A brief conceptual tutorial on multilevel analysis in social epidemiology: investigating contextual phenomena in different groups of people

Performance of Pit Latrines and Their Herd Protection Against Diarrhea: A Longitudinal Cohort Study in Rural Ethiopia

In sanitation policies, "improved sanitation" is often broadly described as a goal with little rationale for the minimum standard required. We conducted a secondary analysis of data collected as part of a cluster randomized controlled trial in rural Ethiopia. We compared the performance of well-constructed and poorly constructed pit latrines in reducing child diarrhea. In addition, we explored whether having a well-constructed household latrine provides indirect protection to neighbors if cluster-level coverage reaches a certain threshold. We followed up children aged younger than 5 years (U5C) of 906 households in rural areas of the Gurage zone, Ethiopia, for 10 months after community-led total sanitation interventions. A study-improved latrine was defined as having all the following: pit of ≥2 m depth, slab of any material, drop-hole cover, wall, roof, door, and handwashing facilities (water and soap observed). U5C in households with a study-improved latrine had 54% lower odds of contracting diarrhea than those living in households with a latrine missing 1 or more of the characteristics (adjusted odds ratio [aOR]=0.46; 95% confidence interval [CI]=0.27, 0.81; P=.006). Analyses were adjusted for child age and sex, presence of improved water for drinking, and self-reported handwashing at 4 critical times. The odds of having diarrhea among those with an improved latrine based on the World Health Organization/UNICEF Joint Monitoring Program (JMP) definition (i.e., pit latrines with slabs) were not substantially different from those with a JMP-unimproved latrine (aOR=0.99; 95% CI=0.56, 1.79; P=.99). Of U5C living in households without a latrine or with a study-unimproved latrine, those in the high-coverage villages were less likely to contract diarrhea than those in low-coverage villages (aOR=0.55; 95% CI=0.35, 0.86; P=.008). We recommend that academic studies and routine program monitoring and evaluation should measure more latrine characteristics and evaluate multiple latrine categories instead of making binary comparisons only.

Association between high-risk fertility behaviors and neonatal mortality in Ethiopia: A multilevel mixed-effects logit models from 2019 Ethiopian mini demographic and health survey

Objectives

This study aimed to explore the association between high-risk fertility behaviors and neonatal mortality in Ethiopia.

Study design

A community-based cross-sectional study was conducted using data from the 2019 Ethiopian Mini-Demographic and Health Survey.

Methods

Mixed-effects logit regression models were fitted to 5527 children nested within 305 clusters. The definition of high-risk fertility behavior was adopted from the 2019 EMDHS. The fixed effects (the association between the outcome variable and the explanatory variables) were expressed as adjusted odds ratios (ORs) with 95 % confidence intervals and measures of variation explained by intra-class correlation coefficients, median odds ratio, and proportional change invariance.

Results

The presence of births with any multiple high-risk fertility behaviors was associated with a 70 % higher risk of neonatal mortality (AOR = 1.7, (95 % CI: 1.2, 2.3) than those with no high-risk fertility behavior. From the combined risks of high-risk fertility behaviors, the combination of preceding birth interval <24 months and birth order four or higher had an 80 % increased risk of neonatal mortality (AOR = 1.8, (95 % CI, 1.2, 2.7) as compared to those who did not have either of the two. The 3-way risks (combination of preceding birth interval <24 months, birth order 4+, and mother's age at birth 34+) were associated with approximately four times increased odds of neonatal mortality (AOR (95 % CI:3.9 (2.1, 7.4)].

Conclusions

High-risk fertility behavior is a critical predictor of neonatal mortality in Ethiopia, with three-way high-risk fertility behaviors increasing the risk of neonatal mortality fourfold. In addition, antenatal follow-up was the only non-high fertility behavioral factor significantly associated with the risk of neonatal mortality in Ethiopia.

Geographic Variation of Antidementia and Antipsychotic Medication Use Among US Nursing Home Residents With Dementia

BACKGROUND

Several antidementia medications have been approved for symptomatic treatment of cognitive and functional impairment due to Alzheimer disease. Antipsychotics are often prescribed off-label for behavioral symptoms.

OBJECTIVE

The aim of this study was to describe the basis for regional variation in antidementia and antipsychotic medication use.

SETTING

US nursing homes (n=9735), hospital referral regions (HRR; n=289).

SUBJECTS

Long-stay residents with dementia (n=273,004).

METHODS

Using 2018 Minimum Data Set 3.0 linked to Medicare data, facility information, and Dartmouth Atlas files, we calculated prevalence of use and separate multilevel logistic models [outcomes: memantine, cholinesterase inhibitor (ChEI), antipsychotic use] estimated adjusted odds ratios (aOR) and 95% CIs for resident, facility, and HRR characteristics. We then fit a series of cross-classified multilevel logistic models to estimate the proportional change in cluster variance (PCV).

RESULTS

Overall, 20.9% used antipsychotics, 16.1% used memantine, and 23.3% used ChEIs. For antipsychotics, facility factors [eg, use of physical restraints (aOR: 1.08; 95% CI: 1.05-1.11) or poor staffing ratings (aOR: 1.10; 95% CI: 1.06-1.14)] were associated with more antipsychotic use. Nursing homes in HRRs with the highest health care utilization had greater antidementia drug use (aOR memantine: 1.68; 95% CI: 1.44-1.96). Resident/facility factors accounted for much regional variation in antipsychotics (PCVSTATE: 27.80%; PCVHRR: 39.54%). For antidementia medications, HRR-level factors accounted for most regional variation (memantine PCVSTATE: 37.44%; ChEI PCVSTATE: 39.02%).

CONCLUSION

Regional variations exist in antipsychotic and antidementia medication use among nursing home residents with dementia suggesting the need for evidence-based protocols to guide the use of these medications.

Socioeconomic inequalities in the uptake of postpartum care at home across Dutch neighbourhoods

BACKGROUND

Postpartum care focuses on prevention of health problems by performing medical check-ups and through enhancing maternal empowerment, the parent-infant interaction and knowledge about mother's own health and that of her newborn. We aimed to investigate whether there was significant clustering within neighbourhoods regarding the uptake of postpartum care and to what extent neighbourhood-level differences are explained by individual socio-demographic factors, pregnancy-related factors and neighbourhood-level determinants (i.e. deprivation and urbanization).

METHODS

A nationwide population-based observational study was carried out using linked routinely collected healthcare data from appropriate-for-gestational-age weight live-born term singleton deliveries (2015-18) in the Netherlands. We performed two-level multivariable logistic regression analyses, using three different models. Model 1 contained no explanatory variables and was used to assess clustering of postpartum care uptake within neighbourhoods. In model 2, individual-level determinants were added one by one and in model 3, neighbourhood-level determinants were added.

RESULTS

About 520 818 births were included. Multilevel modelling showed that 11% of the total variance in postpartum care uptake could be attributed to the neighbourhood of residence. Individual characteristics explained 38% of the neighbourhood variance, of which income and migration background were the most important contributors. An additional 6% of the variation could be explained by neighbourhood-level determinants.

CONCLUSION

We found substantial neighbourhood differences in postpartum care uptake. These differences are influenced by a complex interplay between individual-level and neighbourhood-level determinants, highlighting the importance of addressing both individual and neighbourhood-level determinants to improve the uptake of postpartum care and therewith overall community health.

Determinants of tobacco use among pregnant women in sub-Saharan Africa. A multilevel mixed-effect logistic regression model

INTRODUCTION

Although it is known that maternal tobacco use during pregnancy substantially declined in higher-income countries, information on the magnitude and determinants of tobacco use among pregnant women in sub-Saharan Africa (SSA) remains limited. Establishing evidence on maternal tobacco during pregnancy is crucial for guiding targeted interventions in SSA. This study aimed to determine the overall prevalence of tobacco use and its determinants among pregnant women in SSA countries.

METHODS

The study used data from Demographic and Health Surveys conducted in 33 countries across SSA from 2010 and 2021. Our analysis included a total weighted sample of 40,291 pregnant women. A multilevel logistic regression model was used to identify factors associated with maternal tobacco use during pregnancy. The measure of association between explanatory variables and the outcome was reported using adjusted odds ratios (AORs) with 95% confidence intervals (CIs).

RESULTS

The pooled prevalence of tobacco use among pregnant women in SSA was 1.76% (95% CI: 1.41, 2.12). Our findings showed that pregnant women in the age groups of 25-34 years (AOR 1.44; 95% CI: 1.14, 1.82) and 35+ years (AOR 2.18; 95% CI: 1.68, 2.83) had higher odds of tobacco use during pregnancy. Pregnant women who attained primary education (AOR 0.57; 95% CI: 0.46, 0.70) and secondary or higher education (AOR 0.39; 95% CI: 0.30, 0.53) were associated with lower odds of tobacco use. Similarly, pregnant women who resided in households with a high wealth index (AOR 0.36; 95% CI: 0.55 0.90) and those with media exposure (AOR 0.81; 95% CI: 0.67, 0.99) were less likely to use tobacco during pregnancy.

CONCLUSION

This study revealed that the overall prevalence of maternal tobacco use during pregnancy was relatively low in SSA, but some countries exhibited higher estimates. To address this, it is crucial to implement targeted smoking prevention and cessation strategies, particularly for young pregnant women, those facing socioeconomic disadvantages, and those with lower educational status.

Computer vision models enable mixed linear modeling to predict arbuscular mycorrhizal fungal colonization using fungal morphology

The presence of Arbuscular Mycorrhizal Fungi (AMF) in vascular land plant roots is one of the most ancient of symbioses supporting nitrogen and phosphorus exchange for photosynthetically derived carbon. Here we provide a multi-scale modeling approach to predict AMF colonization of a worldwide crop from a Recombinant Inbred Line (RIL) population derived from Sorghum bicolor and S. propinquum. The high-throughput phenotyping methods of fungal structures here rely on a Mask Region-based Convolutional Neural Network (Mask R-CNN) in computer vision for pixel-wise fungal structure segmentations and mixed linear models to explore the relations of AMF colonization, root niche, and fungal structure allocation. Models proposed capture over 95% of the variation in AMF colonization as a function of root niche and relative abundance of fungal structures in each plant. Arbuscule allocation is a significant predictor of AMF colonization among sibling plants. Arbuscules and extraradical hyphae implicated in nutrient exchange predict highest AMF colonization in the top root section. Our work demonstrates that deep learning can be used by the community for the high-throughput phenotyping of AMF in plant roots. Mixed linear modeling provides a framework for testing hypotheses about AMF colonization phenotypes as a function of root niche and fungal structure allocations.

