Two-level Analysis Research Articles

Community-level group sports participation and all-cause, cardiovascular disease, and cancer mortality: a 7-year longitudinal study

BackgroundCommunity-level group sports participation is a structural aspect of social capital that can potentially impact individual health in a contextual manner. This study aimed to investigate contextual relationship between the community-level prevalence of group sports participation and the risk of all-cause, cardiovascular disease (CVD), and cancer mortality in older adults.MethodsIn this 7-year longitudinal cohort study, data from the Japan Gerontological Evaluation Study, a nationwide survey encompassing 43,088 functionally independent older adults residing in 311 communities, were used. Cause of death data were derived from the Japanese governmental agency, The Ministry of Health, Labour and Welfare, for secondary use. “Participation” was defined as engaging in group sports for one or more days per month. To analyze the data, a two-level survival analysis was employed, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated.ResultsAmong the participants, 5,711 (13.3%) deaths were identified, with 1,311 related to CVD and 2,349 to cancer. The average group sports participation rate was 28.3% (range, 10.0–52.7%). After adjusting for individual-level group sports participation and potential confounders, a higher community-level group sports participation rate was found to be significantly associated with a lower risk of both all-cause mortality (HR: 0.89, 95% CI: 0.83–0.95) and cancer mortality (HR: 0.89, 95% CI: 0.81–0.98) for every 10% point increase in the participation rate. For CVD mortality, the association became less significant in the model adjusted for all covariates (HR: 0.94, 95% CI: 0.82–1.09).ConclusionsOur findings support the existence of a preventive relationship between community-level group sports participation and the occurrence of all-cause and cancer mortality among older individuals. Promoting group sports within communities holds promise as an effective population-based strategy for extending life expectancy, regardless of individual participation in these groups.

Quality of antenatal care in 13 sub-Saharan African countries in the SDG era: evidence from Demographic and Health Surveys

BackgroundMaternal and neonatal mortality remains high in sub-Saharan Africa (SSA) with women having 1 in 36 lifetime risk. The WHO launched the new comprehensive recommendations/guidelines on antenatal care (ANC) in 2016, which stresses the essence of quality antenatal care. Consequently, the objective of this cross-sectional study is to investigate the quality of ANC in 13 SSA countries.MethodsThis is a cross-sectional study that is premised on pre-existing secondary data, spanning 2015 to 2021. Data for the study was obtained from the Measure DHS Programme and included a total of 79,725 women aged 15–49 were included. The outcome variable was quality ANC and it was derived as a composite variable from four main ANC services: blood pressure taken, urine taken, receipt of iron supplementation and blood sample taken. Thirteen independent variables were included and broadly categorised into individual and community-level characteristics. Descriptive statistics were used to present the proportion of women who had quality ANC across the respective countries. A two-level multilevel regression analysis was conducted to ascertain the direction of association between quality ANC and the independent variables.ResultsThe overall average of women who had quality ANC was 53.8% [CI = 51.2,57.5] spanning from 82.3% [CI = 80.6,85.3] in Cameroon to 11% [CI = 10.0, 11.4] in Burundi. Women with secondary/higher education had higher odds of obtaining quality ANC compared with those without formal education [aOR = 1.23, Credible Interval [Crl] = 1.10,1.37]. Poorest women were more likely to have quality ANC relative to the richest women [aOR = 1.21, Crl = 1.14,1.27]. Married women were more likely to receive quality ANC relative to those cohabiting [aOR = 2.04, Crl = 1.94,3.05]. Women who had four or more ANC visits had higher odds of quality ANC [aOR = 2.21, Crl = 2.04,2.38]. Variation existed in receipt of quality ANC at the community-level [σ2 = 0.29, Crl = 0.24,0.33]. The findings also indicated that a 36.2% variation in quality ANC is attributable to community-level factors.ConclusionTo achieve significant improvement in the coverage of quality ANC, the focus of maternal health interventions ought to prioritise uneducated women, those cohabiting, and those who are unable to have at least four ANCs. Further, ample recognition should be accorded to the existing and potential facilitators and barriers to quality ANC across and within countries.

