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PubMed2005

Hospital level of care and neonatal mortality in low- and high-risk deliveries: reassessing the question in Sweden by multilevel analysis.

BACKGROUND: In high-risk births, the availability and concentration of neonatal resources in larger regional hospitals increases the chance of survival. The advantages of regionalization for low-risk deliveries are still unclear, but some studies have suggested that regionalization also is beneficial for low risk deliveries. The aim of the present study was to investigate both the relevance of regionalization and the concentration of neonatal resources as determinants of mortality in low- and high-risk deliveries in Sweden. METHODS: Interhospital differences in 28-day neonatal mortality were analyzed distinguishing maternal and delivery factors from institutional ones. Using information from the Swedish Birth Register (1990-1995), we performed risk-stratified multilevel logistic regression analysis to study 691,742 births (first level) nested within the 66 Swedish hospitals with maternity wards (second level). RESULTS: In low-risk deliveries, mortality decreased with improved access to neonatal resources. Mortality was lowest in larger regional hospitals with full access to neonatal care. This association remained unchanged after adjusting for patient mix. With regard to high-risk deliveries, mortality was higher in large county and regional hospitals than in small hospitals without access to neonatal care but, as expected, this increased risk disappeared after adjustment for patient mix. CONCLUSIONS: Increased regionalization and concentration of neonatal resources for low-risk births is justified from a strictly medical point of view. From a public health perspective, closing small obstetrics units may prevent an appreciable number of deaths, but it would have only a very small impact on the risk of mortality from the individual's point of view. The cost-effectiveness of such a step remains to be analyzed from a health economics perspective.

Adult↗
PubMed2005

Normative processes and adolescents' smoking behaviour in Norway: a multilevel analysis.

Currently, smoking prevalence is still high among adolescents. This is of major concern for public health organizations. Factors that influence adolescent smoking behaviour need to be identified and addressed. Research in this area has identified attitudes, subjective norms and perceived behavioural control as some of the contributing factors, but subjective norms have often been the weakest predictor of smoking behaviour. This could be due to inadequate measurement. The current paper suggests that examining different types of norms and their relationship with smoking behaviour could help increase the contribution of norms. The paper set out to identify other normative concepts, such as the subjective estimate of smoking prevalence, and descriptive and desired societal norms that are not captured by subjective norms but that could be related to adolescents' smoking behaviour. Data were collected from 15-year-old students from Norway (n = 1670 in 89 grade 10 school classes). Multilevel logistic regression analysis was used to determine how the various concepts of norms relate to each other and their relationship with adolescent smoking behaviour. The findings of the study showed that an individual's opinion of societal norms, and the expectations of significant others as well as their behaviour all seem significantly related to adolescent smoking behaviour, either as an individual or as a school class predictor. Hence, rather than playing down the role of norms, the addition of a subjective estimate of smoking prevalence, and descriptive and desired societal norms could extend the normative concept as well as increase its predictive power. Future intervention could address different types of norms as well as the effect of shared context to help prevent adolescents from smoking.

Adolescent↗
PubMed2005

Anxiolytic-hypnotic drug use associated with trust, social participation, and the miniaturization of community: a multilevel analysis.

The concept of social capital has gained wide interest in public health research in recent years. However, we suggest a concept that was introduced and developed by Fukuyama, named "miniaturization of community", as an alternative to that of social capital. The concept of miniaturization of community emphasizes that a high level of social participation can be accompanied by a low level of trust, both at the individual and at the community level, which may in turn result in social disorder and lack of social cohesion. When society becomes more disordered, people may tend to feel more insecure and anxious. Use of anxiolytic-hypnotic drugs (AHDs) could under such circumstances be a coping strategy. In this study, we first wanted to investigate whether the contextual component of the miniaturization of community concept (i.e. area high social participation and low trust) is associated with individual AHD use, over and above individual characteristics. Secondly, we aimed to study whether people living in the same municipality share a similar probability of AHD use, after adjusting for individual characteristics, and if so, how large this contextual phenomenon is. We used data on 20,319 women and 17,850 men aged 18-79 years from 58 municipalities in six regions in central Sweden, who participated in the Life & Health year 2000 postal survey. We applied multilevel logistic regression analysis with individuals at the first level and areas at the second level. Our results suggest that living in an area with a high level of miniaturization of community seems to be associated with individual AHD use, beyond people's individual characteristics including their own level of social participation and trust. The concept of miniaturization of community may be an extension of the classic concept of social capital and may increase our understanding of contextual effects on health.