Machine learning models for prediction of double and triple burdens of non-communicable diseases in Bangladesh

Increasing prevalence of non-communicable diseases (NCDs) has become the leading cause of death and disability in Bangladesh. Therefore, this study aimed to measure the prevalence of and risk factors for double and triple burden of NCDs (DBNCDs and TBNCDs), considering diabetes, hypertension, and overweight and obesity as well as establish a machine learning approach for predicting DBNCDs and TBNCDs. A total of 12,151 respondents from the 2017 to 2018 Bangladesh Demographic and Health Survey were included in this analysis, where 10%, 27.4%, and 24.3% of respondents had diabetes, hypertension, and overweight and obesity, respectively. Chi-square test and multilevel logistic regression (LR) analysis were applied to select factors associated with DBNCDs and TBNCDs. Furthermore, six classifiers including decision tree (DT), LR, naïve Bayes (NB), k-nearest neighbour (KNN), random forest (RF), and extreme gradient boosting (XGBoost) with three cross-validation protocols (K2, K5, and K10) were adopted to predict the status of DBNCDs and TBNCDs. The classification accuracy (ACC) and area under the curve (AUC) were computed for each protocol and repeated 10 times to make them more robust, and then the average ACC and AUC were computed. The prevalence of DBNCDs and TBNCDs was 14.3% and 2.3%, respectively. The findings of this study revealed that DBNCDs and TBNCDs were significantly influenced by age, sex, marital status, wealth index, education and geographic region. Compared to other classifiers, the RF-based classifier provides the highest ACC and AUC for both DBNCDs (ACC = 81.06% and AUC = 0.93) and TBNCDs (ACC = 88.61% and AUC = 0.97) for the K10 protocol. A combination of considered two-step factor selections and RF-based classifier can better predict the burden of NCDs. The findings of this study suggested that decision-makers might adopt suitable decisions to control and prevent the burden of NCDs using RF classifiers.

An empirical analysis of the demand for family planning satisfied by modern methods among married or in-union women in Nigeria: Application of multilevel binomial logistic modelling technique

BACKGROUND

Given the health and economic benefits of family planning (FP), Nigeria's very low demand for FP satisfied by modern methods (mDFPS) of less than 50% is therefore a major public health concern, especially considering the global target aimed at achieving an mDFPS of at least 75% by year 2030 for all countries. In view of this, together with recognising the possible contextual nature of health outcomes, this study aimed to empirically analyse the mDFPS among married or in-union women of reproductive age (WRA) in Nigeria.

MATERIALS AND METHODS

A multilevel binomial logistic model with two levels of analysis was used: individual and community levels. Secondary cross-sectional data were obtained from the 2018 Nigeria Demographic and Health Survey, and analyses were performed using Stata 15.0. The analytical sample size was 9,122 WRA nested in a total of 1,072 communities.

RESULTS

The mDFPS was approximately 31.0%. The median odds ratio (MOR) estimated from the final multilevel model was 2.245, which was greater than the adjusted odds ratio (aOR) for most of the individual-level variables, suggesting that the unexplained/residual between-community variation in terms of the odds of women having their mDFPS was more relevant than the regression effect of most of the individual-level variables. This was with the exception of the regression effects of the following individual-level variables: women's husbands that had higher education level in comparison to their counterparts who had husbands with no formal education (aOR = 2.539; 95% CI = 1.896 to 3.399; p<0.001); and women from the Yoruba ethnic group in comparison to their counterparts from the Hausa/Fulani/Kanuri ethnic group (aOR = 2.484; 95% CI = 1.654 to 3.731; p value<0.001). However, other individual-level variables with positive statistically significant regression effects on mDFPS were: women who mentioned that money for accessing health care was not a problem; women's empowerment in relation to the visitation of family and relatives; and women being exposed to FP messages through various media sources, all in comparison to their respective counterparts. On the other hand, at the community level, women in communities where a high percentage of them had at least a secondary education had statistically significant greater odds of having mDFPS than women in communities with lower education levels (aOR = 1.584; 95% CI = 1.259 to 1.991; p<0.001). We found similar findings regarding women residing in communities with exposure to FP messages through various media sources. However, using the 80% interval ORs (80% IORs) as a supplemental statistical measure for further understanding the regression effects of community-level variables showed that all of the 80% IORs had a value of '1', signifying considerable uncertainty in the regression effects of all community-level variables due to the substantial residual variation existing between communities.

CONCLUSIONS

Our study showed that to achieve the dire increase in mDFPS in Nigeria, policy interventions aimed at improving the education level of both females and males, especially beyond the secondary school level, should be implemented. Additionally, all of the various media sources should be extensively utilised, both at the individual and the community level, by the Nigerian government to spread information on the importance of women having their mDFPS.

Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial

BACKGROUND

Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection.

METHODS

This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment.

DISCUSSION

Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives.

TRIAL REGISTRATION

Clinicaltrials.gov NCT06106204 on 10/30/23.

Health inequalities at the intersection of multiple social determinants among under five children residing Nairobi urban slums: An application of multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

In this analysis we examine through an intersectionality lens how key social determinants of health (SDOH) are associated with health conditions among under-five children (<5y) residing in Nairobi slums, Kenya. We used cross-sectional data collected from Nairobi slums between June and November 2012 to explore how multiple interactions of SDoH shape health inequalities in slums. We applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) approach. We constructed intersectional strata for each health condition from combinations of significant SDoH obtained using univariate analyses. We then estimated the intersectional effects of health condition in a series of MAIHDA logistic regression models distinguishing between additive and interaction effects. We quantified discriminatory accuracy (DA) of the intersectional strata by means of the variance partitioning coefficient (VPC) and the area under the receiver operating characteristic curve (AUC-ROC). The total participants were 2,199 <5y, with 120 records (5.5%) dropped because health conditions were recorded as "not applicable". The main outcome variables were three health conditions: 1) whether a child had diarrhea or not, 2) whether a child had fever or not, and 3) whether a child had cough or not in the previous two weeks. We found non-significant intersectional effects for each health condition. The head of household ethnic group was significantly associated with each health condition. We found good DA for diarrhea (VPC = 9.0%, AUC-ROC = 76.6%) an indication of large intersectional effects. However, fever (VPC = 1.9%, AUC-ROC = 66.3%) and cough (VPC = 0.5%, AUC-ROC = 61.8%) had weak DA indicating existence of small intersectional effects. Our study shows pathways for SDoH that affect diarrhea, cough, and fever for <5y living in slums are multiplicative and shared. The findings show that <5y from Luo and Luhya ethnic groups, recent migrants (less than 2 years), and households experiencing CHE are more likely to face worse health outcomes. We recommend relevant stakeholders to develop strategies aimed at identifying these groups for targeted proportionate universalism based on the level of their need.

Geographic variation in inpatient medical expenditure among older adults aged 75 years and above in Japan: a three-level multilevel analysis of nationwide data

Introduction

In Japan, a country at the forefront of population ageing, significant geographic variation has been observed in inpatient medical expenditures for older adults aged 75 and above (IMEP75), both at the small- and large-area levels. However, our understanding of how different levels of administrative (geographic) units contribute to the overall geographic disparities remains incomplete. Thus, this study aimed to assess the degree to which geographic variation in IMEP75 can be attributed to municipality-, secondary medical area (SMA)-, and prefecture-level characteristics, and identify key factors associated with IMEP75.

Methods

Using nationwide aggregate health insurance claims data of municipalities for the period of April 2018 to March 2019, we conducted a multilevel linear regression analysis with three levels: municipalities, SMA, and prefectures. The contribution of municipality-, SMA-, and prefecture-level correlates to the overall geographic variation in IMEP75 was evaluated using the proportional change in variance across six constructed models. The effects of individual factors on IMEP75 in the multilevel models were assessed by estimating beta coefficients with their 95% confidence intervals.

Results

We analysed data of 1,888 municipalities, 344 SMAs, and 47 prefectures. The availability of healthcare resources at the SMA-level and broader regions to which prefectures belonged together explained 57.3% of the overall geographic variance in IMEP75, whereas the effects of factors influencing healthcare demands at the municipality-level were relatively minor, contributing an additional explanatory power of 2.5%. Factors related to long-term and end-of-life care needs and provision such as the proportion of older adults certified as needing long-term care, long-term care benefit expenditure per recipient, and the availability of hospital beds for psychiatric and chronic care and end-of-life care support at home were associated with IMEP75.

Conclusion

To ameliorate the geographic variation in IMEP75 in Japan, the reallocation of healthcare resources across SMAs should be considered, and drivers of broader regional disparities need to be further explored. Moreover, healthcare systems for older adults must integrate an infrastructure of efficient long-term care and end-of-life care delivery outside hospitals to alleviate the burden on inpatient care.

Incidence of moral hazards among health care providers in the implementation of social health insurance toward universal health coverage: evidence from rural province hospitals in Indonesia

Objective

To identify the incidence of moral hazards among health care providers and its determinant factors in the implementation of national health insurance in Indonesia.

Methods

Data were derived from 360 inpatient medical records from six types C public and private hospitals in an Indonesian rural province. These data were accumulated from inpatient medical records from four major disciplines: medicine, surgery, obstetrics and gynecology, and pediatrics. The dependent variable was provider moral hazards, which included indicators of up-coding, readmission, and unnecessary admission. The independent variables are Physicians' characteristics (age, gender, and specialization), coders' characteristics (age, gender, education level, number of training, and length of service), and patients' characteristics (age, birth weight, length of stay, the discharge status, and the severity of patient's illness). We use logistic regression to investigate the determinants of moral hazard.

Results

We found that the incidences of possible unnecessary admissions, up-coding, and readmissions were 17.8%, 11.9%, and 2.8%, respectively. Senior physicians, medical specialists, coders with shorter lengths of service, and patients with longer lengths of stay had a significant relationship with the incidence of moral hazard.

