Three-level Multilevel Models Research Articles

Detecting Consensus Emergence in Organizational Multilevel Data: Power Simulations

Theories suggest that groups within organizations often develop shared values, beliefs, affect, behaviors, or agreed-on routines; however, researchers rarely study predictors of consensus emergence over time. Recently, a multilevel-methods approach for detecting and studying emergence in organizational field data has been described. This approach—the consensus emergence model—builds on an extended three-level multilevel model. Researchers planning future studies based on the consensus emergence model need to consider (a) sample size characteristics required to detect emergence effects with satisfactory statistical power and (b) how the distribution of the overall sample size across the levels of the multilevel model influences power. We systematically address both issues by conducting a power simulation for detecting main and moderating effects involving consensus emergence under a variety of typical research scenarios and provide an R-based tool that readers can use to estimate power. Our discussion focuses on the future use and development of multilevel methods for studying emergence in organizational research.

Therapist and clinic effects in psychotherapy: A three-level model of outcome variability.

The study aimed to (a) investigate the effect of treatment location on clinical outcomes for patients receiving psychological therapy (a clinic effect, akin to the concept of a therapist effect) and (b) assess the impact of explanatory individual and aggregate demographic and process variables on the clinic and therapist effects. The sample comprised 26,888 patients, seen by 462 therapists, across 30 clinics. Mean patient age was 38 years (69% female, 90% White, 92% planned ending). The dependent variable was patients' posttherapy score on the Clinical Outcomes in Routine Evaluation-Outcome Measure. An incremental 3-level multilevel model was constructed. Markov Chain Monte Carlo estimation created 95% probability intervals for the clinic and therapist effects. A 3-level model with no explanatory variables detected a clinic effect of 8.2%, significantly larger than the therapist effect of 3.2%. Adding explanatory variables significantly reduced the clinic effect to 1.9% but did not significantly alter the therapist effect (3.4%). Patient-level symptom severity and employment status, and clinic-level percentage of White patients and health care sector, explained the most clinic outcome variance and overall outcome variance. Substantial variability in clinical outcomes was found between clinics providing psychological therapy. Socioeconomic mix of patients explained significant proportions of variability at the clinic level but not the therapist level. Clinical implications include the need to go beyond the therapist-patient interaction to deliver effective psychological therapy. Future research is also needed to identify the mechanisms by which clinic and/or area-level factors impact on clinical outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Implementing the protocol of a pilot randomized controlled trial for the recovery-oriented intervention to people with psychoses in two Latin American cities.

Several Latin American countries have made remarkable strides towards offering community mental health care for people with psychoses. Nonetheless, mental health clinics generally have a very limited outreach in the community, tending to have weaker links to primary health care; rarely engaging patients in providing care; and usually not providing recovery-oriented services. This paper describes a pilot randomized controlled trial (RCT) of Critical Time Intervention-Task Shifting (CTI-TS) aimed at addressing such limitations. The pilot RCT was conducted in Santiago (Chile) and Rio de Janeiro (Brazil). We included 110 people with psychosis in the study, who were recruited at the time of entry into community mental health clinics. Trial participants were randomly divided into CTI-TS intervention and usual care. Those allocated to the intervention group received usual care and, in addition, CTI-TS services over a 9-month period. Primary outcomes include quality of life (WHO Quality of Life Scale - Brief Version) and unmet needs (Camberwell Assessment of Needs) at the 18-month follow-up. Primary outcomes at 18 months will be analyzed by Generalized Estimating Equations (GEE), with observations clustered within sites. We will use three-level multilevel models to examine time trends on the primary outcomes. Similar procedures will be used for analyzing secondary outcomes. Our hope is that this trial provides a foundation for planning a large-scale multi-site RCT to establish the efficacy of recovery-oriented interventions such as CTI-TS in Latin America.

Are protective behavioral strategies associated with fewer negative consequences on high-intensity drinking days? Results from a measurement-burst design.