Adolescent↗
PubMed2005

A multilevel analysis of cognitive dysfunction and psychopathology associated with chromosome 22q11.2 deletion syndrome in children.

We present a multilevel approach to developing potential explanations of cognitive impairments and psychopathologies common to individuals with chromosome 22q11.2 deletion syndrome. Results presented support our hypothesis of posterior parietal dysfunction as a central determinant of characteristic visuospatial and numerical cognitive impairments. Converging data suggest that brain development anomalies, primarily tissue reductions in the posterior brain and changes to the corpus callosum, may affect parietal connectivity. Further findings indicate that dysfunction in "frontal" attention systems may explain some executive cognition impairments observed in affected children, and that there may be links between these domains of cognitive function and some of the serious psychiatric conditions, such as attention-deficit/hyperactivity disorder, autism, and schizophrenia, that have elevated incidence rates in the syndrome. Linking the neural structure and the cognitive processing levels in this way enabled us to develop an elaborate structure/function mapping hypothesis for the impairments that are observed. We show also, that in the case of the catechol-O-methyltransferase gene, a fairly direct relationship between gene expression, cognitive function, and psychopathology exists in the affected population. Beyond that, we introduce the idea that variation in other genes may further explain the phenotypic variation in cognitive function and possibly the anomalies in brain development.

Attention↗
PubMed2001

Multilevel analysis with messy data.

This paper reviews applications of the method of multiple imputation to dealing with multilevel data that have several kinds of imperfections. These are classified into two broad categories: missing values and imprecise measurement (corrupted recording). The role of the model describing the data imperfections is emphasized. With multiple imputation, these imperfections and information about the processes underlying them can be taken into account. The inferences drawn exploit all the collected information and appropriately reflect the information contained in the data.

Algorithms↗
PubMed2002

State expenditures on home and community based services and use of formal and informal personal assistance: a multilevel analysis.

Despite wide state variation in commitment to home and community-based services (HCBS) for functionally impaired older persons, little is known about how such variation affects older adults' strategies to compensate for their functional limitations. This study examines the association of state HCBS expenditures with use of formal and informal personal assistance among non-institutionalized older Americans aged 70 and older with functional limitations. We conducted multilevel multinomial logistic regression analysis using data from the first wave of the Assets and Health Dynamics among the Oldest Old Survey, combined with data on state HCBS expenditures. Controlling for individuals' demographic, socioeconomic, and care needs factors, persons residing in states with higher HCBS expenditures were more likely to use formal personal assistance, but not less likely to use informal assistance. Our study suggests state variation in HCBS expenditures leads to inequitable access to formal personal assistance, especially among those with high functional limitations.

Aged↗
PubMed1998

The influence of households on drinking behaviour: a multilevel analysis.

This paper examines the influence of household membership and area of residence on individual drinking behaviour using a multilevel modelling approach. The effects are investigated using data from the Health Survey for England (HSE) in which multiple interviews were conducted in the same household. With the use of postal address, the data were organised into a hierarchical structure of individuals within households within enumeration districts. After controlling for characteristics of individuals thought to influence or correlate with drinking behaviour, unexplained variation in alcohol consumption was attributed to individual, household and area effects. Household influences on drinking behaviour far outweigh the influences of place of residence. Policies aimed at reducing alcohol consumption, particularly by heavy drinkers, may be best targeted at the household level.

