Three-level Multilevel Models Research Articles

Exploring the impact of community-based choral participation on cognitive function and well-being for persons with dementia: evidence from the Voices in Motion project

Objectives Music-based interventions are postulated to mitigate cognitive decline in individuals with dementia. However, the mechanisms underlying why music-based interventions facilitate cognitive benefits remain unknown. The present study examines whether a choral intervention can modulate patterns of cognitive change in persons with dementia and whether within-person variation in affect is associated with this change. Methods Thirty-three older adults with dementia engaged weekly in the Voices in Motion (ViM) study consisting of 3 choral seasons spanning 18-months. Performance on the Mini-Mental State Examination (MMSE) and the Positive and Negative Affect Schedule was assessed monthly within each choral season using a longitudinal intensive repeated-measures design. Three-level multilevel models were employed to disaggregate between- and within-person effects across short- (month-to-month) and long-term (season-to-season) intervals. Results ViM participants exhibited an annual MMSE decline of 1.8 units, notably less than the clinically meaningful 3.3 units indicated by non-intervention literature. Further, variability in negative affect shared a within-person time-varying association with MMSE performance; decreases in negative affect, relative to one’s personal average, were linked to corresponding improvements in cognitive function. Conclusion Engagement in the ViM choral intervention may attenuate cognitive decline for persons with dementia via a reduction of psychological comorbidities such as elevated negative affect.

Parameterizing Practice in a Longitudinal Measurement Burst Design to Dissociate Retest Effects From Developmental Change: Implications for Aging Neuroscience.

Background: In longitudinal designs, the extraneous influence of retest effects can confound and obscure estimates of developmental change. The current study provides a novel approach to independently parameterize short-term retest effects and long-term developmental change estimates by leveraging a measurement burst design and three-level multilevel modeling. We further employ these short- and long-term slopes as predictors of cognitive status at long-term follow-up assessments.Methods: Participants included 304 older adults from Project MIND: a longitudinal measurement burst study assessing cognitive performance across both biweekly sessions and annual retests. Participants were classified as either Healthy controls (HC) or Cognitively Impaired, not Demented (CIND) at baseline, the final burst assessment (Year 4), and at an additional four-year follow-up (Year 8). Response time inconsistencies (RTI) were computed at each burst occasion for a simple choice response time (CRT) task and a one-back response time (BRT) task. Three-level multilevel models were employed to simultaneously examine change in RTI for both CRT and BRT across weeks within years, as well as across years, in order to dissociate within-individual retest effects (short-term) from developmental (long-term) change slopes. Individual slopes were then extracted and utilized in a series of multinomial logistic regression equations to contrast short- vs. long-term RTI change as predictors of cognitive status.Results: Separately parameterizing short- and long-term change estimates yielded distinct patterns of variation. CRT RTI remained stable across short-term weekly assessments, while significantly increasing across years. In contrast, BRT RTI decreased significantly across short-term assessments but showed no change across long-term assessments. After dissociating change estimates, short-term BRT as well as long-term CRT and BRT estimates predicted cognitive status at long-term follow-ups; increases in RTI, suggesting either an inability to benefit from retest or process-based developmental decline, were associated with an increased likelihood of being classified as CIND.Conclusions: We showcase an innovative approach to dissociate retest effects from developmental change across and within individuals. Accurately parameterizing these distinct change estimates can both reduce systematic bias in longitudinal trend estimates as well as provide a clinically useful tool by utilizing retest effects to predict cognitive health and impairment.

Marriage checkup in integrated primary care: A randomized controlled trial with active-duty military couples.

