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PubMed2004

Fostering reading comprehension in fifth grade by explicit instruction in reading strategies and peer tutoring.

BACKGROUND: Research reveals that explicit reading strategies instruction and engaging students in interaction about texts promote students' reading comprehension ability. The present intervention study combines both aspects. AIMS: The study examines the educational benefits of explicit reading strategies instruction, followed by practice in (a) teacher-led whole-class activities (STRAT), (b) reciprocal same-age (STRAT + SA), or (c) cross-age peer tutoring activities (STRAT + CA) on fifth graders' reading comprehension achievement. SAMPLE: Twenty-two fifth-grade teachers and their 454 students from 19 different schools throughout Flanders (Belgium) participated. METHOD: A quasi-experimental pretest post-test retention test design was used with three experimental (STRAT, STRAT + SA, and STRAT + CA) and a matched control group. The experimental interventions were implemented during an entire school year. RESULTS: Multilevel analysis revealed that the STRAT and STRAT + CA condition made a significantly larger pretest to retention test progress than the control group. The significant major progress was especially situated from pretest to post-test, during which the intervention took place. Concerning the STRAT + SA condition no significant differences with regard to the control group were detected. Pairwise comparisons of the experimental conditions indicated that the STRAT + CA condition's progress from pretest to retention test also exceeded the STRAT + SA condition's advancement significantly. CONCLUSION: The study corroborated the efficacy of the STRAT and STRAT + CA conditions' interventions as feasible tools to enhance fifth graders' reading comprehension achievement.

Belgium↗
PubMed2004

Teachers' task demands, students' test expectations, and actual test content.

BACKGROUND: Previous studies on instructional importance show that individual students and their teachers differ in the topics that they consider important in the context of an upcoming teacher-made test. AIMS: This study aimed to examine whether such differences between students' test expectations and teachers' intended task demands can be explained by the actual test content. SAMPLES: Participants were history teachers (N=19) and their 11th-grade students (N=388). METHOD: Teachers and students rated the importance of text sections that would be tested in the near future. By means of multilevel analysis, ratings were compared with the occurrence of sections in the tests. RESULTS: Although teachers considered a majority of sections as important and tested only a minority of the sections, their tests still included sections rated as unimportant. The number of such discrepancies, however, was relatively small. Sections the teachers rated important had a much higher probability of being included in the test than sections rated unimportant. For students, a similar but lower degree of correspondence between ratings and test content was found. Interestingly, for sections that teachers considered important, students more often gave a higher rating when these sections appeared in the test than when they did not. The same holds for sections that teachers considered unimportant. CONCLUSIONS: For both teachers and students there is a limited correspondence between perceived task demands and test content. Furthermore, students' perceptions of task demands show a compensation for some of the differences between their teachers' intended task demands and the test demands.

Adolescent↗
PubMed2003

Ten-year longitudinal relationship between physical activity and lumbar bone mass in (young) adults.

Little is known about the influence of long-term daily physical activity (PA) on lumbar bone mass after peak bone mass has been reached, that is, during [young] adulthood. The purpose of this study was to investigate the longitudinal relationship between PA and lumbar bone mineral density (LBMD) in healthy subjects over a 10-year period. The data reported here relate to 225 male and 241 female participants in the Amsterdam Growth and Health Longitudinal Study, who were measured at the mean ages of 27, 32, and/or 36. LBMD, habitual daily PA, total body weight, and calcium intake were assessed at each measurement point. The effects of two aspects of PA were analyzed: the mechanical (MECHPA; sum of all ground reaction forces) and metabolic (METPA; weighted metabolic score of intensity, frequency, and duration) components, each within a separate model. Multilevel analysis was used to investigate the relationship between PA and LBMD over the 10-year period. Gender, total body weight, and calcium intake were included in the analysis as covariates. The results indicated that MECHPA was a significant positive linear predictor of LBMD for males (r = 0.09; p < 0.001) but not for females. For the METPA, no linear longitudinal relationship with LBMD was found. The results suggest that there is a metabolic threshold at which extra PA becomes "deleterious" and METPA in its totality becomes ineffective for LBMD. It is concluded that during the (young) adult period, between 27 and 36 years of age, PA causing mechanical loading on the skeleton has a small positive influence on LBMD in males.