Adolescent↗
PubMed2003

Occupational variations in drinking and psychological distress: a multilevel analysis.

The relationship between alcohol intake and psychological distress has been overlooked in studies on the working population. Using a multilevel multivariate model, this study reports results obtained from a sample of 8812 workers nested in 387 occupations. Results show that alcohol intake and psychological distress vary significantly at the worker and occupation levels, but they do not show a large variation at the occupation level. Occupational socioeconomic status appears to be a common factor explaining the correlation between alcohol intake and psychological distress at the occupation level. Semi-professionals, middle management, foreman and semiskilled clerical-sales-services occupations are particularly at risk. Gender is related to both outcomes, while work schedule and number of weekly working hours are associated only with psychological distress. Implications and limitations of these results are discussed.

Adolescent↗
PubMed2001

Does the state you live in make a difference? Multilevel analysis of self-rated health in the US.

This paper investigates the different sources of variation between US states in self-rated health using multilevel statistical procedures. The different sources that are considered are based on individual- and state-level factors. Data for the analysis comes from the 1993-94 Behavioral Risk Factor Surveillance System and the 1986-90 General Social Surveys. Results show that individual-level factors (such as low income, being black, smoking) are strongly associated with self-rated poor health. Significant variation, however, remain between states after allowing for individual characteristics. Crucially, between-state variation in self-rated health is different for different income groups. State-level contextual effects are found for per-capita median-income and 'social capital'. While not strong, there seems to be a differential impact of state income-inequality on high-income groups, such that the affluent report better health from living in high inequality states. The paper substantiates the need to connect individual health to their macro socioeconomic context. Importantly, it is argued that without adopting an explicitly multilevel approach, the debate on linkages between individual health and income-inequality/social capital cannot be adequately addressed.

Adolescent↗
PubMed1998

A multilevel analysis of factors affecting the longevity of fixed partial dentures, retainers and abutments.

There is a methodological problem in analysis of data belonging to different hierarchical levels, e.g. patient, arch, and tooth. A method for multilevel modelling (MLM) that resolves this problem is available. This method which is presented in this article, was used to reanalyse previously published long-term treatment results concerning the longevity of fixed partial dentures, retainers and abutments. The main results were consistent, indicating that no great faults were committed when using the conventional logistic regression method. There were, however, differences when calculating the combined risks for various situations. The conventional method was found to over- and underestimate probabilities of survival in different cases, compared to the MLM method. Especially when the most negative factors were combined, the conventional method had a tendency to underestimate the risk. For example, if an abutment had the combination 'endodontically treated'; 'FPD placed by 'another dentist''; 'distal abutment'; and 'marginal bone loss > 50%'; the probability of the tooth remaining after 18-23 years was only 20% according to the MLM method but 35% according to the conventional method. It was concluded that MLM is the method of choice for many situations in dental research where data belonging to different levels are to be analysed.

Dental Abutments↗
PubMedDate not supplied

Income inequality and health in Ontario: a multilevel analysis.

OBJECTIVE: To examine the association of income inequality at the public health unit level with individual health status in Ontario. METHODS: Cross-sectional multilevel study carried out among subjects aged 25 years or older residing in 42 public health units in Ontario. Individual-level data drawn from 30,939 respondents in 1996-97 Ontario Health Survey. Median area income and income inequality (Gini coefficient) calculated from 1996 census. Self-rated health status (SRH) and Health Utilities Index (HUI-3) scores were used as main outcomes. RESULTS: Controlling for individual-level factors including income, respondents living in public health units in the highest tercile of income inequality had odds ratios of 1.20 (95% CI 1.04 - 1.38) for fair/poor self-rated health, and 1.11 (95% CI 1.01 - 1.22) for HUI score below the median, compared with people living in public health units in the lowest tercile. Controlling further for median area income had little effect on the association. CONCLUSION: Income inequality was significantly associated with individual self-reported health status at public health unit level in Ontario, independent of individual income.

Adult↗
PubMed1998

Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis.