This study assessed the efficacy of the marriage checkup, as adapted to integrated primary care settings and active-duty military couples, for improving relationship health and depressive symptoms. Married couples (N = 244, Mage = 32.4, 67.6% Caucasian) in which at least one member was active-duty Air Force were recruited from bases across the U.S. via online advertisement, emails sent from medical clinics to enrolled beneficiaries, social media posts, and flyers, and randomly assigned to active treatment or waitlist control. Treatment and control couples were linked in pairs sequentially and pairs completed nine sets of questionnaires at baseline, 1-, and 6-month posttreatment. Outcome measures included the Couples Satisfaction Index, Intimate Safety Questionnaire, Responsive Attention Scale, Partner Compassion Scale, Communication Skills Test, and the Center for Epidemiologic Studies Depression Scale. A three-level multilevel model indicated, after adjustment for multiple comparisons, treatment couples experienced statistically significant small-to-moderate improvements compared to the control group (Cohen's d from 0.21 to 0.55) at 1 month that were sustained at 6 months for relationship satisfaction, responsive attention, compassion toward their partners, communication skills, intimate safety, and depressive symptoms. A longitudinal randomized control trial of the MC supports the hypothesis that the MC significantly improves relationship satisfaction, intimacy, communication, partner compassion, responsive attention, and depressive symptoms. Implications for theory, treatment, and dissemination are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Hormonal Contraception Use and Sexual Frequency across Young Women’s Intimate Relationships

ABSTRACT We examined whether hormonal contraception (HC) use predicts sexual frequency throughout and across young women’s intimate relationships. From 2008–2012, the Relationships Dynamics and Social Life Study collected weekly surveys over 2.5 years, and included 893 women (aged 18–19 at baseline) who reported 2,547 intimate relationships across 32,736 weeks. Three-level logistic multilevel models assessed the weekly probability of sexual intercourse based on 1) weekly HC use (vs. nonuse) and 2) duration of HC use, both accounting for several relational and individual characteristics, including relationship duration. Women had more frequent sexual intercourse when they were using HC than when they were not (predicted probabilities .65 vs .41). The weekly probability of sexual intercourse increased sharply within the first month of HC initiation (by about 27 percentage points), remained high for several months, then began to slowly decline (yet remained above that of nonuse). When separated by method type, similar trajectories were found for the pill, ring, and IUD/implant; following the initial increase, steeper declines in intercourse frequency were found for the contraceptive injectable, eventually dropping below pre-initiation levels. Findings signify the immediate influence of reduced pregnancy fears in facilitating sexual intercourse among young women, which may decline as HC use continues long-term.

Creating accountable hospital service areas in China: a case analysis of health expenditure in the metropolis of Chengdu

ObjectivesTo delineate hospital service areas (HSAs) using the Dartmouth approach in China and identify the hypothesised demand-side, supply-side and region-specific factors of health expenditure within HSAs.DesignPopulation-based descriptive study.SettingWe selected the...

The Positive and Negative Affect Relation in the Context of Stress and Age

The Omnibus Budget Reconciliation Act (OBRA) of 1987 included provisions for the Preadmission Screening and Resident Review (PASRR) program, which requires states to create and maintain systems to assess persons with serious mental illness (SMI) seeking NH care. The prevalence of SMI in NHs is increasing, and little is known about the effectiveness of the PASRR program intervention. We conducted 20 interviews with state and national PASRR stakeholders, including assessors, hospital discharge planners, mental health advocates, geriatricians and geriatric psychiatrists. Interview data were triangulated with state provided materials on PASRR collection and implementation. Based on these interviews, we identified four themes: 1) variation in the implementation of federal PASRR legislation across states and jurisdictions, 2) the need for investment in professional development and workforce capacity, 3) lack of usefulness of PASRR in ongoing care planning, and 4) the need to consider the role of age, race/ethnicity, and stigma on quality of care for NH residents with SMI. Stakeholders agree that PASRR legislation was well intentioned, but also expressed concern regarding the completion of PASRR as an issue of compliance versus meaningful assessment. More work is needed to determine how best to develop and support the care needs of people with SMI, while being mindful of the original goals of deinstitutionalization that prompted OBRA passage. In order to assess the impact of the PASRR program on quality of care and mental health outcomes, further research should take an evaluative approach through meaningful use of PASRR data.