Adult↗
PubMed1998

Children's contributions to pediatric outpatient encounters.

OBJECTIVE: Generally, increasing attention is being paid to the quality of doctor-patient communication. However, children's contributions have been, until now, primarily ignored in communication research, although there are indications that considering their views increases satisfaction and compliance. In the present study, we examined how children contributed to communication during outpatient pediatric encounters and what factors were associated with children's contributions. PATIENTS: Twenty-one consulting pediatricians videotaped a total of 302 consecutive outpatient encounters. DESIGN: Multilevel analysis was used to take into account the similarity among encounters with the same pediatrician. RESULTS: Children's contributions to the outpatient encounters were limited to 4%. Pediatricians directed one out of every four statements to the child. Although pediatricians asked children a lot of medical questions (26%), only a small part of the medical information (13%) was directed at the children. Apart from social talk and laughter, the amount of pediatrician-child communication increased with children's age. Communication with children suffering from disorders of the nervous system seemed to differ from that with children suffering from other diseases. Allowing children more room in the medical visit did not seem to increase the duration of the visit. CONCLUSIONS: Although recent legislation requires children to be adequately informed, in pediatric outpatient encounters information still tends to be directed primarily at the parents. Children do get the opportunity to talk about social and psychosocial issues. Pediatricians may need to acquire similar communication skills to discuss medical-technical issues with the children.

Ambulatory Care↗
PubMed2004

Urban sprawl and risk for being overweight or obese.

OBJECTIVES: I examined the association between urban sprawl and the risk for being overweight or obese among US adults. METHODS: A measure of urban sprawl in metropolitan areas was derived from the 2000 US Census; individual-level data were obtained from the Behavioral Risk Factor Surveillance System. I used multilevel analysis to assess the association between urban sprawl and obesity. RESULTS: After I controlled for gender, age, race/ethnicity, income, and education, for each 1-point rise in the urban sprawl index (0-100 scale), the risk for being overweight increased by 0.2% and the risk for being obese increased by 0.5%. CONCLUSIONS: The current obesity epidemic has many causes, but there is an association between urban sprawl and obesity.

Adult↗
PubMed2001

Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice.

OBJECTIVE: To assess the long-term effectiveness of a quality improvement program on care provided and patient outcomes in patients with diabetes. RESEARCH DESIGN AND METHODS: A nonrandomized trial was performed with 312 patients with type 2 diabetes in the intervention group and 77 patients with type 2 diabetes in the reference group. The follow-up period was 42 months. The quality improvement program focused on improving both the provision of diabetes care and the patient outcomes. The program consisted of clinical practice guidelines, postgraduate education, audit and feedback, templates to register diabetes care, and a recall system. Data on the care provided were abstracted from medical records. Main outcomes on the provision of care were annual number of patient visits, blood pressure, and HbA(1c) and blood lipid levels. Main patient outcomes were blood pressure and HbA(1c) and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices. RESULTS: Patients in the intervention group received care far more in accordance with the guidelines than patients in the reference group. Odds ratios ranged from 2.43 (95% CI 1.01-5.82) for the measurement of urine albumin to 12.08 (4.70-31.01) for the measurement of blood pressure. No beneficial effect was found on any patient outcome. CONCLUSIONS: The quality improvement program improved the provision of diabetes care, but this was not accompanied by any effect on patient outcomes.

Aged↗
PubMed2004

Physician, organizational, and patient factors associated with suboptimal blood pressure management in type 2 diabetic patients in primary care.