Heavy episodic drinking (HED) is prevalent among college students and associated with harms. However, many students engage in "high-intensity drinking" (HID) by drinking at thresholds beyond HED. HID relative to HED-only is associated with elevated risk for acute and severe negative consequences. When used, protective behavioral strategies (PBS) are shown to help drinkers limit their drinking and lower their odds of experiencing consequences. This study assessed whether PBS use was associated with reduced consequences on occasions college students engaged in HID relative to HED-only. Data were from a longitudinal measurement-burst design (14-day bursts across 4 semesters) from 256 college students who engaged in HID on at least 1 reported day, yielding 2,352 daily drinking reports. Participants reported the number of standard drinks consumed on each day and, on days with 1+ drinks, whether they used PBS and experienced a variety of negative drinking-related consequences. Three-level multilevel models revealed that on days when students used manner of drinking PBS there was a weaker association between HID and passing out from drinking. On days students used serious harm reduction PBS there was a weaker association of HID with having no one sober enough to drive and experiencing regretted sexual behaviors. Use of some PBS may help college students reduce harms on HID occasions relative to HED-only occasions. Interventions should promote use of planning strategies to minimize harm, especially on HID occasions. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Daily Stress Reactivity Across the Life span: Longitudinal and Cross-Sectional Effects of Age.

Exploration of development requires the use of research designs and process-oriented methodologies that can capture daily fluctuations within individuals, systematic changes within individuals, and differences between individuals. We examine the stress-affect relationship in this way to assess how the relationship between daily stress and negative affect (NA) as well as the relationship between daily stress and positive affect (PA) differs between individuals and changes over time depending on age and stress differences. Participants (N = 966) completed daily "burst" assessments of stress, NA, and PA. Three-level multilevel 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 stress regulation.

A multi-level modeling approach to understanding residential segregation in the United States

A well-known limitation of commonly used segregation measures is their inability to describe patterns at multiple scales. Multi-level modeling approaches can describe how different levels of geography contribute to segregation, but may be difficult to interpret for non-technical audiences and have rarely been applied in the US context. This paper provides a readily interpretable description of multi-scale Black–non-Black segregation in the United States using a multi-level modeling approach and the most recent Census data available. We fit a three-level random intercept multi-level logistic regression model predicting the proportion of the population that is Black (Hispanic and non-Hispanic) at the block group level, with block groups nested in tracts and tracts nested in Metropolitan Statistical Areas (MSAs). For the 102 largest MSAs in the United States, we then estimated the extent to which micro- versus meso-level variability drives overall racial residential patterning within the MSA. Finally, we created a typology of racial residential patterning within MSAs based on the total proportion of the MSA population that is Black and the relative contribution of block groups (micro) versus tracts (meso) in driving variation. We find that nearly 80% of the national variation in the geographic concentration of Black residents is driven by within-MSA, tract-level processes. However, the relative contribution of small versus larger scales to within-MSA segregation varies substantially across metropolitan areas. We detect five meaningfully different types of metropolitan segregation across the largest MSAs. Multi-level descriptions of segregation may help planners and policymakers understand how and why segregated residential patterns are evolving in different places and could provide important insights into interventions that could improve integration at multiple scales.

Dynamic Changes in Peer Victimization and Adjustment Across Middle School: Does Friends' Victimization Alleviate Distress?

Although some adolescents are chronically bullied throughout middle school, others may only experience peer victimization temporarily. This study examined the effects of time-invariant (average level) and time-varying (year-to-year) victimization experiences across middle school on adolescents' depressive symptoms, somatic complaints, and self-blame. A key question was whether friends' victimization buffered students from their victimization-related distress. The diverse sample (n=5,991) was surveyed four times between sixth and eighth grade (Mage at sixth grade=11.54years). Three-level multilevel models revealed both time-invariant and time-varying effects of victimization on adjustment, but these maladaptive associations were attenuated when adolescents' friends experienced more victimization across middle school. The results suggest that even temporarily victimized youth may have unmet mental health needs, and sharing social plight with friends can protect victims.

GP Practices as a One-Stop Shop: How Do Patients Perceive the Quality of Care? A Cross-Sectional Study in Thirty-Four Countries.