Conclusion

Unnecessary admission is the most common form of a provider's moral hazard. The characteristics of physicians and coders significantly contribute to the incidence of moral hazard. Hospitals should implement reward and punishment systems for doctors and coders in order to control moral hazards among the providers.

Sexual lives of reproductive-aged people with disabilities in Central Sidama National Regional State, Ethiopia: a mixed-methods study

BACKGROUND

Sexuality is an important part of human life; people with disabilities have the same sexual desires as people without disabilities. However, the status of the sexual lives of reproductive-aged people with disabilities is unfolded in Ethiopia. Therefore, this study was aimed to assess sexual lives and its associated factors among reproductive-aged people with disabilities in central Sidama National Regional State, Ethiopia.

METHODS

A mixed-methods study was conducted among randomly selected 685 reproductive-age people with disabilities and fifteen (15) in-depth interviews among individuals who have sexual practice experience from June 20 to July 15, 2022. The quantitative data were collected through face-to-face interviewing techniques using a structured and semi-structured questionnaire. A multilevel logistic regression analysis model was employed to analyze the data. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to report the measures of associations. The qualitative data were managed and analyzed using the phenomenological research analysis approach.

RESULTS

In this study, 59.9% (95% CI: 56.1, 63.5) of the people with disabilities have practiced sexual intercourse. Of these, 30.8% (95% CI: 27.4, 34.4) were males and 29.1% (95% CI: 25.7, 32.6) were females with disabilities. Being female (AOR = 2.81; 95% CI: 1.70, 4.62), having an occupation (AOR = 7.55; 95% CI: 4.03, 14.1), having a disability and being in a wheelchair (AOR = 0.27; 95% CI: 0.09, 0.82), having a good self-perception (AOR = 0.46; 95% CI: 0.28, 0.77), and having a rich economic status (AOR = 2.05; 95% CI: 1.08, 3.89) were factors associated with the sexual practice. The qualitative findings revealed that having sexuality information (training) is the facilitator, and community discrimination and low economic income are the barriers to sexual practice.

CONCLUSION

Sexual practice among people with disabilities is low in the Dale and Wonsho districts and Yirgalem city administration. Socio-demographic and economic factors and sexuality training are the associated factors. Therefore, creating job opportunities and economic empowerment, providing sexuality training, and creating community awareness are crucial to improving the sexual practice of reproductive-age people with disabilities.

Individual and community-level factors associated with discrimination among women aged 15-49 years in Bangladesh: Evidence based on multiple indicator cluster survey

BACKGROUND

This research aimed to examine the factors at both the individual and community levels that are linked to discrimination experienced by women aged 15-49 in Bangladesh.

METHODS

The relevant data was taken from the 2019 Multiple Indicator Cluster Survey in Bangladesh. The risk factors for discrimination against women in Bangladesh were determined using multilevel logistic regression models.

RESULTS

The overall prevalence of discrimination against women was found to be 10.4% (95% CI: 10.1-10.6). Based on the final model (Model 1V), at the individual level higher odds of discrimination were observed among women from poor (AOR:1.21,95%CI: 1.12-1.32) and middle income households (AOR:1.12, 95%CI:1.02-1.22) compared to those from rich households etc. Women who have never used ICT were 1.27 times (AOR = 1.27, 95% CI = 1.07-1.51) higher odds of discrimination when compared with women who were ICT exposed. Respondents who married before 18 years 10% more likely to (AOR = 1.10, 95% CI:1.02-1.19) discriminated than women married aged 18 years old or above. Women from urban communities were 15% less likely to experience discrimination than their rural counterparts. In comparison to the Sylhet Division, women in the Barisal, Chattogram, Dhaka, Khulna Mymensingh, Rajshahi, and Rangpur Divisions were respectively 3.02, 1.84, 1.68, 2.06, 4.97, 4.06, and 1.74 times more likely to experience discrimination.

CONCLUSION

Findings revealed that various individual-level factors such as wealth index, CEB, ICT exposure, marital status, functional difficulty, age, women's happiness, magazine and radio exposure, age at marriage, current contraceptive use, polygamy, husband beating, place of attack, and household head age were found to have a significant association with women discrimination. Community-level factors such as residence and division were also found to have a notable impact on discrimination. Policymakers should incorporate substantial components targeting both individual and community levels into intervention programs with the goal of raising awareness about women's discrimination.

Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery

BACKGROUND

Hemorrhage control surgery is an essential trauma center function. Airway management of the unstable bleeding patient in the emergency department (ED) presents a challenge. Premature intubation in the ED can exacerbate shock and precipitate extremis. We hypothesized that ED versus operating room intubation of patients requiring urgent hemorrhage control surgery is associated with adverse outcomes at the patient and hospital-levels.

METHODS

Patients who underwent hemorrhage control within 60 minutes of arrival at level 1 or 2 trauma centers were identified (National Trauma Data Bank 2017-2019). To minimize confounding, patients dead on arrival, undergoing ED thoracotomy, or with clinical indications for intubation (severe head/neck/face injury or Glasgow Coma Scale score of ≤8) were excluded. Two analytic approaches were used. First, hierarchical logistic regression measured the risk-adjusted association between ED intubation and mortality. Secondary outcomes included ED dwell time, units of blood transfused, and major complications (cardiac arrest, acute respiratory distress syndrome, acute kidney injury, sepsis). Second, a hospital-level analysis determined whether hospital tendency ED intubation was associated with adverse outcomes.

RESULTS

We identified 9,667 patients who underwent hemorrhage control surgery at 253 trauma centers. Patients were predominantly young men (median age, 33 years) who suffered penetrating injuries (71%). The median initial Glasgow Coma Scale and systolic blood pressure were 15 and 108 mm Hg, respectively. One in five (20%) of patients underwent ED intubation. After risk-adjustment, ED intubation was associated with significantly increased odds of mortality, longer ED dwell time, greater blood transfusion, and major complications. Hospital-level analysis identified significant variation in use of ED intubation between hospitals not explained by patient case mix. After risk adjustment, patients treated at hospitals with high tendency for ED intubation (compared with those with low tendency) were significantly more likely to suffer in-hospital cardiac arrest (6% vs. 4%; adjusted odds ratio, 1.46; 95% confidence interval, 1.04-2.03).

CONCLUSION

Emergency department intubation of patients who require urgent hemorrhage control surgery is associated with adverse outcomes. Significant variation in ED intubation exists between trauma centers not explained by patient characteristics. Where feasible, intubation should be deferred in favor of rapid resuscitation and transport to the operating room.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Hospital-level variation in practices and outcomes for patients with severe acute exacerbations of idiopathic pulmonary fibrosis: a retrospective multicentre cohort study

BACKGROUND

In the absence of evidence-based strategies to improve patient outcomes, the management of patients with severe idiopathic pulmonary fibrosis (IPF) exacerbations may vary widely across centres. We assessed between-hospital variation in practices and mortality for patients with severe IPF exacerbations.

METHODS

Using the Premier Healthcare Database from 1 October 2015 to 31 December 2020, we identified patients admitted to intensive care unit (ICU) or intermediate care unit with an IPF exacerbation. We assessed idiosyncratic, between-hospital variation in ICU practices (invasive mechanical ventilation (IMV), non-invasive mechanical ventilation (NIMV), corticosteroid use, and immunosuppressive and/or antioxidant use) and hospital mortality by determining median risk-adjusted hospital rates and intraclass correlation coefficients (ICCs) from hierarchical multivariable regression models. A priori, an ICC>15% was deemed 'high variation'.

RESULTS

We identified 5256 critically ill patients with a severe IPF exacerbation at 385 US hospitals. Hospital median risk-adjusted rates of practices were: IMV (14% (IQR: 8.3%-26%)), NIMV (42% (31%-54%)), corticosteroid use (89% (84%-93%)), and immunosuppressive and/or antioxidant use (3.3% (1.9%-5.8%)). Model ICCs were: IMV (19% (95% CI: 18% to 21%)), NIMV (15% (13% to 16%)), corticosteroid use (9.8% (8.3% to 11%)), and immunosuppressive and/or antioxidant use (8.5% (7.1% to 9.9%)). The median risk-adjusted hospital mortality was 16% (IQR: 11%-24%) with an ICC of 7.5% (95% CI: 6.2% to 8.9%).

INTERPRETATION

We observed high variation in the use of IMV and NIMV, and less variation in corticosteroid and immunosuppressant and/or antioxidant use among patients hospitalised with severe IPF exacerbations. Further research is needed to guide the decisions surrounding initiation of IMV and role of NIMV and to understand the effectiveness of corticosteroids among patients with severe IPF exacerbations.

Does the place of residence influence your risk of being hypertensive? A study-based on Nepal Demographic and Health Survey

Even though several studies have examined various risk factors for hypertension, residential influence is poorly explored especially in the low-income countries. We aim to investigate the association between residential characteristics and hypertension in resource limited and transitional settings like Nepal. A total of 14,652 individuals aged 15 and above were selected from 2016-Nepal Demographic and Health Survey. Individuals with blood pressure ≥140/90 mmHg or a history of hypertension (as identified by physicians/health professionals) or under antihypertensive medication were defined as hypertensive. Residential characteristics were represented by area level deprivation index, with a higher score representing higher level of deprivation. Association was explored using a two-level logistic regression. We also assessed if residential area modifies the association between individual socio-economic status and hypertension. Area deprivation had a significant inverse association with the risk of hypertension. Individuals from the least deprived areas had higher odds of hypertension compared to highly deprived areas 1.59 (95% CI 1.30, 1.89). Additionally, the association between literacy a proxy of socio-economic status and hypertension varied with a place of residence. Literate individuals from highly deprived areas were likely to have a higher odds of hypertension compared to those with no formal education. In contrast, literate from the least deprived areas had lower odds of hypertension. These results identify counterintuitive patterns of associations between residential characteristics and hypertension in Nepal, as compared with most of the epidemiological data from high-income countries. Differential stages of demographic and nutritional transitions between and within the countries might explain these associations.

