Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “multilevel analysis”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 127 records · Page 7Linked to original sources
PubMed2004

Country of birth, socioeconomic position, and healthcare expenditure: a multilevel analysis of Malmö, Sweden.

STUDY OBJECTIVE: The principle of equity aims to guarantee allocation of healthcare resources on the basis of need. Therefore, people with a low income and persons living alone are expected to have higher healthcare expenditures. Besides these individual characteristics healthcare expenditure may be influenced by country of birth. This study therefore aimed to investigate the role of country of birth in explaining individual healthcare expenditure. DESIGN: Multilevel regression model based on individuals (first level) and their country of birth (second level). SETTING: The city of Malmö, Sweden. PARTICIPANTS: All the 52 419 men aged 40-80 years from 130 different countries of birth, who were living in Malmö, Sweden, during 1999. MAIN RESULTS: At the individual level, persons with a low income and persons living alone showed a higher healthcare expenditure, with regression coefficients (and 95% confidence intervals) being 0.358 (0.325 to 0.392) and 0.197 (0.165 to 0.230), respectively. Country of birth explained a considerable part (18% and 13%) of the individual differences in the probability of having a low income and living alone, respectively. However, this figure was only 3% for having some health expenditure, and barely 0.7% with regard to costs in the 74% of the population with some health expenditure. CONCLUSIONS: Malmö is a socioeconomically segregated city, in which the country of birth seems to play only a minor part in explaining individual differences in total healthcare expenditure. These differences seem instead to be determined by individual low income and living alone.

Adult↗
PubMed2005

Hospital quality improvement in context: a multilevel analysis of staff job evaluations.

OBJECTIVE: To investigate how much of the variance in data on nurse evaluation of different aspects of hospital work can be attributed to individual, ward, department and hospital levels, and to discuss the implication of the findings on quality improvement strategies. DESIGN AND METHOD: National survey data of work experiences were collected from hospital nurses working at 124 hospital wards in 36 departments in 15 hospitals across Norway during the autumn of 1998. The multilevel structure of the variation of nine indices of job satisfaction was explored by fitting four-level random intercept models (nurse, ward, department and hospital). RESULTS: A total of 2606 nurses (66%) responded. The indices showed varying clustering to organizational units. Intraclass correlations (ICCs) varied from 0.05 to 0.38, representing considerable higher level variation. The ward level was the dominating level for the clustering of nurses' job aspect evaluations. CONCLUSION: Multilevel modelling of staff work experiences may identify which improvement goals can be addressed at which organizational level. Improvement efforts should be directed specifically towards each aspect of work and at its most relevant organizational level. Strategies aimed at the micro-organizational level (ward management) rather than the individual level or the macro level (hospital top management) might prove worthwhile.

Adult↗
PubMed2006

Validation of the thoracic impedance derived respiratory signal using multilevel analysis.

The purpose of the current study was to validate the change in thoracic impedance (dZ) derived respiratory signal obtained from four spot electrodes against incidental spirometry. Additionally, a similar validation was performed for a dual respiratory belts signal to compare the relative merit of both methods. Participants were 38 healthy adult subjects (half male, half female). Cross-method comparisons were performed at three (paced) respiration frequencies in sitting, supine and standing postures. Multilevel regression was used to examine the within- and between-subjects structure of the relationship between spirometric volume and the respiratory amplitude signals obtained from either dZ or respiratory belts. Both dZ derived respiratory rate and dual belts derived respiratory rate accurately reflected the pacing frequencies. For both methods, fixed factors indicated acceptable but posture-specific regression on spirometric volume. However, random factors indicated large individual differences, which was supported by variability of gain analyses. It was concluded that both the dZ and dual belts methods can be used for measurement of respiratory rate and within-subjects, posture-specific, changes in respiratory volume. The need for frequent subject-specific and posture-specific calibration combined with relatively large measurement errors may strongly limit the usefulness of both methods to assess absolute tidal volume and minute ventilation in ambulatory designs.

Adolescent↗
PubMed2006

Individual, neighborhood, and state-level predictors of smoking among US Black women: a multilevel analysis.

Baseline data from the Black Women's Health Study (BWHS) were analyzed to assess the relation of smoking to individual, neighborhood, and state socioeconomic characteristics. Data on smoking status and individual socioeconomic characteristics were obtained via a self-administered postal questionnaire at entry. Neighborhood characteristics of 41,726 never and current smokers were obtained by linking participants' addresses with census tract data from the 1990 US Census. In a multilevel logistic regression model, higher neighborhood poverty was associated with increased smoking prevalence after adjusting for age, education, marital status, and occupation at the individual level, and percent high school graduate, percent college graduate, and percentage Black at the neighborhood level. Relative to women residing in neighborhoods with less than 5% of the residents below the poverty line, the odds ratio was 1.1 (95% confidence interval: 1.0-1.2) for women in neighborhoods with 5-9.9% of the residents below the poverty line, 1.3 (1.2-1.4) for women in neighborhoods with 10-19.9% of the residents below the poverty line, and 1.6 (1.5-1.8) for women in neighborhoods with 20% or more of the residents below poverty. State of residence was also significantly associated with prevalence of current smoking. These results suggest that contextual factors (at both the neighborhood and state level) play a role in Black women's smoking behaviors over and above individual characteristics.