To contribute to the current knowledge on how a broad range of services offered by general practitioners (GPs) may contribute to the patient perceived quality and, hence, the potential benefits of primary care. Between 2011 and 2013, primary care data were collected among GPs and their patients in 31 European countries, plus Australia, Canada, and New Zealand. In these countries, GPs are the main providers of primary care, mostly specialized in family medicine and working in the ambulatory setting. In this cross-sectional study, questionnaires were completed by 7,183 GPs and 61,931 visiting patients. Moreover, 7,270 patients answered questions about what they find important (their values). In the analyses of patient experiences, we adjusted for patients' values in each country to measure patient perceived quality. Perceived quality was measured regarding five areas: accessibility and continuity of care, doctor-patient communication, patient involvement in decision making, and comprehensiveness of care. The range of GP services was measured in relation to four areas: (1) to what extent they are the first contact to the health care system for patients in need of care, (2) their involvement in treatment and follow-up of acute and chronic conditions, in other words treatment of diseases, (3) their involvement in minor technical procedures, and (4) their involvement in preventive treatments. Data of the patients were linked to the data of the GPs. Multilevel modeling was used to construct scale scores for the experiences of patients in the five areas of quality and the range of services of GPs. In these four-level models, items were nested within patients, nested in GP practices, nested in countries. The relationship between the range of services and the experiences of patients was analyzed in three-level multilevel models, also taking into account the values of patients. In countries where GPs offer a broader range of services patients perceive better accessibility, continuity, and comprehensiveness of care, and more involvement in decision making. No associations were found between the range of services and the patient perceived communication with their GP. The range of GP services mostly explained the variation between countries in the areas of patient perceived accessibility and continuity of care. This study showed that in countries where GP practices serve as a "one-stop shop," patients perceive better quality of care, especially in the areas of accessibility and continuity of care. Therefore, primary care in a country is expected to benefit from investments in a broader range of services of GPs or other primary care physicians.

Cognitive conflict resolution during psychotherapy: Its impact on depressive symptoms and psychological distress

Objective: The aim of this study was to assess the resolution of cognitive conflicts (CCs) within a randomized controlled trial testing the differential efficacy of group cognitive behavioral therapy (CBT) plus an individually tailored intervention module focused on CCs vs. group plus individual CBT, and to determine whether CC resolution was related to improvement in symptoms and psychological distress. Methods: The data come from 104 adults meeting criteria for major depressive disorder and/or dysthymia. Change in scores on the Beck Depression Inventory-II and Clinical Outcomes in Routine Evaluation-Outcome Measure was assessed at the end of treatment and at three-month follow-up. Outcomes were compared between those participants who resolved their CCs and those who maintained them using three-level multilevel growth models. Results: CC resolution did not depend on treatment allocation. Participants who resolved their CCs acquired greater benefits with regards to reduction of depressive symptoms and psychological distress than those who maintained their conflicts. Conclusions: CC seems to be a relevant notion to take into consideration to understand symptom improvement. Further research on CC might lead to the advancement of treatments which involve conflict resolution as a change mechanism.

AVP‐825 (Sumatriptan Nasal Powder) Reduces Nausea Compared to Sumatriptan Tablets: Results of the COMPASS Randomized Clinical Trial

Migraine-related nausea is associated with significant disability, increased burden of disease, and personal distress. Nausea can lead to delays or avoidance of initiating oral migraine treatment, sometimes resulting in treatment failures and poor outcomes. Nausea is often a symptom of migraine, but nausea may also be a consequence of treatment (ie, treatment emergent nausea [TEN]). Relieving nausea and minimizing TEN are important goals in acute migraine therapy. We analyzed data from the COMPASS study, a randomized, double blind, double-dummy, comparative efficacy study that contrasted two active treatments, AVP-825 (breath-powered intranasal delivery of powdered sumatriptan 22 mg) and oral sumatriptan tablets (100 mg). Three-level logistic multilevel models were used to examine longitudinal changes in nausea from three distinct perspectives across multiple attacks. Model 1 (Overall Nausea) examined longitudinal change in nausea from pre-dose through 120 minutes post-dose for the entire sample, independent of baseline nausea. Model 2 examined TEN from 10 minutes through 120 minutes post-dose in attacks free of nausea at baseline to investigate whether or not nausea developed following treatment. Model 3 examined Nausea Relief from 10 minutes through 120 minutes post-dose in eligible attacks with nausea at baseline to examine whether or not nausea was relieved over the first 2 hours post-dose. Models tested for differences in rate of change in nausea over time and odds of nausea at specific time-points. Longitudinal nausea trajectories differed for AVP-825 and oral sumatriptan in the Overall Nausea model (Model 1) and TEN model (Model 2), but were more comparable across treatments for the Nausea Relief (Model 3). More specifically, in the Overall Nausea model (Model 1), an individual treating an attack with AVP-825 had a significantly faster decrease in nausea through the first 60 minutes post-dose and reduced odds of nausea at each time-point from 30 minutes through 120 minutes post-dose compared to oral sumatriptan. In Model 2, an individual's risk for TEN increased at a significantly faster rate through the first 45 minutes post-dose when treating an attack with oral sumatriptan, with significantly greater odds of experiencing TEN at 45, 60, and 90 minutes post-dose compared to AVP-825. The Nausea Relief model (Model 3) showed similar rates of change in nausea over time for the two treatments, but there was a constant difference in nausea level leading to reduced odds of nausea when treating with AVP-825 compared to oral sumatriptan. All three longitudinal models showed that AVP-825 had more favorable nausea outcomes compared to oral sumatriptan. AVP-825 treatment led to more rapid early reductions in Overall Nausea rates during the first hour, reduced odds of nausea from 30 minutes to 2 hours following treatment and reduced risk of TEN compared to oral sumatriptan. These results highlight the importance of separately assessing TEN and Nausea Relief in acute treatment trials of migraine.