Process- and Product-Oriented Fundamental Movement Skills in Early Childhood as Predictors of Later Health-Related Fitness.

The skill domains of fundamental movement skills (FMS), emphasizing gross motor movements, including locomotor skills (LMS) and object control skills (OCS), along with process- and product-oriented measures of FMS, may predict cardiorespiratory fitness (CRF) and muscular fitness (MF) differently. This study investigates the longitudinal relationship from early childhood FMS, focusing on process-oriented LMS and OCS and product-oriented FMS, to CRF and MF in late childhood. The study involved 441 Finnish children (49.9% female, mean age at baseline 5.5 years) over a six-year period. FMS was evaluated using the Test of Gross Motor Development, third version (TGMD-3) for process-oriented LMS and OCS and, the Körperkoordinationstest Für Kinder (KTK) was used to evaluate the product-oriented FMS. CRF was assessed through the total number of laps completed in the 20-meter shuttle run test, while MF was measured via repetitions of curl-ups and push-ups. Employing a two-level cross-classified regression analysis and Cholesky decomposition, this study aimed to determine the contributions of product-oriented KTK and process-oriented LMS and OCS. Adjustments for variations in age, measurement intervals, and maturation were achieved through residualization. Additionally, gender and body mass index (BMI) were incorporated as covariates in the analysis. The analysis revealed that process-oriented LMS (CRF: ΔR2 = 0.016, MF: ΔR2 = 0.014) significantly predicted later health-related fitness, while OCS did not. However, KTK exhibited a better ability to predict both CRF (ΔR2 = 0.092) and MF (ΔR2 = 0.032), overshadowing process-oriented measures. In conclusion, the findings suggest that KTK, which potentially encompasses a broader spectrum of fitness elements along with FMS, more effectively predicts health-related fitness components than process-oriented FMS.

A retrospective comparison of mechanical cardio-pulmonary ventilation and manual bag valve ventilation in non-traumatic out-of-hospital cardiac arrests: A study from the Belgian cardiac arrest registry

BackgroundThe optimal ventilation modalities to manage out-of-hospital cardiac arrest (OHCA) remain debated. A specific pressure mode called cardio-pulmonary ventilation (CPV) may be used instead of manual bag ventilation (MBV). We sought to analyse the association between mechanical CPV and return of spontaneous circulation (ROSC) in non-traumatic OHCA. MethodsMBV and CPV were retrospectively identified in patients with non-traumatic OHCA from the Belgian Cardiac Arrest Registry. We used a two-level mixed-effects multivariable logistic regression analysis to determine the association between the ventilation modalities and outcomes. The primary and secondary study criteria were ROSC and survival with a Cerebral Performance Category (CPC) score of 1 or 2 at 30 days. Age, sex, initial rhythm, no-flow duration, low-flow duration, OHCA location, use of a mechanical chest compression device and Rankin status before arrest were used as covariables. ResultsBetween January 2017 and December 2021, 2566 patients with OHCA who fulfilled the inclusion criteria were included. 298 (11.6%) patients were mechanically ventilated with CPV whereas 2268 were manually ventilated. The use of CPV was associated with greater probability of ROSC both in the unadjusted (odds ratio: 1.28, 95% confidence interval [CI]: 1.01–1.63; p = 0.043) and adjusted analyses (adjusted odds ratio [aOR]: 2.16, 95%CI 1.37–3.41; p = 0.001) but not with a lower CPC score (aOR: 1.44, 95%CI 0.72–2.89; p = 0.31). ConclusionsCompared with MBV, CPV was associated with an increased risk of ROSC but not with improved an CPC score in patients with OHCA. Prospective randomised trials are needed to challenge these results.