Individual and Family Determinants for Quality of Life in Parents of Children with Inborn Errors of Metabolism Requiring a Restricted Diet: A Multilevel Analysis Approach

OBJECTIVE

The objective of this study was to compare the quality of life (QoL) for parents of children with inborn errors of metabolism (IEMs) requiring a restricted diet with French population norms and investigate parental QoL determinants.

STUDY DESIGN

This cross-sectional study included mothers and/or fathers of children < 18 years of age affected by IEMs requiring a restricted diet (except phenylketonuria) from January 2015 to December 2017. Parents' QoL was assessed using the World Health Organization Quality of Life BREF questionnaire and compared with age- and sex-matched reference values from the French general population. Linear mixed models were used to examine the effects of demographic, socioeconomic, disease-related, and psychocognitive factors on parental QoL, according to a 2-level regression model considering individuals (parents) nested within families.

RESULTS

Of the 1156 parents invited to participate, 785 (68%) were included. Compared with the general population, parents of children with IEMs requiring a restricted diet reported a lower QoL in physical and social relationship domains but a higher QoL in the psychological domain. In the multivariate analysis, characteristics associated with poorer parental QoL included both parent-related factors (being a father, older age, more educated parent, nonworking parent, greater anxiety, seeking more social support, and using less positive thinking and problem-solving coping strategies) and family-related factors (disease complications, increased number of hospital medical providers, child's younger age, single-parent family, and lower family material wealth).

CONCLUSION

Parents of children with IEMs requiring a restricted diet reported poorer QoL in physical and social relationship domains than population norms. Psychocognitive factors, beyond disease-specific and family-related characteristics, were the most important determinants influencing parental QoL and may represent essential aspects for interventions.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02552784.

Regional Patterns of Hospital-Level Guideline Adherence in Gastric Cancer: An Analysis of the National Cancer Database

BACKGROUND

Adherence to evidence-based guidelines for gastric cancer is low, particularly at the hospital level, despite a strong association with improved overall survival (OS). We aimed to evaluate patterns of hospital and regional adherence to National Comprehensive Cancer Network guidelines for gastric cancer.

METHODS

Using the National Cancer Database (2004-2015), we identified patients with stage I-III gastric cancer. Hospital-level guideline adherence was calculated by dividing the patients who received guideline adherent care by the total patients treated at that hospital. OS was estimated for each hospital. Associations between adherence, region, and survival were compared using mixed-effects, hierarchical regression.

RESULTS

Among 576 hospitals, the median hospital guideline adherence rate was 25% (range 0-76%) and varied significantly by region (p = 0.001). Adherence was highest in the Middle Atlantic (29%) and lowest in the East South Central region (19%); hospitals in the New England, Middle Atlantic, and East North Central regions were more likely to be guideline adherent than those in the East South Central region (all p < 0.05), after adjusting for patient and hospital mix. Most (35%) of the adherence variation was attributable to the hospital. Median 2-year OS varied significantly by region. After adjusting for hospital and patient mix, hazard of mortality was 17% lower in the Middle Atlantic (hazard ratio 0.82, 95% confidence interval 0.74-0.90) relative to the East South Central region, with most of the variation (54%) attributable to patient-level factors.

CONCLUSIONS

Hospital-level guideline adherence for gastric cancer demonstrated significant regional variation and was associated with longer OS, suggesting that efforts to improve guideline adherence should be directed toward lower-performing hospitals.

Gestational Age, Socioeconomic Context and Infection-Related Hospital Admissions of Infants Born With Gestational Age Less Than 33 Weeks

Using data from a regional medical follow-up network database of preterm infants born with gestational age (GA) <33 weeks, we found that low GA and deprived socioeconomic neighborhoods increased incidence of infection-related hospitalization during the first year of life. Respiratory tract infections rates were higher in extremely preterm infants.

Multilevel analysis of individual- and community-level determinants of birth certification of children under-5 years in Nigeria: evidence from a household survey

Promoting birth certification is central to achieving legal identity for all - target 16.9 of the 2030 Sustainable Development Goals. Nigeria is not on track to achieve this goal with its low coverage of birth certification (BC). This study is aimed at identifying patterns of BC and its associated individual- and community-level factors, using pooled cross-sectional data from three rounds (2008, 2013, and 2018) of the nationally representative Nigerian Demographic and Health Survey. A weighted sample of 66,630 children aged 0–4 years was included, and a two-level multilevel logistic model which accommodates the hierarchical nature of the data was employed. Of the total sample, 17.1% [95% CI: 16.3–17.9] were reported to be certified. Zamfara state (2.3, 95% CI: 0.93–3.73) and the Federal Capital Territory (36.24, 95% CI: 31.16–41.31) reported the lowest and the highest BC rates. Children with an SBA [AOR = 1.283, 95% CI: 1.164–1.413] and with at least one vaccination [AOR = 1.494, 95% CI: 1.328–1.681] had higher odds of BC. The AOR for mothers with at least one prenatal visit was 1.468 [95% CI: 1.271–1.695], and those aged 30–34 years at the time of birth [AOR = 1.479, 95% CI: 1.236–1.772] had the highest odds. Further, the odds of BC increased the most for mothers [AOR = 1.559, 95% CI: 1.329–1.829] and fathers [AOR = 1.394, 95% CI: 1.211–1.605] who were tertiary-educated. In addition, children in middle-income [AOR = 1.430, 95% CI: 1.197–1.707] or rich wealth HHs [AOR = 1.776, 95% CI: 1.455–2.169] or those whose families had bank accounts [AOR = 1.315, 95% CI: 1.187–1.456] had higher odds. Living in non-poor and within close proximity to a registration center (RC) act as protective factors for BC, while living in poor communities [AOR = 0.613, 95% CI: 0.486–0.774] and more than 10kms from an RC reduce the odds of BC [AOR = 0.466, 95% CI: 0.377–0.576]. The study identified several protective and risk factors which policymakers can adopt as strategic areas for universal birth certification. National and sub-national programs should integrate non-formal institutions as well as target child and maternal utilization of healthcare services to promote BC in Nigeria.

Spatial and hierarchical Bayesian analysis to identify factors associated with caesarean delivery use in Ethiopia: Evidence from national population and health facility data

BACKGROUND

Caesarean section has a significant role in reducing maternal and neonatal mortality. A linked analysis of population and health facility data is valuable to map and identify caesarean section use and associated factors. This study aimed to identify geographic variation and associated factors of caesarean delivery in Ethiopia.

METHOD

Linked data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) and the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey was performed. Spatial analysis was conducted to identify geographic variations and factors associated with caesarean delivery. Hierarchical Bayesian analysis was also performed to identify factors associated with caesarean delivery using the SAS MCMC procedure.

RESULTS

Women's age and education, household wealth, parity, antenatal care (ANC) visits, and distance to caesarean section facility were associated with caesarean delivery use. Women who had ≥4 ANC visits were 4.67 (95% Credible Interval (CrI): 2.17, 9.43) times more likely to have caesarean delivery compared to those who had no ANC visits. Women who had education and were from rich households were also 2.80 (95% CrI: 1.83, 4.19) and 1.80 (95% CrI: 1.08, 2.84) times more likely to have caesarean deliveries relative to women who had no education and were from poor households, respectively. A one-kilometer increase in distance to a caesarean section facility was associated with an 88% reduction in the odds of caesarean delivery (Adjusted Odds Ratio (AOR) = 0.12, 95% CrI: 0.01, 0.78). Hotspots of high caesarean section rates were observed in Addis Ababa, Dire Dawa, and the Harari region. In addition, women's age at first childbirth and ≥4 ANC visits showed significant spatially varying relations between caesarean delivery use across Ethiopia.

CONCLUSION

Caesarean section is a lifesaving procedure, and it is essential to narrow disparities to reduce maternal and neonatal mortality and avoid unnecessary procedures.

Multilevel analysis of factors associated with perinatal intimate partner violence among postpartum population in Southern Ethiopia

Violence around pregnancy is critical in nature and major public health problem worldwide. Thus, the present study aims to determine the extent of perinatal partner violence and to identify its individual and community-level factors among postpartum women in Southern Ethiopia. A total of 1342 postpartum women nested in 38 'Kebles' (clusters) were enumerated using multistage-clustered sampling techniques for multilevel analysis. Different parameters were computed for model comparison and model fitness. The overall prevalence of intimate partner violence before, during, and/or after pregnancy was estimated to be 39.9% [95% CI 36.9-44.5]. About 18% of women reported continuous abuse over the perinatal period. Postpartum women who live in rural areas [adjusted odds ratio (AOR) = 2.46; 95% CI 1.21-5.01], or in neighborhoods with high IPV favoring norms [AOR = 1.49; 95%CI 1.01-2.20], high female literacy [AOR = 2.84; 95%CI 1.62-5.01], high female autonomy [AOR = 2.06; 95%CI 1.36-3.12], or in neighborhoods with lower wealth status [AOR = 1.74; 95%CI 1.14-2.66] were more likely to encounter PIPV. The complex patterns of interplaying factors operating at different levels could put pregnant or postpartum women at higher risk of IPV victimization. Therefore, policies that prioritize the improvement of contextual factors, particularly norms toward IPV and women's empowerment are likely to be the most effective interventions.

Association Between Geospatial Access to Care and Firearm Injury Mortality in Philadelphia

Importance

The burden of firearm violence in US cities continues to rise. The role of access to trauma center care as a trauma system measure with implications for firearm injury mortality has not been comprehensively evaluated.

Objective

To evaluate the association between geospatial access to care and firearm injury mortality in an urban trauma system.

Design, Setting, and Participants

Retrospective cohort study of all people 15 years and older shot due to interpersonal violence in Philadelphia, Pennsylvania, between January 1, 2015, and August 9, 2021.

Exposures

Geospatial access to care, defined as the predicted ground transport time to the nearest trauma center for each person shot, derived by geospatial network analysis.

Main Outcomes and Measures

Risk-adjusted mortality estimated using hierarchical logistic regression. The population attributable fraction was used to estimate the proportion of fatalities attributable to disparities in geospatial access to care.