Can schools reduce bullying? The relationship between school characteristics and the prevalence of bullying behaviours.

Bullying remains a persistent phenomenon in schools, but the extent to which day-to-day policies and practices relate to bullying prevalence has not been widely studied. In this study, we use an educational effectiveness framework to interrogate this relationship. The aim was to study the relationship between school factors and prevalence of bullying in primary schools. We hypothesize that school conditions (e.g., size), school policies (e.g., behaviour policies), and school processes (e.g., teaching quality) are related to bullying prevalence. Surveys were administered to pupils in 35 primary schools in four local authorities in England. Pupils (N=1,411) and teachers (N=68) in the final year of primary school (year 6) were surveyed. This study drew on the following data sources: A pupil survey on bullying behaviours A survey of teachers on school policies and processes Analysis of data on school processes from school inspection reports Analysis of secondary data on school conditions and pupil characteristics. Three-level multilevel models were used to analyse the data. Results show a substantial school- and classroom-level effect on prevalence of bullying. Effective school policies were found to be related to levels of bullying. The study provides support for the importance of schools' embedded policies and practices in relation to bullying prevalence and provides evidence for policy on the importance of focusing on a broad range of outcomes.

Multiple Time Scale Models in Sport and Exercise Science

ABSTRACTIn sport and exercise research, examining both within- and between-individual variation is crucial. The ability to investigate change both within competitive events and across a competitive season is a priority for many sport researchers. The aim of this article is to demonstrate an approach to analyzing intensive longitudinal data collected through time-scale-dependent longitudinal designs. Following didactic presentation of the approach, two illustrations from secondary data analysis are used to describe the modeling process in detail. Illustration 1 includes affective response data from an exercise intervention randomized pilot study. Illustration 2 uses referee and player distance data collected during professional soccer games in the English Premier League. Each illustration describes a process for testing and comparing multiple time scale models based on the three-level multilevel model, and results are interpreted. In the discussion, advantages and limitations of the approach are highlighted.

Native Student Attitudes towards Equal Rights for Immigrants. A Study in 18 European Countries

The present study investigates the determinants of native student attitudes towards equal rights for immigrants giving particular attention to the effect of immigrant share in the classroom and the extent to which it can be generalized across country contexts. The contribution sheds some new light on the validity of the contact hypothesis, which suggests that mixing native and immigrant students in schools and classrooms can contribute to higher levels of support for immigrants’ rights. The analyses were conducted across 18 countries participating to the ICCS survey in 2009. For the analyses we applied a three-level multilevel model controlling for individual, classroom, and country characteristics. We tested a random slope for immigrant share in the classroom at country level, and we modeled both linear and quadratic effects of immigrant share. The overall pattern suggests that in most countries there is a small positive effect of immigrant share, which does not change dramatically in direction or size at higher immigrant share levels.

Do Physical Proximity and Availability of Adequate Infrastructure at Public Health Facility Increase Institutional Delivery? A Three Level Hierarchical Model Approach.

This study aims to examine the inter-district and inter-village variation of utilization of health services for institutional births in EAG states in presence of rural health program and availability of infrastructures. District Level Household Survey-III (2007–08) data on delivery care and facility information was used for the purpose. Bivariate results examined the utilization pattern by states in presence of correlates of women related while a three-level hierarchical multilevel model illustrates the effect of accessibility, availability of health facility and community health program variables on the utilization of health services for institutional births. The study found a satisfactory improvement in state Rajasthan, Madhya Pradesh and Orissa, importantly, in Bihar and Uttaranchal. The study showed that increasing distance from health facility discouraged institutional births and there was a rapid decline of more than 50% for institutional delivery as the distance to public health facility exceeded 10 km. Additionally, skilled female health worker (ANM) and observed improved public health facility led to significantly increase the probability of utilization as compared to non-skilled ANM and not-improved health centers. Adequacy of essential equipment/laboratory services required for maternal care significantly encouraged deliveries at public health facility. District/village variables neighborhood poverty was negatively related to institutional delivery while higher education levels in the village and women’s residing in more urbanized districts increased the utilization. “Inter-district” variation was 14 percent whereas “between-villages” variation for the utilization was 11 percent variation once controlled for all the three-level variables in the model. This study suggests that the mere availability of health facilities is necessary but not sufficient condition to promote utilization until the quality of service is inadequate and inaccessible considering the inter-districts variation for the program implementation.