Adult↗
PubMed2006

Performance assessment in the context of multiple objectives: a multivariate multilevel analysis.

The pursuit of multiple objectives by public sector organisations makes it difficult to assess and compare their performance. Considering objectives in isolation ignores the possibility of correlations between objectives, and a single index of performance requires subjective judgements to be made about the relative value of each objective. An alternative approach is to estimate a multivariate system of equations in which objectives are analysed individually but correlations across objectives are considered explicitly. We analyse the performance of English health authorities against 13 objectives using hierarchical data for electoral wards that are nested within health authorities. We find evidence of correlation across objectives, suggesting that some are complementary and others subject to trade-off. The estimates generated when assessing performance with multivariate multilevel models as compared to ordinary least squares or multilevel models differ, with the magnitudes varying by objective and health authority.

Efficiency, Organizational↗
PubMed2007

A multilevel analysis on the determinants of regional health care expenditure: a note.

Health care in most countries is a rather "local good" for which the fiscal decentralization theory applies and heterogeneity is the result. In order to address the issue of multijurisdictional health care in estimating income elasticity, we constructed a unique sample using data for 110 regions in eight Organisation for Economic Co-operation and Development (OECD) countries in 1997. We estimated this sample data with a multilevel hierarchical model. In doing this, we tried to identify two sources of random variation: within- and between-country variation. The basic purpose was to find out whether the different relationships between health care spending and the explanatory variables are country specific. We concluded that to take into account the degree of fiscal decentralization within countries in estimating income elasticity of health expenditure proves to be important. Two plausible reasons lie behind this: (a) where there is decentralization to the regions, policies aimed at emulating diversity tend to increase national health care expenditure and (b) without fiscal decentralization, central monitoring of finance tends to reduce regional diversity and therefore decrease national health expenditure. The results of our estimation do seem to validate both these points.

Age Factors↗
PubMed2000

A multilevel analysis of income inequality and cardiovascular disease risk factors.

Recent research has suggested that inequality in the distribution of income is associated with increased mortality, even after accounting for average income levels. Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we investigated whether inequality in the distribution of income within US states is related to the prevalence of four cardiovascular disease risk factors (body mass index (BMI), history of hypertension, sedentarism, and smoking). Multilevel models (including both state-level and individual-level variables) were used to examine associations of state inequality with risk factor levels before and after adjustment for individual-level income. For three of the four risk factors investigated (BMI, hypertension, and sedentarism), state inequality was associated with increased risk factor levels, particularly at low income levels (annual household incomes <$25,000), with associations persisting after adjustment for individual-level income. Inequality was also positively associated with smoking, but associations were either stronger or only present at higher income levels. Associations of inequality with the outcomes were statistically significant in women but not in men. Although not conclusive, findings for three of the four risk factors are suggestive of a contextual effect of income inequality, particularly among persons with lower incomes.

Adult↗
PubMed1992

Social psychological contributions to the decade of the brain. Doctrine of multilevel analysis.

The 1990s were declared by Congress to be the "decade of the brain." This declaration is important to all psychologists, not only neuroscientists, because with this declaration come expectations of the cognitive and behavioral sciences generally and because the brain does not exist in isolation but rather is a fundamental component of developing and aging individuals who themselves are mere actors in the larger theater of life. This article examines the importance of a multilevel, integrative approach to the study of mental and behavioral phenomena in the decade of the brain, reviews how this approach highlights the synergistic relationship between theoretical and clinically relevant research, and illustrates how this approach can foster the transition from microtheories to general psychological theories.

Behavior↗
PubMed2000

Evidence of a structural effect for alcohol outlet density: a multilevel analysis.

BACKGROUND: Ecological studies reveal that alcohol-related outcomes tend to occur in high alcohol outlet density neighborhoods. The ecological design of these studies limits the interpretation of the findings in terms of the level of the effect. The effect of alcohol outlet density could be related to greater individual access to alcohol, an individual level effect, or to the grouping of drinkers by neighborhood, a structural effect at the neighborhood level. METHODS: To differentiate between individual and neighborhood level possibilities, we conducted a multilevel study. Individual distance to the closest alcohol outlet was the individual level measure of the effect of alcohol outlet density, whereas the mean distance to the closest alcohol outlet for all individuals within a census tract was the neighborhood level measure for the effect of alcohol outlet density. We analyzed telephone surveys of 2604 telephone households within 24 census tracts stratified by poverty status and alcohol outlet density. Individual distance to alcohol outlets, age, sex, race/ethnicity, and level of education were entered as individual level covariates, and their corresponding aggregated means were entered as census tract level covariates (i.e., mean distance to outlets, mean age, percentage male, percentage Black, mean education). RESULTS: Analysis of variance revealed that 16.2% of the variance in drinking norms and 11.5% of the variance in alcohol consumption were accounted for at the census tract level. In multivariate hierarchical analysis, individual distance to the closest alcohol outlet was unrelated with drinking norms and alcohol consumption, whereas mean distance to the closest alcohol outlet demonstrated a negative relation with drinking norms (betae = -5.50+/-2.37) and with alcohol consumption (betae = -0.477+/-0.195); that is, the higher the mean distance to the closest alcohol outlet, the lower the mean drinking norms score and mean level of alcohol consumption. CONCLUSIONS: The findings suggest that the effect of alcohol outlet density on alcohol-related outcomes functions through an effect at the neighborhood level rather than at the individual level. Problem drinkers tend to be grouped in neighborhoods, an effect predicted by alcohol outlet density.