Results

During the study period, 10 105 people (910 [9%] female and 9195 [91%] male; median [IQR] age, 26 [21-28] years; 8441 [84%] Black, 1596 [16%] White, and 68 other [<1%], including Asian and unknown, consolidated owing to small numbers) were shot due to interpersonal violence in Philadelphia. Of these, 1999 (20%) died. The median (IQR) predicted transport time was 5.6 (3.8-7.2) minutes. After risk adjustment, each additional minute of predicted ground transport time was associated with an increase in odds of mortality (odds ratio [OR], 1.03 per minute; 95% CI, 1.01-1.05). Calculation of the population attributable fraction using mortality rate ratios for incremental 1-minute increases in predicted ground transport time estimated that 23% of shooting fatalities could be attributed to differences in access to care, equivalent to 455 deaths over the study period.

Conclusions and Relevance

These findings indicate that geospatial access to care may be an important trauma system measure, improvements to which may result in reduced deaths from gun violence in US cities.

Use of failure-to-rescue after emergency surgery as a dynamic indicator of hospital resilience during the COVID-19 pandemic. A multicenter retrospective propensity score-matched cohort study

Background

Surgical failure-to-rescue (FTR, death rate following complications) is a reliable cross-sectional quality of care marker, but has not been evaluated dynamically. We aimed to study changes in FTR following emergency surgery during the COVID-19 pandemic.

Material and methods

Matched cohort study including all COVID-19-non-infected adult patients undergoing emergency general surgery in 25 Spanish hospitals during COVID-19 pandemic peak (March–April 2020), non-peak (May–June 2020), and 2019 control periods. A propensity score-matched comparative analysis was conducted using a logistic regression model, in which period was regressed on observed baseline characteristics. Subsequently, a mixed effects logistic regression model was constructed for each variable of interest. Main variable was FTR. Secondary variables were post-operative complications, readmissions, reinterventions, and length of stay.

Results

5003 patients were included (948, 1108, and 2947 in the pandemic peak, non-peak, and control periods), with comparable clinical characteristics, prognostic scores, complications, reintervention, rehospitalization rates, and length of stay across periods. FTR was greater during the pandemic peak than during non-peak and pre-pandemic periods (22.5% vs. 17.2% and 12.7%), being this difference confirmed in adjusted analysis (odds ratio [OR] 2.13, 95% confidence interval [95% CI] 1.27–3.66). There was sensible inter-hospital variability in FTR changes during the pandemic peak (median FTR change +8.77%, IQR 0–29.17%) not observed during the pandemic non-peak period (median FTR change 0%, IQR -6.01−6.72%). Greater FTR increase was associated with higher COVID-19 incidence (OR 2.31, 95% CI 1.31–4.16) and some hospital characteristics, including tertiary level (OR 3.07, 95% CI 1.27–8.00), medium-volume (OR 2.79, 95% CI 1.14–7.34), and high basal-adjusted complication risk (OR 2.21, 95% CI 1.07–4.72).

Conclusion

FTR following emergency surgery experienced a heterogeneous increase during different periods of the COVID-19 pandemic, suggesting it to behave as an indicator of hospital resilience. FTR monitoring could facilitate identification of centres in special needs during ongoing health care challenges.

What Drives Abdominal Obesity in Peru? A Multilevel Analysis Approach Using a Nationally Representative Survey

Abdominal obesity (AO) is a serious public health threat due to its increasing prevalence and effect on the development of various non-communicable diseases. A multilevel analysis of the 2019 Demographic and Family Health Survey (ENDES in Spanish) using the Latin American Diabetes Association (ALAD in Spanish) cut-off points was carried out to evaluate the individual and contextual factors associated with AO in Peru. A total of 30,585 individuals 18 years and older were included in the analysis. The prevalence of AO among Peruvians in 2019 was 56.5%. Individuals of older age (aOR 4.64; 95% CI: 3.95-5.45), women (aOR 2.74; 95% CI: 2.33-3.23), individuals with a higher wealth index (aOR 2.81; 95% CI: 2.40-3.30) and having only secondary education (aOR 1.45; 95% CI: 1.21-1.75) showed increased odds of presenting AO compared to their peers. At a contextual level, only the Human Development Index (aOR 1.59; 95% CI: 1.17-2.16) was associated with the development of AO. A high Human Development Index is the contextual factor most associated with AO. It is necessary to formulate and implement new public health policies focused on these associated factors in order to reduce the prevalence of OA and prevent the excessive burden of associated noncommunicable diseases.

Intervening at the Right Level to Improve Student Health: An Analysis of Levels of Influence on Sexual Behavior of High School Students

This study adopts a socio-ecological framework and examines school- and district-level influences on sexual behaviors among high school students from 16 school districts that were federally funded to conduct a school-based, multilevel sexual health program. We drew cross-sectional data from the 2015 and 2017 Youth Risk Behavior Survey from funded school districts containing 648 schools and 101,728 students. We used multilevel modeling to determine the percentage of variance in sexual health outcomes explained at school and district levels, overall and by race/ethnicity and biological sex. We found protective behaviors such as using hormonal birth control had considerable district-level variance (10.1%) while sexual risk behaviors such as having multiple sex partners showed considerable school-level variance (12.7%). We also found significant subgroup heterogeneity in the variance. Findings indicate school-based interventions should address all levels of influences of the educational system to effectively improve a myriad of student sexual health outcomes.

Household Air Pollution from Cooking Fuels Increases the Risk of Under-Fives Acute Respiratory Infection: Evidence from Population-Based Cross-Sectional Surveys in Tanzania

Background and Aims:

Increased risk of acute respiratory infection (ARI) in children has been linked with exposure to household air pollution (HAP) from solid biomass fuels. However, information is limited on the trend use of biomass fuels and their association with ARI among children in Tanzania. The current study analysed nationally representative data from the Tanzania Demographic Health Surveys of the years 2004, 2010, and 2015–16 to explore the prevalence of the trend of cooking fuels and ARI as well as ascertain their association among under-fives.

Methods:

A total sample of 20,323 under-fives were included in the current analysis. A mixed-effects multilevel logistic regression was fitted to assess the association between unclean fuels (solid biomass fuels and kerosene) and ARI among under-fives.

Results:

The use of solid biomass fuels has remained persistent high (98.6%) while ARI among under-fives has declined from 16% in 2004 to 9% in 2016; p < 0.001. Furthermore, under-fives exposed to unclean fuel combustion had a significantly higher incidence of ARI (AOR = 3.47; 95% CI, 1.31–9.21).

Conclusion:

Efforts should be made to switch to alternative sources of clean energy such as natural gas and biogas in Tanzania and other countries with similar settings.

Explaining regional variation in elective hip and knee arthroplasties in Finland 2010 - 2017-a register-based cohort study

Background

A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need.

Methods

We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models – individuals and hospital regions – were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 − 2013 and 2014 − 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios.

Results

We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 − 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 − 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 − 2013, but only 5% in 2014 − 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially.

Conclusions

Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08305-7.

Correlates of Zero-Dose Vaccination Status among Children Aged 12–59 Months in Sub-Saharan Africa: A Multilevel Analysis of Individual and Contextual Factors

Despite ongoing efforts to improve childhood vaccination coverage, including in hard-to-reach and hard-to-vaccinate communities, many children in sub-Saharan Africa (SSA) remain unvaccinated. Considering recent goals set by the Immunization Agenda 2030 (IA2030), including reducing the number of zero-dose children by half, research that goes beyond coverage to identify populations and groups at greater risk of being unvaccinated is urgently needed. This is a pooled cross-sectional study of individual- and country-level data obtained from Demographic and Health Surveys Program and two open data repositories. The sample includes 43,131 children aged 12–59 months sampled between 2010 and 2020 in 33 SSA countries. Associations of zero-dose status with individual and contextual factors were assessed using multilevel logistic regression. 16.5% of children had not received any vaccines. Individual level factors associated lower odds of zero-dose status included mother’s primary school or high school education, employment, use of antenatal care services and household wealth. Compared to children in countries with lower GDP, children in countries with relatively high GDP had nearly four times greater odds of being unvaccinated. Both individual and contextual factors are correlated with zero-dose status in SSA. Our results can inform efforts to identify and reach children who have not received any vaccines.

Effects of social determinants on children's health in informal settlements in Bangladesh and Kenya through an intersectionality lens: a study protocol

INTRODUCTION

Several studies have shown that residents of urban informal settlements/slums are usually excluded and marginalised from formal social systems and structures of power leading to disproportionally worse health outcomes compared to other urban dwellers. To promote health equity for slum dwellers, requires an understanding of how their lived realities shape inequities especially for young children 0-4 years old (ie, under-fives) who tend to have a higher mortality compared with non-slum children. In these proposed studies, we aim to examine how key Social Determinants of Health (SDoH) factors at child and household levels combine to affect under-five health conditions, who live in slums in Bangladesh and Kenya through an intersectionality lens.

METHODS AND ANALYSIS

The protocol describes how we will analyse data from the Nairobi Cross-sectional Slum Survey (NCSS 2012) for Kenya and the Urban Health Survey (UHS 2013) for Bangladesh to explore how SDoH influence under-five health outcomes in slums within an intersectionality framework. The NCSS 2012 and UHS 2013 samples will consist of 2199 and 3173 under-fives, respectively. We will apply Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy approach. Some of SDoH characteristics to be considered will include those of children, head of household, mothers and social structure characteristics of household. The primary outcomes will be whether a child had diarrhoea, cough, fever and acute respiratory infection (ARI) 2 weeks preceding surveys.

ETHICS AND DISSEMINATION

The results will be disseminated in international peer-reviewed journals and presented in events organised by the Accountability and Responsiveness in Informal Settlements for Equity consortium and international conferences. Ethical approval was not required for these studies. Access to the NCSS 2012 has been given by Africa Population and Health Center and UHS 2013 is freely available.