Age-Related Change in the Extent Physical Activity Attenuates Negative Affect Reactivity to Stressors in Daily Life

Theories suggest that with increasing age, adults more effectively regulate their emotions and seek to limit high physiological arousal. Prior research indicates physical activity attenuates negative affect reactivity to stress, but also increases physiological arousal. The present study extends prior work by examining age-related differences and changes over time in the extent of attenuation. Participants (n=3,484; MedianAge=53.42 years, SD=13.3; 56% female), from the National Study of Daily Experiences completed 8 end-of-day assessments of their negative emotions, stress, and physical activity across 3 measurement bursts spaced approximately 10 years apart. Results from three-level multilevel models suggest that when full random effects are specified, physical activity does not attenuate negative affect reactivity to stress. Additionally, extent of attenuation did not differ with age or change over time. Discussion pertains to how these findings advance theoretical understanding of socioemotional development and to methodological nuances of random effects and non-normally distributed data.

Momentary associations between stress and alcohol craving in the naturalistic environment: differential associations for Black and White young adults.

Black drinkers compared with White drinkers experience more alcohol-related problems. Examination of social determinants of inequities in alcohol problems is needed. The current study measured (1) associations between acute stress and alcohol craving in the naturalistic environment for self-identified Black and White individuals who drink alcohol and (2) whether a history of attention deficit hyperactivity disorder (ADHD) moderated these associations. Observational study using ecological momentary assessment (EMA) to collect data from participants at six semi-random time-points throughout the day during a 10-day period. A series of three-level multi-level models examined between- and within-person associations for stress and alcohol and tested if these associations differed for Black and White adults. Participants were 229 adult drinkers (aged 21-35 years) who completed a larger study examining alcohol response for Black and White adults with and without a history of childhood ADHD. Momentary stress and alcohol craving, ADHD history and socio-demographic characteristics (i.e. racial identity, sex, age, current education level, household income) were assessed. Participants were required to self-identify as either 'African American or Black' or 'European American or White'. Significant racial identity × stress interactions indicated that associations between stress and craving were stronger for Black compared with White adults across the 10-day period (between-person: B= 0.14, P= 0.007), concurrently within a given EMA time-point (within-person: B= 0.04, P= 0.001) and prospectively from time-point to time-point (within-person: B= 0.05, P= 0.001). Results remained while accounting for income × stress interactions. Acute stress appears to be more strongly related to alcohol craving in self-identified Black compared with self-identified White individuals. This provides support for policy changes to eliminate structural inequities that increase stress exposure and the development of just-in-time culturally responsive interventions focused on coping with acute stress for Black individuals.

The positive and negative affect relation in the context of stress and age.

Research suggests that the within-person inverse relationship between negative affect (NA) and positive affect (PA) indicates poorer emotional well-being, and this interaffect correlation fluctuates in relation to the context of the individual. Specifically, age, stress, and global PA all relate to changes in the interaffect correlation. The current study used comprehensive data from the Notre Dame Study of Health and Well-Being, which allowed us to uniquely examine between-person differences in within-person change and variability in the interaffect correlation, thereby examining these constructs from a process-oriented perspective. Midlife and later-life participants (N = 965) completed daily questionnaires assessing stress, NA, and PA. Three-level multilevel models illustrated that the interaffect correlation becomes more negative during times of stress, adults with greater global PA experience a stronger inverse interaffect correlation during times of stress, and days of higher stress relate to a stronger inverse interaffect correlation for older adults compared to midlife adults. The findings illustrate the idiographic nature of these relationships and suggest that later-life adults and adults with high levels of global PA undergoing higher than typical stressful situations experience stronger inverse interaffect correlations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Is improvement in indicators of women’s empowerment associated with uptake of WHO recommended IPTp-SP levels in sub-Saharan Africa? A multilevel approach

ObjectivesThe global burden of malaria has reduced considerably; however, malaria in pregnancy remains a major public health problem in sub-Saharan Africa (SSA), where about 32 million pregnant women are at...