Development of Alternative Thinking Strategy Curriculum Design to Improve Academic, Social and Emotional Competence

The majority of curriculum designs focus on academic competencies, and only very few curricular are designed that not only improve academic abilities but also improve students' social emotional and psychological competencies. In this research, the researcher designed an alternative thinking strategy curriculum and investigated its impact in improving students' social emotional competence, psychological health and academic competence. Quasi-experiment design was used involving 30 secondary schools who participated in the study. The research sample was divided into two groups, a control and experimental group, from a random cluster. The experimental group received the alternative thinking strategy curriculum (15 schools) and the control group followed the regular national curriculum (15 schools). The subjects investigated are science and language. Two-level hierarchical linear model analysis was used to investigate the impact of an alternative thinking strategies curriculum. Findings of this research show that alternative thinking strategy curriculum design is not only able to improve students’ social and emotional competence, but is also able to increase students' academic achievements. This can be seen in the average increase in student academic achievement and better student attitudes compared to students in the control group who received the national curriculum intervention. The most superior in providing an impact on each aspect is the cluster with medium frequency or the second cluster (C2). Another cluster shows that the implementation of the alternative thinking strategy curriculum is less than optimal regarding aspects of suitability, quality, responsiveness and reach of the curriculum. This is due to differences in the duration of implementation time. This alternative thinking strategy curriculum design also needs to consider students' cultural aspects related to geographic location. This is important to do as content for intervention in improving students' social and emotional competence.

Applying the Robust Chi-Square Goodness-of-Fit Test to Multilevel Multitrait-Multimethod Models: A Monte Carlo Simulation Study on Statistical Performance

As the robust maximum likelihood χ2 goodness-of-fit test had been found to yield inflated type-I error rates for certain two-level confirmatory factor analysis (CFA) models, a new correction for the test was implemented in Mplus version 8.7. In this simulation study, we inspected whether the corrected test statistics follow the expected χ2 distributions when applying more complex two-level models for multitrait-multimethod data with varying sample sizes and correlations within trait factors. Investigating rejection rates and probability-probability plots, we found that the new correction markedly and sufficiently reduced previously inflated rejection rates in conditions with within-trait correlations equal to 1, 100 between-level units, and 10 or 20 within-level units. In other conditions, rejection rates were hardly affected or not sufficiently reduced by the new correction. While in most conditions, 2 within-level units did not suffice, 5 within-level units and 250 between-level units were enough to yield correct rejection rates given within-trait correlations did not exceed 0.80. Correlations above 0.80 required larger sample sizes. In planning studies with multilevel CFA models, researchers should be aware that sample size requirements for likelihood-based model fit evaluations can depend on several different factors and might consider conducting Monte Carlo simulations tailored to their specific modeling conditions.

Planning for the urban future: two-level spatial analysis to discover 15-Minute City potential in urban area and expansion in Tallinn, Estonia

Planning for the urban future: two-level spatial analysis to discover 15-Minute City potential in urban area and expansion in Tallinn, Estonia

Lonely online: A social model of digital media addiction: A study in 21 countries

ABSTRACT Digital media addiction limits face-to-face communication, which can have negative effects on the subjective wellbeing of individuals. However, the effect of digital media addiction on subjective wellbeing has not been adequately explored, and it is recommended in the literature that the role of mediating variables related to social life should be investigated. These include loneliness and satisfaction with relationships. The current study investigated whether loneliness and satisfaction with relationships explained the link between people’s digital media addiction and their sense of flourishing. A sample of 6,434 respondents from 21 countries (Mage = 25.92 years, SD = 9.78; 65.5% women) took part in a cross-sectional survey study. The study included a comprehensive evaluation of digital media addiction using several measures. The following scales were applied: the Internet Addiction Scale, the Facebook Intrusion Questionnaire, the Phubbing Scale, the De Jong Gierveld Loneliness Scale, the Relationship Assessment Scale, and the Flourishing Scale. A two-level path analysis showed that loneliness and satisfaction with interpersonal relationships fully mediated the link between digital media addiction and flourishing on the individual level. This suggests that digital media addiction may affect flourishing only through its impact on loneliness and satisfaction with interpersonal relationships.