Multilevel Understanding of the Impact of Individual- and School-Level Determinants on Lipid Profiles in Adolescents: The Cross-Level Interaction of Food Environment and Body Mass Index

Adolescents with comparable personal risk factors may have different lipid profiles because of the school’s context. Lipid determinants in adolescents should be considered using a multilevel perspective. This multilevel study investigated the effects of individual-level and school-level factors on lipid profiles in adolescents and evaluated the cross-level influence of lipid determinants. A representative adolescent cohort (n = 2727) was randomly selected from 36 schools in three diverse economic areas in Taiwan and assessed for their personal dietary patterns, physical parameters, and lipid profiles. For individual-level factors, both low physical activity and high body mass index (BMI) were associated with elevated triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC) levels, and a sugar-sweetened beverage intake of >500 mL/day was associated with increases of 5.97 and 6.12 mg/dL in LDL-C and TC levels, respectively, compared with abstinence. Regarding school-level factors, students in schools with ≥2 health promotion programs per year had a 5.27 mg/dL lower level of LDL-C than those in schools with 0−1 program, and students in schools with ≥46 food outlets within 600 m of the school had 6.90 and 13.3 mg/dL higher levels of TG and TC, respectively, than those in schools with <46 food outlets. School context modified the individual-level positive correlation between BMI and TG level (the p-value for the random-slope effect was 0.003). In conclusion, individual-level and school-level factors exert a multilevel effect on adolescent lipid profiles. The food environment near the school has a stronger cross-level impact on individual TG levels in adolescents with a high BMI than in those with a normal BMI.

Multilevel Analysis of Individual and Neighborhood Characteristics Associated with Viral Suppression Among Adults with HIV in Rio de Janeiro, Brazil

Understanding the impact of neighborhood context on viral suppression outcomes may help explain health disparities and identify future interventions. We assessed the relationship between individual characteristics, neighborhood socioeconomic context, and viral suppression using multilevel logistic regression models. Adults with HIV initiating antiretroviral therapy (ART) between 2000 and 2017, who resided in Rio de Janeiro and had an HIV-1 RNA level (viral load) measured 90-270 days after ART initiation were included. Overall, 83.9% achieved viral suppression. Participants who were older, had a higher level of education, and identified as heterosexual cisgender men and cisgender men-who-have-sex-with-men had increased odds of viral suppression. Later calendar year of ART initiation carried the strongest association with viral suppression, reflecting the increased effectiveness and tolerability of ART over time. Neighborhood socioeconomic indicators did not predict viral suppression in unadjusted or adjusted analyses, which may result from the integrated care provided in our health care facility together with Brazil's universal treatment.

Magnitude and factors associated with intimate partner violence against pregnant women in Ethiopia: a multilevel analysis of 2016 Ethiopian demographic and health survey

Background

Intimate partner violence (IPV) is defined as acts of physical aggression, sexual coercion, psychological/emotional abuse, or controlling behaviors by a current or former partner or spouse. IPV has a special concern for pregnant women since it leads to higher rates of miscarriage, several complications including adverse birth outcomes. So far, the effect of contextual factors on IPV was largely overlooked. Therefore, this study aimed to assess the magnitude and factors associated with IPV among pregnant women in Ethiopia.

Method

Data from the 2016 Ethiopian Demographic and Health Survey was used for this study. A total of 4167 (weighted sample) pregnant women were included in the analysis. The multi-level logistic regression model was fitted to identify factors associated with IPV. Finally, the adjusted odds ratio (AOR) with 95% CI and random effects for the multilevel logistic regression model was reported.

Results

In this study, the overall magnitude of IPV among pregnant women was 28.74 (95% CI 27.38, 30.13) with emotional violence being the most common (24.09%) type. In the multi-level analysis, women with no education (AOR = 2.07; 95%CI 1.23, 3.48), primary education (AOR = 2.04; 95%CI:1.24, 3.38), and secondary education (AOR = 1.53; 95%CI:1.29.2.62), women from households with poorest (AOR = 1.72; 95%CI: 1.16, 2.56), poorer (AOR = 1.62;95% CI:1.09, 2.41), middle (AOR = 1.74;95%CI:1.17, 2.56), and richer (AOR = 1.58;95%CI: 1.08, 2.33) wealth index, women aged 35–39 years (AOR = 1.28;95%CI:1.01, 1.63) and 40–49 years (AOR = 1.78;95%CI:1.28, 2.45) and those from pastoral (AOR = 1.47;95%CI:1.04, 1.93) and agrarian regions (AOR = 1.32;95%CI 1.02, 1.88) had a higher likelihood of having IPV. Of the partner-related factors, women with husbands who drink alcohol (AOR = 2.94; 95%CI: 2.36, 3.42) and secondary educational level (AOR = 1.47; 95%CI 1.02, 2.12) had higher odds of experiencing IPV during pregnancy.

Conclusion

Intimate partner violence during pregnancy is a public health problem in Ethiopia. Therefore, improving the educational status of women and their husbands, improving the economic capacity of women, and promoting the healthy behavior of husbands by reducing the alcohol consumption in those agrarian and pastoral regions of Ethiopia is vital to reduce the magnitude of IPV.

Geographic variation in caesarean delivery in India

BACKGROUND

The rate of caesarean delivery has increased markedly both globally and within India. However, there is considerable variation within countries. No previous studies have examined the relative importance of multiple geographic levels in shaping the distribution of caesarean delivery and to what extent they can be explained by individual-level risk factors.

OBJECTIVES

To describe geographic variation in caesarean delivery and quantify the contribution of individual-level risk factors to the variation in India.

METHODS

We conducted four-level logistic regression analysis to partition total variation in caesarean delivery to three geographic levels (states, districts and communities) and quantify the extent to which variance at each level was explained by a set of 20 sociodemographic, medical and institutional risk factors. Stratified analyses were conducted by the type of delivery facility (public/private).

RESULTS

Overall prevalence of caesarean delivery was 19.3% in India in 2016. Most geographic variation was attributable to states (44%), followed by communities (32%), and lastly districts (24%). Adjustment for all risk factors explained 44%, 52% and 46% of variance for states, districts and communities, respectively. The proportion explained by individual risk factors was larger in public facilities than in private facilities at all three levels. A substantial proportion of between-population variation still existed even after clustering of individual risk factors was comprehensively adjusted for.

CONCLUSIONS

Diverse contextual factors driving high or low rate of caesarean delivery at each geographic level should be explored in future studies so that tailored intervention can be implemented to reduce the overall variation in caesarean delivery.

Minimum dietary diversity and its associated factors among infants and young children in Ethiopia: evidence from Ethiopian Demographic and Health Survey (2016)

Background

Adequate infant and young child feeding during the first 1000 days of life is very essential to improve child health, survival, growth, and development through minimum dietary diversity (MDD). Hence, this study aimed to assess MDD and its multi-level factors among infants and young children aged 6–23 months in Ethiopia.

Methods

Ethiopian Demographic and Health Survey (EDHS-2016) data was used to identify both individual and community-level factors of dietary diversity. Weighted samples of 2,962 children were eligible and a multi-level regression model was used for the analysis. Finally, factors with a P-value of <0.05 were considered statistically significant.

Results

The prevalence of MDD among children in Ethiopia was 12.09%. According to this study, factors such as having a mother who attended higher education (AOR = 3.09, (95% CI; _1.67–5.71)), being a female household head (AOR = 0.62, (95% CI; _0.40–0.95)), having a mother's agricultural occupation (AOR = 1.89, (95% CI; _1.10–3.23)) and living in the household in the richest wealth index were significantly associated at the individual level. At the community level, children living in rural areas (AOR = 0.62, 95% CI; 0.39–0.98) were significant risk factors for MDD (AOR = 0.62, 95% CI; 0.39–0.98).

Conclusion

The educational and occupational status of the mother, wealth index, and region were significantly associated with MDD. Hence, strengthening of the existing nutritional intervention is helpful to increase diversified food consumption among children.

User satisfaction with the secondary dental care services: Is there an association between structure and work process?

OBJECTIVE

To assess the association between user satisfaction in relation to secondary dental care services and the structure and process of Brazilian Dental Specialty Centers (CEO, in Portuguese).

METHODS

This study used nationwide secondary data from two CEO evaluation cycles. Ten users from each CEO answered questions on the self-perception of healthcare quality and satisfaction with health services. Latent class analysis (LCA) was performed to identify subgroups of satisfied and dissatisfied users (outcome). The CEO structure included equipment, supplies, instruments, ambience and type of CEO (type I, II or III, according to the number of dental chairs and dental professionals). The work process referred to the planning/monitoring of actions, collaborative care, characteristics of the demand for medical care /the organization of scheduling, and continuing education for employees. Covariables concerned user profiles. A multilevel logistic regression model was used (p-value <.05).

RESULTS

Seven thousand nine hundred and ninety-seven users in 794 CEOs, together with 10056 users in 911 CEOs, participated in the 1st and 2nd evaluation cycles, and satisfied users corresponded to 85.3% and 87.1%, respectively. In both cycles, the CEO's structural characteristics explained most of the variance in satisfaction. CEOs with more favourable structural characteristics showed higher satisfaction. Users from CEOs, type II and III, and those who received dental care where there was an interruption of services due to a lack of equipment or instruments reported a lower level of satisfaction. CEOs that organize their demand through referrals received from primary care dentists who have participated in continuing education actions for dental professionals presented a higher frequency of satisfied users.

CONCLUSIONS

Characteristics of the process and structure were associated with user satisfaction, but a quality of care was perceived by users, mainly due to structural characteristics.

Hospital Variation in Time to Endovascular Treatment for Ischemic Stroke: What Is the Optimal Target for Improvement?

Background

Time to reperfusion in patients with ischemic stroke is strongly associated with functional outcome and may differ between hospitals and between patients within hospitals. Improvement in time to reperfusion can be guided by between‐hospital and within‐hospital comparisons and requires insight in specific targets for improvement. We aimed to quantify the variation in door‐to‐reperfusion time between and within Dutch intervention hospitals and to assess the contribution of different time intervals to this variation.

Methods and Results

We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. The door‐to‐reperfusion time was subdivided into time intervals, separately for direct patients (door‐to‐computed tomography, computed tomography‐to‐computed tomography angiography [CTA], CTA‐to‐groin, and groin‐to‐reperfusion times) and for transferred patients (door‐to‐groin and groin‐to‐reperfusion times). We used linear mixed models to distinguish the variation in door‐to‐reperfusion time between hospitals and between patients. The proportional change in variance was used to estimate the amount of variance explained by each time interval. We included 2855 patients of 17 hospitals providing endovascular treatment. Of these patients, 44% arrived directly at an endovascular treatment hospital. The between‐hospital variation in door‐to‐reperfusion time was 9%, and the within‐hospital variation was 91%. The contribution of case‐mix variables on the variation in door‐to‐reperfusion time was marginal (2%–7%). Of the between‐hospital variation, CTA‐to‐groin time explained 83%, whereas groin‐to‐reperfusion time explained 15%. Within‐hospital variation was mostly explained by CTA‐to‐groin time (33%) and groin‐to‐reperfusion time (42%). Similar results were found for transferred patients.