Layers of Influence: Exploring Institutional- and State-Level Effects on College Student Views Toward Access to Public Education for Undocumented Immigrants

Providing undocumented immigrants access to public education remains a pertinent issue facing both institutions of higher education and state governments. While instate resident tuition (ISRT) has remained a contentious policy, little is known about how such policies, as well as other state contexts, influence college students’ attitudes toward unauthorized immigrant students’ educational access. Using three-level multilevel models, we sought to understand how political, economic, and demographic contexts at the institutional and state level affect the development of US citizen students’ views toward undocumented immigrants’ access to public education during their undergraduate years. After controlling for student-level effects, findings show that institutional variables such as selectivity, control, and percentage of low-income students enrolled contribute to students’ attitude development. At the state level, findings show that students who attend institutions within states that have ISRT policies have more positive views towards undocumented immigrants’ access to public education at the end of college. This research highlights the critical need for higher education researchers, institutional leaders, and policy makers to better understand how institutional and state contexts shape students’ understanding of larger sociopolitical issues.

College student affect and heavy drinking: Variable associations across days, semesters, and people.

This study tested associations between positive and negative affect and heavy drinking in 734 college students who completed daily diaries in 14-day bursts once per semester over 7 semesters (≤98 days per person). Three-level multilevel models tested whether affect and heavy drinking were linked across days, semesters, and persons. Higher daily, between-semester, and between-person positive affect were each associated with greater odds of heavy drinking on weekdays and on weekend days. A significant interaction with semester in college showed that the association between daily positive affect and heavy drinking on weekend days became stronger over time. That is, heavy drinking on a weekend day with higher positive affect was more likely in later years of college (OR = 2.93, Fall of 4th year), compared to earlier in college (OR = 1.80, Fall of 1st year). A similar interaction was found for between-semester positive affect and heavy drinking on weekdays. Higher daily negative affect was associated with a greater odds of heavy drinking on weekdays only for students who first began drinking in 7th grade or earlier (OR = 2.36). Results of this study highlight the importance of varied time spans in studying the etiology, consequences, and prevention of heavy drinking. Harm-reduction strategies that target positive affect-related drinking by encouraging protective behaviors during celebratory events may become increasingly important as students transition to later years of college. (PsycINFO Database Record

Factors attributable for the prevalence of dental caries in Queensland children.

Dental caries is a multifactorial condition, prevention of which requires comprehensive understanding of both contextual and compositional determinants and their population impact. To investigate contextual and compositional factors associated with the prevalence of dental caries in children and to estimate the population impact of those factors. Children in one Australian state were selected through stratified random sampling selection in 2010-2011. Oral epidemiological examinations provided individual-level outcomes: prevalence of dental caries in the primary (among 5- to 8-year-olds) and permanent dentitions (9- to 14-year-olds). Socioeconomic status, oral health behaviours and practices and dietary patterns were explanatory factors at the individual-level, school-level and area-level fluoridation status. Three-level multilevel multivariable models were sequentially specified for the prevalence of dental caries to estimate prevalence ratios (PR) associated with explanatory factors, adjusting for covariates and between- and within-group variances. Population attributable fraction (PAF) was estimated as the population impact of the statistically significant explanatory factors. Data from 2214 5- to 8-year-olds and 3186 9- to 14-year-olds from 207 schools in 16 areas were analysed. The prevalence of dental caries in the primary and the permanent dentitions was 47.1% (43.9-50.4) and 38.8% (36.1-41.6), respectively. The highest prevalence of dental caries was observed in the nonfluoridated areas. In bivariate associations, factors at three levels were associated with prevalence of dental caries. In the full models, children in the nonfluoridated areas had significantly higher prevalence of dental caries [PR for the primary: 1.29 (1.11-1.50); PR for the permanent 1.49 (1.01-2.21)] compared with children in fluoridated areas, controlling for other factors. PAF estimates indicated that lack of water fluoridation attributed to 21% and 31% of primary and permanent dental caries, respectively in this child population. A multitude of factors had significant population impact on the prevalence of dental caries in children. Water fluoridation has a significant population impact on dental caries experience in this child population.