Association of same-sex criminalisation laws and national HIV policies with HIV testing in African MSM: an ecological single-level and multilevel cross-sectional study of sub-Saharan African countries

BackgroundHIV incidence among men who have sex with men (MSM) in sub-Saharan Africa (SSA) remains high compared with the general population. Many countries in the region still criminalise consensual homosexual...

Creating Local “Citizen's Governance Spaces” in Austerity Contexts : Food Recuperation and Urban Gardening in Montréal (Canada) as Ways to Pragmatically Invent Alternatives

While there is a growing interest in citizen-led initiatives, there is still no consensus on how to situate them, especially in relation to state institutions. On the one hand, citizen-led initiatives are seen as being co-opted by formal institutions in a context of austerity. On the other hand, these initiatives are often presented as “spaces of resistance” to neoliberalism, or as political acts of reclaiming the city. Mapping and tracing urban gardening and dumpster diving from their grassroots emergence to their inclusion in the institutional world through a two-level analysis, we show that individuals and loosely organized collectives involved in such initiatives are embedded in complex relationships with local institutions and third sector organizations that do, in turn, structure their practice and its consequences. The two-level analysis we propose follows this process: it is through interactions and relationships with other “practitioners” and with their social and institutional environment that these urban social practices gradually institutionalize.

A pragmatic approach to the rhetorical analysis and the metadiscourse markers of research article abstracts in the field of applied linguistics

Using Hyland’s (2000) model as a research tool and drawing on Hyland’s (2005a) model of metadiscourse, this article presents a pragmatic two-level rhetorical analysis of the constituent moves within research article abstracts. It specifically zeroes in on the identification and mapping of the most frequently used metadiscourse markers signifying these moves. The findings highlight that Libyan authors employ interactive markers more often than interactional ones. Both quantitative and qualitative analysis of metadiscourse indicate that transitions, endophoric markers, and frame markers emerge as the dominant interactive categories. In contrast, interactional metadiscourse is predominantly represented by attitude markers, hedges, and boosters. Based on the findings, Move 1 features the highest frequency of metadiscourse markers, followed by Move 2. Notably, transitions stand out as the most prevalent category across all moves. This study carries pedagogical implications for academic writing practices among Libyan academic writers and students alike. Moreover, it enhances the existing body of research on the genre of research articles.

Prevalence and determinants of anemia among school going children in the state of Tamil Nadu, India: applications of two-level logistic regression model

Background: Anemia still remains as one of the major public health problems in India despite implementing preventive measures. The objective was to find the prevalence and determinants of anemia among school going children in Tamil Nadu. Methods: We used the data from the fourth round of district level household survey (DLHS-4) for Tamil Nadu pertaining to the year 2012-13. Our analysis included 23997 children. Descriptive statistics, Random intercept and empty models of two-level logistic regression analysis were used. Results: The overall prevalence of anemia was found to be 41.4% (95% CI: 40.77%-42.02%). We observed a district level variation on anemia (District level variance=0.1, p<0.001) and the intra class correlation coefficient was 0.0295. The prevalence of anemia was more in coastal districts as compared to non-coastal districts (43.85% vs. 40.18%, p<0.001). Variables that are found to have significant association with anemia on multilevel analysis were younger age (Adjusted odds ratio (AOR)=1.343, 95% CI: 1.270-1.420), female children (AOR=1.462, 95% CI: 1.387-1.541), more than eight family members in the household (AOR=1.120, 95% CI: 1.008-1.245), rural residence (AOR=1.103, 95% CI: 1.038-1.172) and lower standard of living (AOR=1.203, 95% CI: 1.084-1.334).  Conclusions: Half of school going children were anemic in the state. Geospatial distribution of anemia varied significantly. Governments and regional health centres should take adequate measures to avert the consequences of anemia in school going children considering these factors.