OBJECTIVE: To assess the quality of hypertension care in patients with type 2 diabetes in general practice and identify physician, organizational, and patient factors associated with suboptimal care. RESEARCH DESIGN AND METHODS: Data from 895 randomly selected diabetic patients were extracted from the electronic medical records of 95 general practitioners. Physician and organizational characteristics were collected with a questionnaire. We conducted a multilevel analysis to identify associations with blood pressure registration, hypertension treatment, and achievement of target blood pressure levels. RESULTS: For 652 patients (73%), a blood pressure measurement was recorded in the last year. Of these patients, 132 (20%) reached a target level of 135/85 mmHg. In total, 595 patients were classified as having hypertension, of whom 192 received no treatment (32%), 193 received an ACE inhibitor (32%), and 210 received other antihypertensives. Patients visiting a diabetes facility, referred to a specialist, with a female general practitioner, or with a general practitioner with </=10 years work experience had better recordings of their blood pressure. Suboptimal treatment was higher in older patients and smoking patients. Treatment was better in patients with coronary comorbidity, hyperlipidemia, or those referred to a specialist. Not achieving the blood pressure target was related to older age of the patients. CONCLUSIONS: Hypertension management of type 2 diabetic patients in primary care is suboptimal. Characteristics of general practitioners as well as additional care provided by a diabetes facility or a specialist are associated with better processes of care, but blood pressure outcomes are not as clearly related to these factors.

Aged↗
PubMed1999

Communication during gynecological out-patient encounters.

The intimate nature of women's health problems presented during gynecological encounters places great demands on gynecologists' communicative behavior. The present study examined what patients expect from their gynecologist, how gynecologists and patients actually communicate during out-patient encounters, and what factors shape the structure and process of the encounter. Twenty-one gynecologists (13 consultants and eight residents) videotaped 303 consecutive out-patient encounters. Multilevel analysis was used to take into account the similarity among encounters with the same gynecologist. The results showed that gynecological patients expected foremost to receive clear and understandable information. One-third of the patients expected support and understanding. Psychosocial issues were hardly ever the topic of conversation. The length of the out-patient visits increased in the presence of patients' partner, with the type of problem presented, and with the frequency with which the patient disagreed with the gynecologist. The visit was also longer when gynecologists provided more medical information and asked more psychosocial questions. Although gynecological encounters focus almost exclusively on medical issues, talking about non-somatic aspects does not seem to prolong the visit as much as the presence of the patient's partner or whether or not the gynecologist and patient had met before. In view of patients' affective needs, it would be worthwhile to examine whether gynecologists can be taught to handle patients' psychosocial needs as well.

Adult↗
PubMedDate not supplied

Successfully improving physical activity behavior after rehabilitation.

PURPOSE: To determine the effects of the physical activity promotion programs Rehabilitation & Sports (R&S) and Active after Rehabilitation (AaR) on sport and daily physical activity 1 year after in- or outpatient rehabilitation. DESIGN: Subjects in intervention rehabilitation centers were randomized into a group receiving R&S only (n = 315) and a group receiving R&S and AaR (n = 284). Subjects in six control centers (n = 603) received usual care. SETTING: Ten Dutch rehabilitation centers. SUBJECTS: Subjects consisted of 1202 rehabilitation patients. Most frequent diagnoses were stroke, neurological disorders, and back disorders. INTERVENTION: Both the sport stimulation program (R&S) and the daily physical activity promotion program (AaR) consisted of personalized tailored counseling. MEASURES: Two sport outcomes and two daily physical activity outcomes were assessed with questionnaires at baseline and 1 year after rehabilitation. ANALYSIS: Multilevel analyses comparing both intervention groups to the control group. RESULTS: The R&S program showed no significant effects. Intention-to-treat analyses in the R&S + AaR group showed borderline significant improvements in one sport (odds ratio [OR] = 1.66, p = .02) and both physical activity outcomes (OR = 1.68, p = .01 and regression coefficient = 10.78, p = .05). On-treatment analyses in the R&S + AaR group showed similar but stronger effects. CONCLUSIONS: The combination of the R&S and AaR programs improved physical activity behavior and sport participation 1 year after in- or outpatient rehabilitation. The R&S program alone did not have any effects.