Drinking in social groups. Does ‘groupdrink’ provide safety in numbers when deciding about risk?

To investigate the impact of alcohol consumption on risk decisions taken both individually and while part of a four- to six-person ad-hoc group. A 2 (alcohol: consuming versus not consuming alcohol) × 2 (decision: individual, group) mixed-model design; decision was a repeated measure. The dependent variable was risk preference, measured using choice dilemmas. Opportunity sampling in campus bars and a music event at a campus-based university in the United Kingdom. A total of 101 individuals were recruited from groups of four to six people who either were or were not consuming alcohol. Participants privately opted for a level of risk in response to a choice dilemma and then, as a group, responded to a second choice dilemma. The choice dilemmas asked participants the level of accident risk at which they would recommend someone could drive while intoxicated. Five three-level multi-level models were specified in the software program HLM 7. Decisions made in groups were less risky than those made individually (B = -0.73, P < 0.001). Individual alcohol consumers opted for higher risk than non-consumers (B = 1.27, P = 0.025). A significant alcohol × decision interaction (B = -2.79, P = 0.001) showed that individual consumers privately opted for higher risk than non-consumers, whereas risk judgements made in groups of either consumers or non-consumers were lower. Decisions made by groups of consumers were less risky than those made by groups of non-consumers (B = 1.23, P < 0.001). Moderate alcohol consumption appears to produce a propensity among individuals towards increased risk-taking in deciding to drive while intoxicated, which can be mitigated by group monitoring processes within small (four- to six-person) groups.

Living with diabetes: a group-based self-management support programme for T2DM patients in the early phases of illness and their partners, study protocol of a randomised controlled trial

BackgroundThe present article presents the protocol for a randomised controlled trial to test the effectiveness of a group-based self-management support programme for recently diagnosed type 2 diabetes mellitus (T2DM) patients (one to three years post-diagnosis) and their partners. The course aims to support T2DM patients and their partners in successfully integrating diabetes care into their daily lives and hereby enhance self-management and diabetes-specific health-related quality of life. The content of the course is based on the Common-Sense Model of Self-Regulation (CSM). Furthermore, principles from the Social Cognitive Theory (SCT) and social support theories are integrated.Methods/DesignWe aim to recruit 160 recently diagnosed T2DM patients and their partners from general practices in six different regions in the Netherlands. Patients need to be diagnosed with T2DM for one to three years and have to experience some degree of diabetes-related difficulties, as measured with a three-item screener. Participating patients and their partners are randomly allocated to the intervention or control condition. Participants in the intervention condition receive three monthly group sessions and a booster session three months later. Participants in the control condition receive a single information meeting. Data will be collected at baseline (T0), directly after the programme (T1) and six months post-programme (T2), including: self-management, diabetes-specific health-related quality of life, illness perceptions, attitudes, social support and empowerment. A three-level multilevel model will be used to compare change-scores between the conditions (intervention/control) on each outcome.DiscussionOur study will be the first to determine whether a group-based support programme based on the CSM is effective in enhancing self-management and diabetes-specific health-related quality of life in recently diagnosed T2DM patients. The important role of patients’ partners in effective diabetes care is also acknowledged in the study.Trial registrationNetherlands National Trial Register (NTR) NTR3302.

A multilevel analysis of late entry in Nigeria

This paper explores how factors operating at the state and community levels are associated with the prevalence of late school enrolment in Nigeria. We investigate the following three research themes. First, whether late entry varies across states and across communities and how much of this variation can be explained by the composition of communities and states. Second, whether community wealth and state wealth are stronger predictors of late entry than household wealth. Third, whether wealth has different effects on the probability of late school entry in different states and in different communities within states. Using the 2010 Nigeria Education Data Survey, and a three-level multilevel logit model, we show that a substantial proportion of the variation in late school entry is explained by community- and state-level factors. We further find that children living in specific communities in Nigeria may face a double disadvantage in terms of on-time school enrolment. In these communities, not only is there a large proportion of children entering school late, but also household wealth has strong effects on the probability that a child is sent to school on on time. These communities could be targeted for educational interventions aimed at promoting on-time school enrolment.