OBJECTIVE: To determine the effect of inequalities in income within a state on self rated health status while controlling for individual characteristics such as socioeconomic status. DESIGN: Cross sectional multilevel study. Data were collected on income distribution in each of the 50 states in the United States. The Gini coefficient was used to measure statewide inequalities in income. Random probability samples of individuals in each state were collected by the 1993 and 1994 behavioural risk factor surveillance system, a random digit telephone survey. The survey collects information on an individual's income, education, self rated health and other health risk factors. SETTING: All 50 states. SUBJECTS: Civilian, non-institutionalised (that is, non-incarcerated and non-hospitalised) US residents aged 18 years or older. MAIN OUTCOME MEASURE: Self rated health status. RESULTS: When personal characteristics and household income were controlled for, individuals living in states with the greatest inequalities in income were 30% more likely to report their health as fair or poor than individuals living in states with the smallest inequalities in income. CONCLUSIONS: Inequality in the distribution of income was associated with an adverse impact on health independent of the effect of household income.

Adolescent↗
PubMed1997

Using the 1991 Census SAR in a multilevel analysis of male unemployment.

"The Sample of Anonymised Records drawn from the 1991 [United Kingdom] Census is used to model geographical, demographic, and socioeconomic variations in male unemployment by means of multilevel logit models. The underlying structure of the problem is such that cells in a multiway cross-tabulation of individual characteristics (level 1) are nested within places (level 2). Geographical variations in male unemployment are found even after allowing for age, marital status, ethnicity, higher education qualifications, social class, and industry."

Developed Countries↗
PubMed1999

A multilevel analysis of factors affecting pocket probing depth in patients responding differently to periodontal treatment.

3 distinct levels are involved in the periodontal inflammatory process: site, tooth, and individual. By focusing attention on the levels in the population, multilevel or hierarchical modelling (MLM) enables the researcher to understand where and how the effects at the levels involved are occurring. The aim of this paper is therefore to analyse the progression of periodontal disease using analytical models that consider the level hierarchy. 22 patients with periodontitis, in previous reports described as either non-responsive or responsive to periodontal treatment, were investigated. In the multilevel modelling method (MLM), the site pocket probing depth (PPD) is summarised in 3 parameters: the overall mean, the between-individual variance, and the within-individual, between-site variance. The model can readily be extended to include independent variables for sites, teeth and individuals. If these variables are important determinants of PPD, their inclusion in the model will lead to a reduction in residual variances between sites, teeth and individuals. The PPDs were used for construction of a PPD change variable (cPPD). This variable, together with the final registrations of PPD (fPPD) alone, were used as dependent variables in the MLM. Independent predictor variables, 12 on site-level, 3 on tooth-level, and 19 on individual-level, were constructed. The total number of sites assessed was 2236 distributed on 559 teeth in 22 subjects. Initially, a fixed, fully unconditional model (models A and E) was assessed, where no predictor variables were specified at any level. Different random-intercept models (B-D, F-H) were then calculated where the independent variables were inserted in blocks relating to each level. The variance components at all 3 levels were significantly larger than zero. This indicates that MLM is recommended for analysing the present data. The inserted predictors showed 100% sensitivity relating to the subject-level variance. Subsequent testing of the patient with disease or at high risk of disease would have to focus on diagnostic tests aimed at the individual teeth and sites. These tests would need to have a balance of sensitivity and specificity. Thus, by using multilevel modelling, the theoretical understanding of important factors in the pathogenesis of periodontitis is stimulated.

Adult↗
PubMed2003

Condom use for preventing HIV infection/AIDS in sub-Saharan Africa: a comparative multilevel analysis of Uganda and Tanzania.