Socioeconomic Roots of Climate Change Denial and Uncertainty among the European Population

Abstract Despite the overwhelming scientific consensus, in many Western countries, there appears to be a considerable share of people questioning the existence and anthropogenic cause of climate change. Climate change disbelief includes the absolute rejection of the existence of anthropogenic climate change (climate change denial) as well as a lack of sureness about the anthropogenic cause of climate change (climate change uncertainty). Although considerable research on this phenomenon has been conducted, the roots of climate change disbelief are not yet fully understood. In this article, data from Round 8 of the European Social Survey are used to study the possible socioeconomic roots of climate change disbelief at the individual, regional, and country level. Results show that climate change denial is a marginal phenomenon among European populations but that a great share of people attributes climate change equally to human influences and natural processes. Thereby, it appears that the level of climate change disbelief varies between countries, and even more so between regions within countries. Results of various three-level multilevel models show that socioeconomic factors can partly explain this variation. Individuals who feel insecure about their economic future are significantly more likely to reject the existence of anthropogenic climate change. Furthermore, climate change denial and uncertainty are more common in more rural and less prosperous regions and in countries more economically dependent on fossil fuels. The results contribute to a deeper understanding of climate change disbelief among the European population and have important implications for climate change mitigation efforts.

Within-day rhythms of pain and cognitive function in people with and without fibromyalgia: synchronous or syncopated?

Cognitive dysfunction is a common fibromyalgia (FM) symptom and can impact on the daily lives of those affected. We investigated whether within-day pain intensity ratings were associated with contemporaneous objective and subjective measures of cognitive function and whether within-day increases in pain intensity preceded increases in cognitive dysfunction or vice versa. Inclusion of a non-FM group allowed us to examine whether effects were specific to FM. Fifty people with FM and 50 non-FM controls provided 7 days of data. Cognitive tests (processing speed and working memory) and ecological momentary assessments (pain intensity and self-reported cognitive functioning) were conducted ×5/day. Three-level multilevel models examined contemporaneous and within-day 1-lag pain intensity-cognitive functioning associations. Interaction terms assessed possible moderating effects of FM status. Momentary increase in pain was associated with increased self-reported cognitive dysfunction, more strongly so for those with FM (B = 0.27, 95% confidence interval 0.22-0.32; non-FM B = 0.17, 95% confidence interval 0.10-0.23). For the FM group, higher pain was associated with longer processing speed; for the non-FM group, higher pain was associated with shorter processing speed. Pain increase did not precede change in subjective or objective cognitive function in the FM group, but reduction in working memory preceded increase in pain intensity. This finding warrants further research attention and, if replicated, could hold prognostic and/or therapeutic potential.

Neighborhoods, Criminal Incidents, Race, and Sentencing: Exploring the Racial and Social Context of Disparities in Incarceration Sentences

Abstract As an extra-legal factor, social context is a key contributor to racial/ethnic disparities in incarceration sentences. Neighborhoods may have important, yet underexplored influences on sentencing. This study evaluates whether the social conditions and racial characteristics of communities where defendants allegedly offend affect Black-White sentencing disparities. Three-level multilevel model results suggest larger Black populations in neighborhoods of criminal incident increase the odds of incarceration and, to a lesser extent, lengthen sentences for all defendants. Offending outside one’s residential community increases the probability and length of a prison sentence. Neighbourhood effects differ by race, however. Unlike Whites, Blacks receive more punitive sentences for committing offences in disadvantaged areas and less proportionally Black communities. Neighbourhoods thus contribute to racial differences in sentencing outcomes.

"Is it us or is it me?": Family experiences of connectedness following a reflecting team intervention.