Two-Level Game Analysis on US Decision to Withdraw from the Trans-Pacific Partnership (TPP)

Abstract
 This study analyzes the reasons behind the U.S. withdrawal from the Trans-Pacific Partnership (TPP) in 2017. Using descriptive methods and Two-level Game theory as an analytical tool supported by secondary data, we found some domestic factors driving this policy. First, different preferences existed between the government as the “chief negotiator” and interest groups and public opinion representing domestic interests. Two-level game theory explains that international agreement can only be ratified if the win-set negotiations are in overlapping conditions or where international and domestic preferences find a meeting point. However, no common ground between international and domestic preferences resulted in a deadlock. Second, the U.S. public strongly resisted the agreement. Public opinion and hearings are factors that, to some extent, can become obstacles for national governments in international negotiations. Ratification is not only carried out through a formal process (legislative approval) but also through an informal process (public opinion and approval). In addition, the election of Donald Trump, who carried protectionist values with his “America First” slogan, strengthened the position of the opposing groups and those who embraced protectionist values. Therefore, the election of Trump as the president marked the end of the TPP debate because both the executive as the “chief negotiator” and the dominant domestic group rejected the ratification.
 Keywords: Trans-Pacific Partnership, Two-Level Game Theory, United States

Maintaining Program Fidelity in a Changing World: National Implementation of a School-Based HIV Prevention Program

AbstractLarge-scale, evidence-based interventions face challenges to program fidelity of implementation. We developed implementation strategies to support teachers implementing an evidence-based HIV prevention program in schools, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT) in The Bahamas. We examined the effects of these implementation strategies on teachers’ implementation in the subsequent year after the initial implementation during the COVID-19 pandemic. Data were collected from 79 Grade 6 teachers in 24 government elementary schools. Teachers completed training workshops and a pre-implementation questionnaire to record their characteristics and perceptions that might affect their program fidelity. School coordinators and peer mentors provided teachers with monitoring, feedback, and mentoring. In Year 1, teachers on average taught 79.3% of the sessions and 80.8% of core activities; teachers in Year 2 covered 84.2% of sessions and 72.9% of the core activities. Teachers with “good” or “excellent” school coordinators in the second year taught significantly more sessions on average (7.8 vs. 7.0, t = 2.04, P < 0.05) and more core activities (26.3 vs. 23.0, t = 2.41, P < 0.05) than teachers with “satisfactory” coordinators. Teachers who had a “good” or “satisfactory” mentor taught more sessions than teachers who did not have a mentor (7.9 vs. 7.3; t = 2.22; P = 0.03). Two-level mixed-effects model analysis indicated that teachers’ program fidelity in Year 1, confidence in the execution of core activities, and school coordinators’ performance were significantly associated with Year 2 implementation dose. Implementation of FOYC + CImPACT was significantly associated with improved student outcomes. Teachers maintained high fidelity to a comprehensive HIV prevention program over 2 years during the COVID-19 pandemic. Future program implementers should consider additional implementation support to improve the implementation of school-based programs.

Dielectric material preparation from pineapple leaf fiber based on two-level factorial analysis and its morphological structure

Natural fiber has earned great attention for its discovery as a green material in dielectric composites. Their excellent dielectric properties have granted them the great capability to be used in high dielectric composites. Hence, this study attempts to determine the most influential factor contributing to the permittivity of pineapple leaf fibers and to examine the morphological structure of the developed fibers. The two-level factorial analysis was applied to determine the significant, influential factors and the best conditions contributing to the permittivity value of fiber. The factors include the pineapple leaf-to-soda ratio (1:5 and 1:10), soda concentration (5–10 wt%), temperature (60–100 ℃), and pulping time (45–75 min). The fiber was extracted from the pineapple leaf through the soda pulping method, and the content was analyzed by the Kurschner-Hanack method. Based on the analysis, the pineapple leaf-to-soda ratio was observed as the most significant factor contributing to the permittivity value of fiber, with an 8.86% contribution. The best conditions were suggested at a 1:10 pineapple leaf-to-soda ratio, 5 wt% soda concentration, 100 ℃ temperature, and 45 min of pulping time, contributing to the 1.85 permittivity value of pineapple leaf fiber. The scanning electron microscope images of the material under test indicate that the morphological structures play a crucial part in determining the permittivity value of fiber. Therefore, with suitable processing factors, pineapple leaf fiber can be a great dielectric material used in many engineering applications.