This study explored the relationships between individual-, household-, and community-level variables and condom use to prevent HIV infection in women and men in Uganda and Tanzania using multilevel modeling. Using data from the Demographic and Health Surveys for Uganda (1995) and Tanzania (1996) as well as data collected by the MEASURE Evaluation Project at the Carolina Population Center for Tanzania (1996 and 1999), the study found higher condom use among men than women. There was also heterogeneity in condom use among different clusters for both women and men. More specifically, women and men living in clusters with higher indicators of development were more likely to use condoms to prevent HIV infection. In addition, condom use was much more prevalent in areas where health care services were nearby (0-5 km). In addition, condom use was more common among women (but not men) who lived in clusters where HIV/AIDS testing, counseling, and treatment were provided. The results further revealed that education improved condom use; however, the effect of education was considerably reduced in the models that included HIV/AIDS knowledge and cluster-level variables. The positive effect of household wealth on condom use also diminished after controlling for the effects of the knowledge and cluster-level factors. Knowledge about HIV and perceiving oneself to be at risk for contracting HIV infection improved condom use.

Acquired Immunodeficiency Syndrome↗
PubMed2003

Income inequality and health: multilevel analysis of Chilean communities.

STUDY OBJECTIVE: The evidence supporting the effect of income inequality on health has been largely observed in societies far more egalitarian than the US. This study examines the cross sectional multilevel associations between income inequality and self rated poor health in Chile; a society more unequal than the US. DESIGN: A multilevel statistical framework of 98 344 people nested within 61 978 households nested within 285 communities nested within 13 regions. SETTING: The 2000 National Socioeconomic Characterization Survey (CASEN) data from Chile. PARTICIPANTS: Adults aged 18 and above. The outcome was a dichotomised self rated health (0 if very good, good or average; 1 if poor, or very poor). Individual level exposures included age, sex, ethnicity, marital status, education, employment status, type of health insurance, and household level exposures include income and residential setting (urban/rural). Community level exposures included the Gini coefficient and median income. MAIN RESULTS: Controlling for individual/household predictors, a significant gradient was observed between income and poor self rated health, with very poor most likely to report poor health (OR: 2.94) followed by poor (OR: 2.77), low (OR: 2.06), middle (OR: 1.73), high (OR: 1.38) as compared with the very high income earners. Controlling for household and community effects of income, a significant effect of community income inequality was observed (OR:1.22). CONCLUSIONS: Household income does not explain any of the between community differences; neither does it account for the effect of community income inequality on self rated health, with more unequal communities associated with a greater probability of reporting poor health.

Adolescent↗
PubMed2005

International differences in the impact of doctors on health: a multilevel analysis of OECD countries.

This paper aims to measure whether there are country variations in the efficiency of the physician workforce in reducing various measures of mortality across 21 OECD countries over 3 decades. It utilises a multilevel modelling approach both to measure country variations in physician efficiency and to explore the determinants of these variations. The results suggested that physician numbers are an important determinant of mortality across OECD countries, and cross-country heterogeneity in the effect of physician availability on health is significant. We also found that availability of advanced medical technology is an important factor intervening in this relationship.

Delivery of Health Care↗
PubMed1997

People, places and coronary heart disease risk factors: a multilevel analysis of the Scottish Heart Health Study archive.

The Scottish Heart Health Study (SHHS), which recruited 5123 men and 5236 women between 1984 and 1986, was set up in part to investigate geographical variation in coronary heart disease in Scotland. Multilevel models are particularly appropriate for such hierarchical data, in which the individuals in the study can be represented by the lower level and the districts in which they live by the higher level. Multilevel models are presented for four coronary heart disease risk factors-diastolic blood pressure, cholesterol, alcohol consumption (defined both as units of alcohol consumed per week and as being a non-drinker) and smoking, for men and women separately. Significant district level variance was found for three out of the four variables studied, after controlling for socioeconomic and other variables considered at the level of the individual. These were for diastolic blood pressure, cholesterol and alcohol. Although the large majority of the variance was present at the individual level, the existence of significant variance at the district level is evidence that places may have a role in the distribution of coronary heart disease risk. Health policy aimed at reducing coronary heart disease should therefore consider the characteristics of places as well as individuals.

Alcohol Drinking↗