Conclusions

Door‐to‐reperfusion time varies between, but even more within, hospitals providing endovascular treatment for ischemic stroke. Quality of stroke care improvements should not only be guided by between‐hospital comparisons, but also aim to reduce variation between patients within a hospital, and should specifically focus on CTA‐to‐groin time and groin‐to‐reperfusion time.

Association of Venous Thromboembolism Prophylaxis After Neurosurgical Intervention for Traumatic Brain Injury With Thromboembolic Complications, Repeated Neurosurgery, and Mortality

Importance

There is a lack of evidence regarding the effectiveness and safety of pharmacologic venous thromboembolism (VTE) prophylaxis among patients who undergo neurosurgical interventions for traumatic brain injury (TBI).

Objective

To measure the association between timing of VTE prophylaxis after urgent neurosurgical intervention for TBI and thromboembolic and intracranial complications.

Design, Setting, and Participants

This retrospective cohort study included adult patients (aged ≥16 years) who underwent urgent neurosurgical interventions (craniotomy/craniectomy or intracranial monitor/drain insertion within 24 hours after admission) for TBI at level 1 and 2 trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program between January 1, 2012, and December 31, 2016. Data were analyzed from January to August 2020.

Exposures

Timing of pharmacologic VTE prophylaxis initiation after urgent neurosurgical intervention (prophylaxis delay) measured in days (24-hour periods).

Main Outcomes and Measures

The primary outcome was VTE (deep vein thrombosis or pulmonary embolism). Secondary outcomes were repeated neurosurgery (neurosurgical reintervention after initiation of VTE prophylaxis) and mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis delay and each outcome at the patient level and were adjusted for patient baseline and injury characteristics.

Results

The study included 4951 patients (3676 [74%] male; median age, 50 years [IQR, 31-64 years]) who underwent urgent neurosurgical intervention for TBI at 304 trauma centers. The median prophylaxis delay was 3 days (IQR, 1-5 days). After adjustment for patient baseline and injury characteristics, prophylaxis delay was associated with increased odds of VTE (adjusted odds ratio [aOR], 1.08 per day; 95% CI, 1.04-1.12). Earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. During the first 3 days, each additional day of prophylaxis delay was associated with a 28% decrease in odds of repeated neurosurgery (aOR, 0.72 per day; 95% CI, 0.59-0.88). After 3 days, each additional day of prophylaxis delay was associated with an additional 15% decrease in odds of repeated neurosurgery (aOR, 0.85 per day; 95% CI, 0.80-0.90). Earlier prophylaxis was associated with greater mortality among patients who initially underwent intracranial monitor/drain procedures, such that each additional day of prophylaxis delay was associated with decreased odds of death (aOR, 0.94 per day; 95% CI, 0.89-0.99).

Conclusions and Relevance

In this cohort study of patients who underwent urgent neurosurgical interventions for TBI, early pharmacologic VTE prophylaxis was associated with reduced risk of thromboembolism. However, earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. These findings suggest that although timely initiation of prophylaxis should be prioritized, caution should be used particularly during the first 3 days after the index procedure, when this risk appears to be highest.

Rates of Low-Value Service in Australian Public Hospitals and the Association With Patient Insurance Status

IMPORTANCE

Low-value services have limited or no benefit to patients. Rates of low-value service in public hospitals may vary by patient insurance status, given that there may be different financial incentives for treatment of privately insured patients.

OBJECTIVE

To assess the variation in rates of 5 low-value services performed in Australian public hospitals according to patient funding status (ie, private or public).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study analyzed New South Wales public hospital data from January 2013 to June 2018. Patients included in the sample were over age 18 years and eligible to receive low-value services based on diagnoses and concomitant procedures. Data analysis was conducted from June to December 2020.

MAIN OUTCOMES AND MEASURES

Hospital-specific rates of low-value knee arthroscopic debridement, vertebroplasty for osteoporotic spinal fractures, hyperbaric oxygen therapy, oophorectomy with hysterectomy, and laparoscopic uterine nerve ablation for chronic pelvic pain were measured. For each measure, rates within each public hospital were compared by patient funding status descriptively and using multilevel models.

RESULTS

A total of 219 862 inpatients were included in analysis from 58 public hospitals across the 5 measures. A total of 38 365 (22 904 [59.7%] women; 12 448 [32.4%] aged 71-80 years) were eligible for knee arthroscopic debridement for osteoarthritis; 2520 (1924 [76.3%] women; 662 [26.3%] aged 71-80 years), vertebroplasty for osteoporotic spinal fractures; 162 285 (82 046 [50.6%] women; 28 255 [17.4%] aged 61-70 years), hyperbaric oxygen therapy; 15 916 (7126 [44.8%] aged 41-50 years), oophorectomy with hysterectomy; and 776 (327 [42.1%] aged 18-30 years), uterine nerve ablation for chronic pelvic pain. Overall rates of low-value services varied considerably between measures, with the lowest rate for hyperbaric oxygen therapy (0.3 procedures per 1000 inpatients [47 of 158 220 eligible inpatients]) and the highest for vertebroplasty (30.8 procedures per 1000 eligible patients [77 of 2501 eligible inpatients]). There was significant variation in rates between hospitals, with a few outlying hospitals (ie, <10), particularly for knee arthroscopy (range from 1.8 to 21.0 per 1000 eligible patients) and vertebroplasty (range from 13.1 to 70.4 per 1000 eligible patients), with higher numerical rates of low-value services among patients with private insurance than for those without. However, there was no association overall between patient insurance status and low-value services. Overall differences in rates among those with and without private insurance by individual procedure type were not statistically significant.

CONCLUSIONS AND RELEVANCE

There was significant variation in rates of low-value services in public hospitals. While there was no overall association between private insurance and rate of low-value services, private insurance may be associated with low-value service rates in some hospitals. Further exploration of factors specific to local hospitals and practices are needed to reduce this unnecessary care.

Double and triple burden of non-communicable diseases and its determinants among adults in Bangladesh: Evidence from a recent demographic and health survey

BACKGROUND

Globally, non-communicable diseases (NCDs) are a significant public health problem. NCDs are the leading cause of death in Bangladesh. This study aimed to estimate the prevalence of double burden of NCDs (DBNCDs) and triple burden of NCDs (TBNCDs) such as hypertension, diabetes and overweight or obesity and to explore the risk factors of DBNCDs and TBNCDs in Bangladesh.

MATERAILS AND METHODS

This study included 12 685 participants (5465 male and 7220 female) from 2017 - 2018 nationally representative Bangladesh Demographic and Health Survey. Descriptive statistics were calculated for the distribution and prevalence of DBNCDs and TBNCDs. Bivariate and multilevel logistic regression analyses were used to assess the individual- and community-level determinants of DBNCDs and TBNCDs.

RESULTS

The prevalence of DBNCDs and TBNCDs was 21.4% and 6.1%, respectively. At individual-level, higher age, female, currently and formerly/ever married, richest, higher education were more likely to suffer from the DBNCDs and TBNCDs. Furthermore, at the community level, the division had a significant association with DBNCDs and TBNCDs. In addition, family size had a significant effect on DBNCDs, and caffeinate drinks and poverty significantly affected TBNCDs.

CONCLUSION

Overall, there is a low prevalence of TBNCDs compared with DBNCDs in Bangladesh. Age, gender, marital status, wealth index, education level and division are significantly associated with DBNCDs and TBNCDs. The government and non-government health organisations should pay proper attention to handle the burden of NCDs in Bangladesh.

Exploring Spatial Variations and Determinants of Dietary Diversity Among Children in Ethiopia: Spatial and Multilevel Analysis Using EDHS (2011-2016)

Introduction

Dietary diversity has a significant impact on children’s nutritional health. For developing and implementing interventions, it is critical to understand the regional distribution of dietary diversity and underlying factors. However, the application of spatial techniques in dietary studies has not been well documented. The study’s goal was to look into the regional variances and factors that influence children’s dietary diversity. Further, we have discussed the spatial correlation of dietary diversity with nutritional status.

Methods

Data from the National Demographic and Health Survey were used during analyses. This work evaluated the overall dietary diversity of children aged 6–23 months based on the 2017 WHO and UNICEF classification of minimum dietary diversity (MDD). The Local Anselin Moran’s I was estimated to look into the regional variation of dietary diversity and hotspot and cold spot areas. Further, multivariate multilevel logistic regression was used for factor analyses.

Results

Overall, only 13.3% (95% CI: 10.2–14.7%) of children in 2011 and 24% (95% CI: 15.5–26.5%) in 2016 achieved MDD. We identified statistically significant clusters of high inadequate dietary diversity (hotspots) in the districts of northern Ethiopia, notably in the Amhara, Tigray, and Afar regions, and clusters of low inadequate dietary diversity (cold spots) in the country’s central and western regions. In both studies, the frequency of dietary diversity was significantly higher among older children, those who had media exposure, and mothers and fathers who had received formal education.

Conclusion

According to our findings, the MDD of children in Ethiopia, as measured by WHO dietary assessment, slightly increased from 2011 to 2016. The dietary diversity of children was distributed non-randomly in different districts across regions of Ethiopia. Localized intervention and preventative methods to improve dietary patterns and culture can be developed using existing socio-demographic factors and districts with a larger distribution of inadequate dietary diversity.

The relationship between the neighborhood built and social environment and hypertensive disorders of pregnancy: A scoping review

BACKGROUND

Theory and limited empirical research suggest that the neighborhood environment influences maternal health outcomes. The goal of this scoping review is to summarize extant research considering the impact of the built and social environment of resident neighborhood on hypertensive disorders of pregnancy (HDP) globally.

