and 9(20%) were truly negative. There was a significant difference between the pre-test and post-test assessments (p=0.0001). The application proved to be effective for the early detection of risky behaviour, and for the promotion of safe reproductive health.

Investments in Electricity Distribution Grids: Strategic versus Incremental Planning

The ongoing electrification of the transport sector is expected to cause an increase in electricity demand and, therefore, trigger significant network investments to accommodate it. This paper focuses on investment decision-making for electricity distribution grids and specifically on the strategic and incremental investment network planning approaches. In particular, the former involves network planning with the consideration of a long-term multi-stage study horizon, as opposed to a shorter–term view of the future that applies to the latter case. An investment analysis that is carried out underlines the economic savings generated from adopting a strategic investment perspective over an incremental one. These economic savings are achieved from the fact that the associated fixed investment costs are incurred only once in the horizon under strategic planning. On the other hand, incremental planning involves a series of network reinforcement decisions, thereby incurring the fixed cost multiple times. In addition, sensitivity analyses that are carried out capture the effect of key parameters, such as investment cost, discount rate and investment delay, on the generated economic savings.

An evaluation of the national testing response during the COVID-19 pandemic in England: a multistage mixed-methods study protocol

IntroductionIn 2020, the UK government established a large-scale testing programme to rapidly identify individuals in England who were infected with SARS-CoV-2 and had COVID-19. This comprised part of the UK...

Prevalence and predictors of prenatal depression during the COVID-19 pandemic: A multistage observational study in Beijing, China.

While growing psychological health issues among pregnant women during the COVID-19 pandemic have been clearly validated, most research was conducted in countries with relatively lax quarantine measures. This study aimed to compare the prevalence of prenatal depression among pre-, peak-, and post-COVID-19 in Beijing, the region with a stringent response policy in China. We also explore predictors of prenatal depression throughout the outbreak. We investigated prenatal depression among 742 pregnant women who received antenatal checkups in Beijing from March 28, 2019 to May 07, 2021 using the Edinburgh Postnatal Depression Scale and associative demographic, pregnancy-related, and psychosocial characteristics were measured. The phase was divided into pre-, peak-, and post-COVID-19 in light of the trajectory of COVID-19. Pearson's Chi-square test was used after the examination of confounders homogeneity. The bivariable and multivariable logistic regression was conducted to explore predictors. The pooled prevalence of prenatal depression was 11.9% throughout the COVID-19 pandemic. Rates at different phases were 10.6%, 15.2%, and 11.1% respectively and no significant difference was observed. Multivariable logistic regression revealed that history of mental illness, number of boy-preference from both pregnant women and husband's family, social support, occupation, and living space were independent predictors of prenatal depression in Beijing. Our data suggested that the impact of this pandemic on prenatal depression in Beijing appears to be not significant, which will strengthen confidence in adhering to current policy for decision-makers and provide important guidance for the development of major outbreak control and management policies in the future. Our findings may also provide a more efficient measure to identify high-risk pregnant women for professionals and help raise gender equity awareness of pregnant women and their husbands' families. Future studies should focus on the value of targeted care and family relations on the mental health of pregnant women.

Age-specific prevalence of IgG against measles/rubella and the impact of routine and supplementary immunization activities: A multistage random cluster sampling study with mathematical modelling

BackgroundVietnam continues to have measles and rubella outbreaks following supplementary immunization activities (SIA) and routine immunization despite both having high reported coverage. To evaluate immunization activities, age-specific immunity against measles and rubella, and the number of averted Congenital Rubella Syndrome (CRS) cases, must be estimated. MethodsDried blood spots were collected from 2091 randomly selected individuals aged 1-39 years. Measles and rubella virus-specific immunoglobulin G (IgG) were measured by enzyme immunoassay. Results were considered positive at ≥120 mIU/mL for measles and ≥10 IU/mL for rubella. The number of CRS cases averted by immunization since 2014 were estimated using mathematical modelling. ResultsOverall IgG seroprevalence was 99.7% (95%CI: 99.2-99.9) for measles and 83.6% (95%CI: 79.3-87.1) for rubella. Rubella IgG seroprevalence was higher among age groups targeted in the SIA than in non-targeted young adults (95.4% [95%CI: 92.9-97.0] vs 72.4% [95%CI: 63.1-80.1]; P < 0.001). The estimated number of CRS cases averted in 2019 by immunization activities since 2014 ranged from 126 (95%CI: 0-460) to 883 (95%CI: 0-2271) depending on the assumed postvaccination reduction in the force of infection. ConclusionsThe results suggest the SIA was effective, while young adults born before 1998 who remain unprotected for rubella require further vaccination.