Association of community-level social capital with dementia: A multilevel nine-year longitudinal study using data from the Japan Gerontological Evaluation Study

BackgroundIndividual-level social capital prevents cognitive decline. However, a few studies have focused on the effects of community-level social capital on dementia. Therefore, we investigated the association between community-level social capital and dementia onset based on longitudinal study data on older adults in Japan. MethodsWe used longitudinal data from the Japan Gerontological Evaluation Study, obtained over nine years (2010–2019). In total, 35,921 physically and cognitively independent individuals (16,848 males and 19,073 females) aged ≥65 years and nested within 308 communities in seven municipalities participated in the study. Dementia onset was assessed using the public long-term care insurance registration. Social capital was assessed using three dimensions: civic participation, social cohesion, and reciprocity. We performed a two-level multilevel survival analysis stratified by sex, calculated hazard ratios (HRs), and 95% confidence intervals (CIs). ResultsDuring the follow-up, 6245 (17.4%) dementia onset cases were identified. The cumulative incidence of dementia was 16.2% in males and 18.4% in females. After adjusting for covariates, individual-level civic participation was associated with a lower incidence of dementia in both males and females (HR, 0.84; 95% CI, 0.77–0.92; HR, 0.78; 95% CI, 0.73–0.84). Community-level civic participation and social cohesion were associated with a lower incidence of dementia among females (HR, 0.96; 95% CI, 0.93–0.99; HR, 0.93; 95% CI, 0.88–0.98) and cross-level interaction on social cohesion among females (HR, 0.95; 95% CI, 0.90–0.99). ConclusionsLiving in a community with high civic participation and social cohesion is associated with a lower incidence of dementia among older females. Therefore, promoting civic participation and social cohesion in the community may be a useful population-based strategy to delay or prevent the onset of dementia.

Effect of factors on dielectric properties of pineapple leaf for microwave application

Nowadays, dielectric materials are widely used in electronic applications, and their permittivity and loss tangent are important properties to consider. Dielectric materials made from waste can help reduce pollution and conserve resources. The aim of this work is to analyze the important factors in pineapple plantation waste preparation as dielectric materials using rapid two-level factor analysis in order to identify significant factors during preparation. It takes a short procedure to determine the optimum variable factor and leads to fast analysis. The dielectric material preparation process involves chemical treatment, sample fabrication, and sample characterization. Measurement of permittivity is performed by using a G-band rectangular waveguide. The highest dielectric permittivity is 3.31 where one of the suitable applications is used as an antenna substrate. The best factor in producing high dielectric permittivity is a 1:10 ratio of pineapple leaves to distilled water, 50 min of boiling time, using a heating effect, and 5 g weight of pineapple leaves powder. The most significant factor in producing high dielectric permittivity is the heating effect, which is contributed by the presence of carbon in the composite material.

Students' regulation of anxiety and hope-A multilevel latent profile analysis.