METHODS

We performed a systematic search of the literature using four databases, PubMed, Web of Science, CINAHL, and Embase on July 15, 2020. We excluded articles not in English, that did not consider one or more HDP as a primary or secondary outcome, and that did not include an element of the neighborhood built or social environment as an exposure. We applied a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies to evaluate quality of included studies.

RESULTS

Our search identified 11,385 unique abstracts for screening. Following exclusions, we included 64 articles in the final review. The majority of articles measured an element of the built environment (70.3% (44)), most commonly traffic-related air pollution (42.2% (27)). A third of articles (31.3% (20)) considered an element of the neighborhood social environment, most commonly neighborhood deprivation (10.9% (7)). Global quality ratings were mostly moderate (29.7% (19)) or weak (68.8% (44)), primarily due to inattention to neighborhood-level confounding.

CONCLUSION

Critical gaps remain in understanding how the resident neighborhood may impact HDP. Future research should focus on designing high-quality studies incorporating elements of both the built and social environment to holistically understand how context may impact maternal health.

Socio-Territorial Inequities in the French National Breast Cancer Screening Programme-A Cross-Sectional Multilevel Study

Simple Summary

France implemented a national breast cancer screening programme in 2004, which, despite recommendations, still coexists with opportunistic screening practices. We aimed to study socio-territorial inequities in participation in the 2013–2014 screening campaign, using multilevel models. With a representative sample of 42% of the estimated eligible population, we found that the organized programme does not erase social or territorial inequities in participation. Social inequities, at multiple levels, were found in nearly all départements, whereas territorial inequities seemed more context dependent. The impact of the coexistence with opportunistic screening, beyond any control and evaluation, is adding more risks (over-diagnosis, over-treatment) and leads to underestimating the true coverage of the population, mainly in the wealthiest, therefore leading to an underestimation of the true social gradient in participation. The French breast cancer screening programme needs to evolve to be more efficient in coverage, notably through the reduction of the unfair inequities in participation.

Abstract

Background. France implemented in 2004 the French National Breast Cancer Screening Programme (FNBCSP). Despite national recommendations, this programme coexists with non-negligible opportunistic screening practices. Aim. Analyse socio-territorial inequities in the 2013–2014 FNBCSP campaign in a large sample of the eligible population. Method. Analyses were performed using three-level hierarchical generalized linear model. Level one was a 10% random sample of the eligible population in each département (n = 397,598). For each woman, age and travel time to the nearest accredited radiology centre were computed. These observations were nested within 22,250 residential areas called “Îlots Regroupés pour l’Information Statistique” (IRIS), for which the European Deprivation Index (EDI) is defined. IRIS were nested within 41 départements, for which opportunistic screening rates and gross domestic product based on purchasing power parity were available, deprivation and the number of radiology centres for 100,000 eligible women were computed. Results. Organized screening uptake increased with age (OR_1SD = 1.05 [1.04–1.06]) and decreased with travel time (OR_1SD = 0.94 [0.93–0.95]) and EDI (OR_1SD = 0.84 [0.83–0.85]). Between départements, organized screening uptake decreased with opportunistic screening rate (OR_1SD = 0.84 [0.79–0.87]) and départements deprivation (OR_1SD = 0.91 [0.88–0.96]). Association between EDI and organized screening uptake was weaker as opportunistic screening rates and as département deprivation increased. Heterogeneity in FNBCSP participation decreased between IRIS by 36% and between départements by 82%. Conclusion. FNBCSP does not erase socio-territorial inequities. The population the most at risk of dying from breast cancer is thus the less participating. More efforts are needed to improve equity.

Variations in hip fracture inpatient care in Japan, Korea, and Taiwan: an analysis of health administrative data

BACKGROUND

Little is known about hip fracture inpatient care in East Asia. This study examined the characteristics of patients, hospitals, and regions associated with delivery of hip fracture surgeries across Japan, Korea, and Taiwan. We also analyzed and compared how the resource use and a short-term outcome of the care in index hospitals varied according to factors in the respective health systems.

METHODS

We developed comparable, nationwide, individual-level health insurance claims datasets linked with hospital- and regional-level statistics across the health systems using common protocols. Generalized linear multi-level analyses were conducted on length of stay (LOS) and total cost of index hospitalization as well as inpatient death.

RESULTS

The majority of patients were female and aged 75 or older. The standardized LOS of the hospitalization for hip fracture surgery was 32.5 (S.D. = 18.7) days in Japan, 24.7 (S.D. = 12.4) days in Korea, and 7.1 (S.D. = 2.9) days in Taiwan. The total cost per admission also widely varied across the systems. Hospitals with a high volume of hip fracture surgeries had a lower LOS across all three systems, while other factors associated with LOS and total cost varied across countries.

CONCLUSION

There were wide variations in resource use for hip fracture surgery in the index hospital within and across the three health systems with similar social health insurance schemes in East Asia. Further investigations into the large variations are necessary, along with efforts to overcome the methodological challenges of international comparisons of health system performance.

Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties

BACKGROUND

Access to pediatric trauma care is highly variable across the United States. The purpose of this study was to measure the association between pediatric trauma center care and motor vehicle crash (MVC) mortality in children (<15 years) at the US county level for 5 years (2014-2018).

METHODS

The exposure was defined as the highest level of pediatric trauma care present within each county: (1) pediatric trauma center, (2) adult level 1/2, (3) adult level 3, or (4) no trauma center. Pediatric deaths due to passenger vehicle crashes on public roads were identified from the NHTSA Fatality Analysis Reporting System. Hierarchical negative binomial modeling measured the relationship between highest level of pediatric trauma care and pediatric MVC mortality within counties. Adjusted analyses accounted for population age and sex, emergency medical service response times, helicopter ambulance availability, state traffic safety laws, and measures of rurality.

RESULTS

During the study period 3,067 children died in fatal crashes. We identified 188 pediatric trauma centers in 141 counties. Significant disparities in access to pediatric trauma care were observed. Specifically, 99% of pediatric trauma centers were situated in population-dense urban counties, while 28% of children lived in counties no trauma center. After risk adjustment, counties with pediatric trauma centers had significantly lower rates of pediatric MVC death than those with no trauma center: 0.7 versus 3.2 deaths/100,000 child-years; mortality rate ratio, 0.58; and 95% confidence interval, 0.39 to 0.86. In counties where pediatric trauma centers were absent, adult level 1/2 trauma centers were associated with comparable risk reduction.

CONCLUSION

The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement.

LEVEL OF EVIDENCE

Epidemiological, level III; Care management, level III.

Physical Activity among Adults Residing in 11 Countries during the COVID-19 Pandemic Lockdown

During the novel coronavirus (COVID-19) pandemic, physical activity (PA) behaviors were altered worldwide due to public health measures such as “lockdown.” This study described PA among adults residing in 11 countries during COVID-19 lockdown and examined factors associated with PA engagement. We conducted a cross-sectional anonymous survey among adults (≥18 years old) in 11 countries (Brazil, Bulgaria, China, India, Ireland, Malaysia, North Macedonia, Singapore, Spain, Turkey, United States). Of 11,775 participants, 63.7% were female and 52.8% were 18–34 years old. More than 40% of participants were insufficiently active (43.9%) and reported a decrease in their PA during lockdown (44.8%). Statistically significant differences were observed in (1) proportions of participants being insufficiently active, (2) level of PA, and (3) decrease in PA across the 11 countries. More stringent governmental policy responses were associated with greater likelihood of being insufficiently active during lockdown (adjusted odds ratio = 1.22, 95% confidence interval = 1.03, 1.45). Higher depression or anxiety scores were associated with greater likelihood of decreased level of PA during lockdown.We found substantial reductions in PA levels during COVID-19 lockdown across countries. Country-specific PA promotion interventions are needed during this and similar global emergencies.

LGB prevalence in schools is associated with unhealthy weight-control behaviors in lesbian, gay, and bisexual youth: a multilevel analysis

Background

Previous studies have found that a school climate of more heteronormativity is associated with adverse effects on the mental health of LGB students. Accordingly, our aim was to assess the association between lower LGB prevalence in schools and unhealthy weight-control behaviors among LGB youth.

Methods

A cross-sectional, multilevel study based in public high schools in the city of Olinda, Northeast Brazil. A multilevel logistic regression was performed, including 2500 adolescents enrolled in 27 schools. The contextual variable was the prevalence of LGB youth in each school (as a proxy for heteronormativity in schools), while the outcome was unhealthy weight-control behaviors (fasting, purging, and taking diet pills). We controlled for socioeconomic characteristics (age, sex, receiving a family allowance), obesity, and self-reported happiness.

Results

Lower LGB prevalence in schools was associated with higher odds of engaging in unhealthy weight-control behaviors (OR: 1.5, 95%CI: 1.0, 2.2) among all youth, regardless of sexual orientation. No cross-level interactions between school context and individual characteristics were statistically significant.

Conclusion

Lower LGB prevalence in schools was associated with a higher risk of unhealthy weight-control behaviors in youth regardless of sexual orientation, which may reflect either the contextual influence of school climate, or may be due to residual confounding.

Variability in time to surgery for patients with acute thoracolumbar spinal cord injuries

There are limited data pertaining to current practices in timing of surgical decompression for acute thoracolumbar spinal cord injury (SCI). We conducted a retrospective cohort study to evaluate variability in timing between- and within-trauma centers in North America; and to identify patient- and hospital-level factors associated with treatment delay. Adults with acute thoracolumbar SCI who underwent decompressive surgery within five days of injury at participating trauma centers in the American College of Surgeons Trauma Quality Improvement Program were included. Mixed-effects regression with a random intercept for trauma center was used to model the outcome of time to surgical decompression and assess risk-adjusted variability in surgery timeliness across centers. 3,948 patients admitted to 214 TQIP centers were eligible. 28 centers were outliers, with a significantly shorter or longer time to surgery than average. Case-mix and hospital characteristics explained < 1% of between-hospital variability in surgical timing. Moreover, only 7% of surgical timing variability within-centers was explained by case-mix characteristics. The adjusted intraclass correlation coefficient of 12% suggested poor correlation of surgical timing for patients with similar characteristics treated at the same center. These findings support the need for further research into the optimal timing of surgical intervention for thoracolumbar SCI.