Technical Efficiency of Mexico's Public Health System in the Delivery of Obstetric Care, during 2012-2018.

The objective of this study was to evaluate the technical efficiency of Mexico's public health system in the delivery of obstetric care from 2012 to 2018. A multi-stage quantitative study of the public health institutions responsible for 95% of the system's obstetric services was conducted using data envelopment analysis. The efficiency of state-level productive units (decision-making units, or DMUs) was calculated and juxtaposed with the DMUs' maximum (0.82) and minimum (0.22) scores. Using the outcomes of the initial stage, the average technical efficiency of each institution at the national level was estimated and compared. The results were also utilized to estimate and compare the average efficiency of each state-level health system based on economic characteristics (state GDP per capita). Outputs included prenatal visits and deliveries, while inputs comprised gynecologists, exam rooms, and delivery rooms. Institutional efficiency ranged from 0.16 to 0.82, with an average of 0.417. The Ministry of Health (0.82) and the Mexican Social Security Institute (0.747) exhibited the highest efficiency scores, while the remaining institutions (Institute for Social Security and Services for State Workers [ISSSTE]; Mexican Petroleum [PEMEX]; the Secretary of National Defense [SEDENA]; and the Navy [SEMAR]) scored below the health system average. Of the 153 DMUs, 20% surpassed the maximum (0.82) and 40.6% fell below the minimum (0.22). These findings indicate that 80% of DMUs have unused operational capacity that could be utilized to enhance technical efficiency. No relationship was found between efficiency and the GDP of Mexico's 32 politico-administrative divisions. The efficiency gap between institutions (0.66) shows that while some DMUs are saturated (exhibiting high efficiency scores), the majority have unused operational capacity. Leveraging this untapped capacity could address the needs of vulnerable populations facing restricted access due to health system fragmentation.

Multicultural personality traits of Chinese university students and their effects on the psychological adjustment in the aftermath of COVID-19 in Shanghai: a scale validation.

This study aims to explore Chinese university students' multicultural personalities and examine how they predict the psychological adjustment of students in Shanghai. In addition, the validation of Multicultural Personality Questionnaire Short Form (MPQ-SF) scale developed to assess the multicultural personality traits of individuals is also aimed in Chinese context. Data were collected after the psychological stresses from restrictions imposed by COVID-19 in China that influenced life adjustments for nearly three years. A total of 1,099 university students participated in this multi-stage study. First, the Chinese version of MPQ-SF (MPQ-SF-C) was developed and validated. The impact of MPQ-SF-C dimensions was then tested through path analysis to establish the effects of Chinese university students' multicultural personality traits on their psychological adjustment using the Schwartz Outcome Scale (SOS-10). The MPQ-SF-C yielded a five-factor solution which accounted for 60.14% of the common variance. The findings indicated that cultural empathy (β = 0.23, p < 0.05), certainty seeking (β = 0.13, p < 0.05), open-mindedness (β = 0.48, p < 0.05), and emotional stability (β = 0.24, p < 0.05) had significant influences on adjustment. Only flexibility was found to have a statistically insignificant impact on adjustment at this time in this context. MPQ-SF-C and SOS-10 scales represented very good psychometric properties in terms of their reliability and validity. The MPQ-SF-C shows good psychometric properties and appropriateness for evaluating multicultural personalities in Chinese contexts. The multicultural personality characteristics of university students using this scale well predicted their psychological adjustment.