Adult↗
PubMed2000

[Practice patterns, physicians' characteristics and patient-evaluated quality of general practice in Norway].

BACKGROUND: Norwegian general practice is a conglomerate of organisational forms. Studies of quality differences between types of practice have not been published. There is scant knowledge of how physician characteristics may influence patients' experience of the quality of care. MATERIALS AND METHODS: In this study of patient experiences with quality in primary care, we received answers to a questionnaire from more than 1,600 patients who had made office visits to 61 GPs working in 44 different practices. The patients expressed their opinion of the quality of medical-technical performance, doctor-patient relationship, information and support, accessibility and the organisation of general practice. Using multilevel analysis we compared solo-practices with group practices, and conventional types of practices with list-patient practices. RESULTS: No significant differences in patient experienced quality were found for different practices with traditional organisation. List-patient practices scored lower on quality than conventional practices, especially on accessibility and organisation. There were no significant differences in patient evaluation related to the doctor's gender. GPs with more than ten years in a practice were rated lower on quality than GPs with ten or fewer years of experience. INTERPRETATION: The way general practice is organised and the number of years the GP has worked in the same practice appear to influence how patients experience the quality of primary health care.

Family Practice↗
PubMed2002

Use of remote sensing and a geographical information system in a national helminth control programme in Chad.

OBJECTIVE: To design and implement a rapid and valid epidemiological assessment of helminths among schoolchildren in Chad using ecological zones defined by remote sensing satellite sensor data and to investigate the environmental limits of helminth distribution. METHODS: Remote sensing proxy environmental data were used to define seven ecological zones in Chad. These were combined with population data in a geographical information system (GIS) in order to define a sampling protocol. On this basis, 20 schools were surveyed. Multilevel analysis, by means of generalized estimating equations to account for clustering at the school level, was used to investigate the relationship between infection patterns and key environmental variables. FINDINGS: In a sample of 1023 schoolchildren, 22.5% were infected with Schistosoma haematobium and 32.7% with hookworm. None were infected with Ascaris lumbricoides or Trichuris trichiura. The prevalence of S. haematobium and hookworm showed marked geographical heterogeneity and the observed patterns showed a close association with the defined ecological zones and significant relationships with environmental variables. These results contribute towards defining the thermal limits of geohelminth species. Predictions of infection prevalence were made for each school surveyed with the aid of models previously developed for Cameroon. These models correctly predicted that A. lumbricoides and T. trichiura would not occur in Chad but the predictions for S. haematobium were less reliable at the school level. CONCLUSION: GIS and remote sensing can play an important part in the rapid planning of helminth control programmes where little information on disease burden is available. Remote sensing prediction models can indicate patterns of geohelminth infection but can only identify potential areas of high risk for S. haematobium.

Adolescent↗
PubMed2003

How mental health providers spend their time: a survey of 10 Veterans Health Administration mental health services.