The present study examined family-wide versus individual perceptions of, and changes in, family connectedness in response to a one-time reflecting team (RT) intervention. Seventy-six families (N=208 individuals), recruited during family therapy, completed family connectedness measures before and after the RT intervention. A subset of adults (n=26) completed 1-week follow-up measures. Three-level (family, individual, time) multilevel models were used to partition sources of variance in connectedness while permitting different fixed and random effects for adults and minors. Results indicate that family connectedness is a characteristic of whole-families (34% of the variance), individuals (43%), and change over time (23%), including measurement error. Additionally, participants reported higher family connectedness after the RT. This study demonstrates the importance of considering family connectedness as a multilevel relationship construct that potentially changes in response to RT.

Health psychology attendance: A multilevel analysis of patient-level predictors and therapist effects.

The study investigated adult outpatient Health Psychology Services appointment attendance, cancellation, and missed appointments (A/C/M). The first objective was to determine which demographic and process factors predicted the probability of A/C/M. The second objective was to determine whether there remained residual significant differences in A/C/M between therapists (i.e., a "therapist effect"), after controlling for explanatory variables. We conducted a practice-based retrospective 2-year cohort study. Three-level multilevel models were constructed and tested to analyze the probability of A/C/M at (1) assessment appointments (N = 1,175) and (2) follow-up appointments (N = 5,441). After controlling for predictor variables, significant therapist effects were found for attendance (10.0% to 13.0%) and cancellation (4.4%) at follow-up appointments (but not assessments), indicating significantly different attendance rates at follow-up between therapists. Predictors of attendance at follow-up included patient age, pretherapy symptom severity scores (including risk and symptom scores), and completion of intake questionnaires. Early morning follow-up appointments were least likely to be canceled, followed by late afternoon and finally midday appointments. Treatment intensity predicted attendance, but among qualified therapists, qualification type and pay level were nonsignificant. No significant predictors of attendance at assessment were detected. Attendance at Health Psychology Services outpatient appointments varies significantly according to patient, therapist, and appointment factors. Key routinely collected variables are predictive of attendance at follow-up. Clinical implications include the potential to identify patients at risk of nonattendance and target engagement interventions to these patients. Research directions include closer examination of variability in follow-up attendance between therapists. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Adolescents' sleep quality in relation to peer, family and school factors: findings from the 2017/2018 HBSC study in Flanders.

While a multitude of studies focused on biological and behavioral determinants of adolescents' sleep quality, a paucity of research examined the impact of social factors. The current study therefore examines the relationship between adolescents' sleep quality and peer, family and school factors. Data of Flemish participants in the 2017/2018 Health Behavior in School-aged Children survey (HBSC) were used, which is representative of the adolescent population (11-18years) in Flanders. Adolescents' sleep quality was linked to individual-level data on peer relationships (i.e., peer support), family relationships (i.e., family support, perceived family wealth, caregiving responsibilities) and school relationships (i.e., teacher support, school support, school pressure) and contextual-level data on the school culture. Three-level multilevel models were fitted to account for the clustering of individuals (N = 8153) within classes (N = 769) and classes within schools (N = 177). The individual-level results indicated that adolescents' sleep quality was positively related to family support, teacher support, student support and perceived family wealth. In contrast, adolescents' sleep quality was negatively related to caregiving responsibilities and school pressure. In addition, the contextual-level results pointed out that adolescents tended to report better sleep quality in less-demanding schools. These findings highlight the need to consider social factors in promoting better sleep in adolescence.

Determinants of intimate partner violence against women in Ethiopia: A multi-level analysis.