Academic examinations are highly emotional for university students, making ER essential for preventing or reducing the negative consequences of negative emotions on well-being and academic performance. Initial theorizing and research suggest that flexibly applying combinations of strategies can promote successful ER. However, studies using intraindividual approaches to examine ER strategy use in specific contexts across multiple occasions, are lacking. Moreover, the combinations of strategies used by students within different contexts, and the adaptiveness of different strategies for regulating different emotions, remain unexplored. To address these gaps, we conducted an experience sampling study to identify patterns of students' momentary ER and to examine how context (achievement-related vs. nonachievement-related), emotions (anxiety vs. hope), and academic performance function as potential covariates. Over 200 university students rated their anxiety, hope, and use of eight ER strategies over a 7-day period, six times a day, prior to an important exam in 2016 and 2017. Results of a two-level latent profile analysis revealed distinct profiles of ER that differed on both levels. Intraindividually, ER patterns differed as a function of type of emotion and context experienced. More specifically, momentary use of multiple strategies tended to be associated with greater anxiety, while in the achievement context this association was reduced. Interindividually, students' tendencies to use different ER patterns were not related to test performance. Our findings suggest that ER strategy selection depends on both context and emotions, and advance ER research by considering intraindividual strategy use in concrete achievement situations. Yet the sample is not sufficiently representative. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Flexural strength increases of concrete with AISI 4140 steel chip as reinforcement

This work is an experimental and numerical study of the flexural strength increase in concrete with steel chips as reinforcement. The concrete was reinforced with different thicknesses of AISI 4140 steel chips: 1.0, 1.5, 2.0, and 2.5 mm, respectively. The metal chip replaced the sand in different percentages: 0 %, 15 %, 25 %, and 50 %. A two-level factor analysis was carried out to study the effect of metal chip thicknesses and their percentages on the flexural strength, making 13 different samples. Flexural tests were carried out in triplicate, making 39 tests. The 39 samples were weighed and measured. Flexural tests, the weights, and the measurements showed that the modulus of rupture and the density increase with the metal chip thicknesses and with its percentage from 2.20 to 2.55 g/cm3 and from 4.6 to 8.6 MPa, respectively. Numerical studies made by the Finite Element Method using Calculix® showed that the concrete can be simulated as an elastic isotropic material where the Younǵs Modulus can be supposed equal to the Flexural Modulus, except in the cracking zone of the concrete, where its behavior is not linear. Flexural tests and numerical studies showed that the mechanical behavior of concrete does not change significantly at the elastic zone, but after the elastic zone, when beginning the microcracking, the effect of metal chips as reinforcement agents is noticeable. The increase in flexural strength of the concrete due to the metal chips is noticeable after the first micro-cracks appear in the specimen.

Public Spending, Governance, and Mortality Probability in the Indian Subnational: A Two-Level Random Intercept Analysis

ABSTRACT: One of the most fundamental yet unresolved health policy issues is whether public expenditure on healthcare leads to improved health outcomes. Given that health reflects one of the critical aspects of human capital, having implications for economic growth and other development goals, there has been enormous advocacy towards investing significantly in the health systems across the countries to improve the overall health status. However, the effect of public spending on health outcomes remains inconclusive. The present paper analyses the impact of public health spending on mortality probability, taking into account the role of governance while treating public spending as an endogenous variable. The study uses individual level data from the National Family Health Survey (NFHS) Round 5 and a few state-level characteristics. For estimation purpose, it uses a two-level mixed effect model to capture the benefit incidence of public spending on Individual mortality probability. The findings reveal that public spending has a significant but differential impact on mortality across the Indian States, whereas the quality of governance is found to be a mediator. Given a level of public spending, States with better government effectiveness and rule of law can translate public health spending more effectively in reducing mortality at the individual level. The study also found heterogeneous mortality status across gender, location of stay, wealth status, and age groups with a differential impact of public spending across gender, wealth, and age groups. The variation in average distance of mortality probability level in each state from the overall mean mortality probability indicates that the states are very different in terms of health challenges that they are facing. The policy options call for state-specific health interventions to reduce the mortality rather than one-size-fits-all health policies. There needs to more unconditional grants/transfers from the Union Government to the States so that states will be able to tailor policy responses to address the unique challenges faced by the respective states. At the same time, states need to adopt output-based conditions with greater flexibility to deliver services and greater accountability to improve transparency, governance quality, and implementation capacity.