BACKGROUND: Allocation of provider time across clinical, administrative, educational, and research activities may influence job satisfaction, productivity, and quality of care, yet we know little about what determines time allocation. AIMS: To investigate factors associated with time allocation, we surveyed all mental health providers in one Veterans Health Administration (VHA) network. We hypothesized that both facility characteristics (academic affiliation, type of organization of services, serving as a hub for treatment of severely mentally ill, facility size) and individual provider characteristics (discipline, length of time in job, having an academic appointment) would influence time allocation. METHODS: Eligible providers were psychiatrists, psychologists, social workers, physician assistants, registered or licensed practical nurses or other providers (psychology technicians, addiction therapists, nursing assistants, rehabilitation, recreational, occupational therapists) who were providing care in mental health services. A brief self-report survey was collected from all eligible providers at ten VHA facilities in late 1998 (N = 997). Data regarding facility characteristics were obtained by site visits and interviews with managers. Multilevel modeling was used to examine factors associated with three dependent variables: (i) total time allocation by activity (clinical, administrative, educational, research); (ii) clinical time allocation by treatment setting (inpatient vs. outpatient); and (iii) clinical time allocation by type of care (mental vs. physical). Licensed Practical Nurses (LPNs) were used as the reference group for all analyses because LPNs were expected to spend the majority of their time on clinical activities. RESULTS: Overall, providers spent most of their time on clinical activities (77%), followed by administrative (11%), and educational (10%). Surprisingly, research activities accounted for only 2% of their time. Multilevel analysis indicated none of the facility-level variables were significant in explaining facility variance in time allocation, but individual characteristics were associated with time allocation. The model for predicting time allocation by inpatient or outpatient settings explained 16-18% of the variance in the dependent variable. In all models, provider discipline and length of time in job played an important role. Having an academic appointment was important only in the model examining total time allocation by activity type. DISCUSSION: These simple models explained only a small amount of variance in the three dependent variables which were intended to capture issues related to time allocation; and the low number of facilities limited our power to examine effects of facility-level factors. Our models performed better in predicting allocation of clinical time to treatment setting and type of treatment than in predicting overall time allocation. Discipline and length of time in job were significant across all models. In contrast, having an academic appointment was associated with allocating significantly less time to clinical activities and more time to administrative activities but not to any significant difference in time spent in either research or education. IMPLICATIONS: While a gold standard of optimal time allocation does not exist, it is striking that research, a stated mission of the VHA, accounted for so little of providers' time. The lack of involvement of clinicians in research has implications for recruitment and retention of high-quality mental health providers in this network and for the education of future providers. Without involvement of clinicians, research conducted in the network by nonclinicians may be less relevant to "real-world" clinical issues. Reductions of funds available to mental health, coupled with increased clinical demands, may have prompted this pattern of time allocation, and these findings attest to the challenges faced by large institutions that are charged with balancing many often seemingly competing missions.

Health Services Research↗
PubMedDate not supplied

[A model of health promotion with emphasis on physical activity for university students].

OBJECTIVE: The project was designed towards a model of health promotion based upon physical activity and directed to the students of the National University of Colombia. METHODS: A three phase multilevel analysis method was employed. Both the disease and the population problems presented by the students were examined and documented, and the information on both of these problems was integrated. In second place, the previous experiences were identified and finally the axes and strategies of the model were established. RESULTS: A model was defined whose main components are the networks of participation and support to the promotion of health and physical activity, the political and regulatory support and transformation, and the academic reorientation towards an integral formation and its strategies. CONCLUSIONS: The project reassured a methodology for designing health models, as well as it favored the integration, from a practical perspective, of the strategies and approaches of health promotion applied to physical activity.

Exercise↗
PubMed2005

Patterns of medical practice variation: variability in referral for back pain by New Zealand general practitioners.

AIMS: To describe patterns of variation in referral among general practitioners, and to establish whether variability among practitioners within a geographic area is associated with high levels of utilisation in an area. METHOD: Multilevel analysis of routinely collected primary care data. The four outcome measures were referral to physiotherapy, specialist assessment, radiology, and approval of earnings-related compensation. RESULTS: The pattern of observed variability is not consistent for different referral activities: groups of general practitioners within one area may practice consistently in referral for one outcome, but be highly variable for another, while practitioners in other areas can show the reverse pattern. The degree of variability among GPs within geographic areas was not significantly correlated at the 95% level with the absolute level of referral to any of the referral options. CONCLUSION: The mechanisms which drive variability operate at the level of the specific clinical management option, rather than at the level of the overall approach to management of the disease. Caution should be exercised about claims that reductions in variability will produce reductions in utilisation.

Accidents↗
PubMed2005

Categorisation of dental care provided in the Netherlands.