Intimate partner violence (IPV) continues to be a major public health problem globally. Although Ethiopia has a high prevalence of IPV, previous studies in this country have only investigated individual-level determinants of IPV within small geographic areas. The current study aimed to identify the individual-, relationship-, community-, and societal-level determinants of IPV directed against women in Ethiopia since women are predominantly affected. A retrospective analysis of nationally representative data from the 2016 Ethiopian Demographic and Health Survey (EDHS) was conducted. A sample of 3,897 married women of reproductive age (15-49 years) who participated in the domestic violence module of the survey were included in the analysis. Three-level mixed-effects multilevel logistic regression models were used to estimate the individual-, relationship-, community-, and societal-level determinants of IPV. Variability at the community- and societal-level were also assessed. About 1,328 (34.1%) of 3,897 participants reported experiencing IPV (a composite measure of physical, sexual and emotional abuse). In adjusted models, the odds of lifetime IPV experience were higher among women who were older, were married before the age of 18 years, witnessed inter-parental violence during their childhood, had a partner who drank alcohol, and lived in a community with high IPV accepting norms. Alternatively, the odds of IPV were lower among women who had decision-making autonomy in the household, had the same or lower educational attainment as their partner, and lived in a community with low proportions of educated women. These findings reveal that although individual-level factors were significant determinants of IPV, higher level factors, including female education and IPV acceptance in the community, were also important influences on this major public health issue in Ethiopia. These findings suggest combined interventions at different levels may reduce IPV in this country.

Health inequalities in Europe: Does minimum income protection make a difference?

Poverty, a risk factor for ill health, could be alleviated by generous welfare states. However, do generous social policies also reduce the health implications of socio-economic inequalities? This study investigates how minimum income protection is associated with socio-economic health inequalities. The author hypothesises that higher benefit levels are associated with lower health inequalities between income groups. Minimum income benefits support the people most in need, and therefore should improve the health of the lowest income groups, which in turn would reduce overall health inequalities. This hypothesis is tested with the European Social Survey (2002–2012) and the SaMip dataset using three-level multilevel models, covering 26 countries. The results show a robust relationship between benefit levels and individual self-rated health. However, the hypothesis of reduced health inequalities is not completely supported, since the findings for the cross-level interactions between income quintiles and benefit levels differ for each quintile.

Contextual Social Trust and Well-Being Inequality: From the Perspectives of Education and Income

In recent decades, much attention has been paid to subjective well-being (SWB). Extensive research in several fields has frequently examined the determinants of SWB, and previous studies have reported well-being inequality within countries due to education and household income. However, knowledge regarding how well-being inequality due to education and household income varies among countries is limited. To fill this gap, this paper examines whether contextual social trust as a country characteristic reduces well-being inequality due to education and household income. This analysis employs repeated cross-sectional international comparative data from four waves of the European Quality of Life Survey conducted between 2003 and 2016 and two types of multilevel modeling, namely, three-level multilevel models with year fixed effects and cross-classified full models, to examine the cross-level interaction effects of contextual social trust and education and of contextual social trust and household income on SWB. By conducting an international comparative analysis, the present study has found that contextual social trust has negative moderation effects on the association between education and SWB and the association between household income and SWB. These results indicate that high contextual social trust reduces well-being inequality due to education and household income by improving the SWB of citizens with lower positions.

DAILY EMOTIONS AND STRESS: AGE CHANGES AND DIFFERENCES

Developmental processes differ between individuals (interindividual differences), fluctuate within them on a short-term basis (intraindividual variability), and change over time on a longer-term basis (intraindividual change; Nesselroade, 1991). We situate the relationship between stress and emotions in this process-oriented perspective by examining how the daily relationship between stress and negative affect (NA) as well as stress and positive affect (PA) change over time, while considering cross-sectional age and stress differences. Participants (N = 966) completed daily questionnaires assessing stress, NA, and PA. Three-level multi-level models depicted how cross-sectional age, within-person age changes, and global stress differences impact the daily stress-affect relationship. Findings illustrate that cross-sectional age and the aging process uniquely buffer the stress-NA relationship whereas global stress exacerbates it. Furthermore, older adults as well as adults with low global stress experience a weaker relationship between daily stress and PA as they age, but midlife adults and adults with high global stress experience a stronger relationship. These results depict differences in aging trajectories for both midlife and older adults and thus inform intervention and preventative care strategies aimed toward promoting emotional well-being, suggesting that targeting these strategies at the daily level can promote better stress regulation. Furthermore, we see that midlife adults and adults with greater global stress perceptions are most in need of these interventions, and encouraging these adults to maintain PA in the face of daily stress can be particularly beneficial.