OBJECTIVE: To describe the dental care provided in the Netherlands and investigate to what extent variations can be explained in accordance with certain general characteristics of patients. METHOD: Besides the more usual classification of treatment into groups of dental procedures, in this study it is done using constructed categorisation of dental care based on characteristics such as 'preventive', 'curative', 'new', 'time-consuming', 'complicated' and 'lucrative' treatment. The data were collected from various groups of dentists. Two smaller groups of dentists-informants were asked to categorise dental procedures: 16 out of 55 (29%) and 57 out of 150 (38%). Finally this resulted in six type-scores for each procedure. From another larger group of dentists (n = 607) data were collected about the procedures they performed on a 25% random sample of their patients. Categorisations of dental care per patient were calculated by combining the data on the factual procedures performed with the six 'type-scores' for the procedures concerned. Furthermore, the financial returns dentists generated per patient were calculated from the care they provided. RESULTS: Multilevel analysis shows that considerable variation exists in the categorisations of dental care provided according to age, gender, insurance situation and income level of patients. In youths, for example, relatively more 'preventive' and less 'curative', 'complicated' and 'lucrative' treatment is done and 'older' adults receive relatively less 'preventive' and more 'curative', 'time-consuming' and 'complicated' treatment. CONCLUSIONS: By classifying the dental care provided in certain categories, a general view is obtained of the variations between patients in the care provided. The age of patients appears to be the most critical factor, but there are differences among dentists in the way the age of patients influences their conduct in the provision of dental care.

Adolescent↗
PubMed2005

[Epidemiology and social epidemiology].

Social epidemiology is a sub-discipline of epidemiology explicitly investigating social determinants of population distributions of health, disease, and well-being. Persistent pattern of social inequalities in health in spite of the broad improvement in the physical environment over the last centuries necessitated the development of this field as an approach to understand disease etiology that incorporates social experiences as more direct determinant of health. Social epidemiology incorporates theories, measurement tools, and techniques from a wide variety of other social sciences. A population perspective, the social context of behavior, contextual multilevel analysis, a developmental and life-course perspective, and general susceptibility to disease are the most important guiding concepts in social epidemiology.

Epidemiologic Methods↗
PubMed1990

[Pathogenesis of congenital heart defects: fiction and truth].

This is a review based on a description of a standardized method (microdissection + SEM) for study of human and animal cardiac development. Two examples of the analytical approach are given. In the first one, concerning the establishment of contact between the aorta and the left ventricle, the previous assumptions for "vectorial bulbus rotation" are disproved by more precise observations of normal cardiac development. Aorta is not transferred into the left ventricle but is connected to it by means of a "conduit" (aortic vestibulum) delimited by the fusion of the conotruncus ridges. For the second example the multilevel-analysis of pathogenesis of conotruncus septum defects in Keeshond dogs was selected. At the organ level, hypoplasia of the right ventricle was diagnosed, accompanied by hypoplasia of conus cushions. Tissue-level analysis indicated that the major cause of these hypoplasias is a decreased relative volume of the myocardium. Further study at the cell level showed that the number of mesenchymal cells in certain parts of conotruncus cushions is also diminished. Combining these observations with what is known about the architecture of cell proliferation in the embryonic heart, allows to formulate a hypothesis on a selective lesion of the right proliferation center, as one of the main causes of the observed anomalies. Further progress towards the subcellular and molecular level will help to complete the pathway from a gene defect toward an organ defect.

Animals↗
PubMed1989

Integrating theory and research on the institutional determinants of fertility.

This article links recent conceptual theories regarding the determinants of fertility with research designs appropriate for testing those theories. The most important causal factors in these theories--typically social or cultural institutions, occasionally emergent properties of the collective behavior of individuals--are properly conceptualized at the macro level. Research designs must therefore feature variation at this level and are at a minimum comparative. Noncomparative micro-level research designs will be misspecified from the standpoint of theory. A case is also made for continuing to incorporate the observation of individual-level behavior into any comprehensive research design. A focus on macro determinants of fertility does not imply that fertility outcomes are determined at the institutional level. Instead, there remains some process whereby systemic properties are translated into individual behaviors. Recommendations for comparative community-level studies are discussed. The multilevel analysis framework is reviewed as a paradigm for the conceptual features of cross-contextual analysis.

Data Interpretation, Statistical↗