Adult↗
PubMed2005

Discretionary hospitalization of nursing home residents with and without Alzheimer's disease: a multilevel analysis.

UNLABELLED: This study analyzes facility variations in hospital admission rates of nursing home (NH) residents with and without Alzheimer's disease (AD) or related dementia with the aim of better understanding how facility-level contextual factors differentially affect hospitalization risks. METHOD: The sample population consists of 19,217 and 18,399 Medicaid residents with and without AD, respectively, from 546 NHs in Massachusetts between 1991 and 1993. Hospital use is measured as annual nonpsychiatric discretionary hospital admissions to short-term general hospitals. Multilevel estimation methods are used to obtain facility and market area parameter estimates. RESULTS: There was greater interfacility variation in discretionary hospital admission rates of AD residents than residents without AD, particularly among more vulnerable subgroups of AD residents. DISCUSSION: The findings underscore the importance of licensed nursing personnel in reducing discretionary hospitalizations among NH residents with AD.

Aged↗
PubMed2004

Traffic stress, vehicular burden and well-being: a multilevel analysis.

This study examined whether health is associated with individually perceived traffic stress and as well as ecologically measured vehicular burden using multi-level analysis. Data from the Chinese American psychiatric epidemiologic study (N = 1503) are linked to data from the 1990 Census in the United States. Hierarchical linear modeling was used to analyze the cross-sectional relationship between traffic stress, neighborhood conditions, depression and health status. Perceived traffic stress is associated with both general health status and depression in multivariate multilevel models, such that persons reporting traffic stress had lower health status and more depressive symptoms. Further, there is an interaction between vehicular burden and traffic stress for both health outcomes. Persons who lived in areas with greater vehicular burden and who reported the most traffic stress also had the lowest health status and greatest depressive symptoms. These findings suggest that traffic stress may represent an important factor that influences the well-being of urban populations, and that studies which examine factors at only one level (either individual level only or ecological level only) may underestimate the effect of the social environment.

Adult↗
PubMed2005

County level socioeconomic position, work organization and depression disorder: a repeated measures cross-classified multilevel analysis of low-income nursing home workers.

UNLABELLED: This study simultaneously tests the effect of county, organizational, workplace, and individual level variables on depressive disorders among low-income nursing assistants employed in US nursing homes. A total of 482 observations are used from two waves of survey data collection, with an average two-year interval between initial and follow-up surveys. The overall response rate was 62 percent. The hierarchically structured data was analyzed using multilevel modeling to account for cross-classifications across levels of data. Nursing assistants working in nursing homes covered by a single union in three states were asked about aspects of their working conditions, job stress, physical and mental health status, individual and family health-care needs, household economics and household strain. PARTICIPANTS: The 241 nursing assistants who participated in this study were employed in 34 nursing homes and lived in 49 counties of West Virginia, Ohio and Kentucky. MAIN RESULTS: The study finds that emotional strain, related to providing direct care to elderly and disabled clients, is associated with depressive disorder, as is nursing home ownership type (for-profit versus not-for-profit). However, when controlling for county level socioeconomic variables (Gini index and proportion of African Americans living in the county), neither workplace nor organizational level variables were found to be statistically significant associated with depressive disorder. CONCLUSIONS: This study supports previous findings that emotional demand in health-care environments is an important correlate of mental health. It also adds empirical evidence to support a link between financial strain and depression in US women. While this study does not find that lack of a seniority wage benefits--a factor that can conceivably exacerbate financial strain over time--is associated with depressive disorder among low-income health-care workers, it does find county level measures of poverty to be statistically significant predictors of depressive disorder. Longitudinal county level measures of low-income as predictors of depression may even offer a methodological advantage in that they are presumably more stable indicators of cumulative exposure of low income than are more transient workplace indicators. Incorporating measures of cumulative exposure to low income into empirical studies would be particularly timely given the global changes that are currently restructuring the labor force and influencing work organization and labor processes--most notably the growth in low income jobs and the deskilling of labor. Though this study provides evidence that workplace and organizational level variables are associated with depressive disorder among low-wage nursing assistants in US nursing homes, the fact that these relationships do not hold once county level measures of poverty are controlled for, suggests that more distal upstream determinants of workplace mental health problems, such economic inequality, may be at play in determining the mental health of low wage workers.

Adult↗
PubMed2006

Multilevel analysis of individual and contextual factors as predictors of return to work.

OBJECTIVE: The objective of this study was to examine if individual and contextual levels of work environment factors predict return to work (RTW). METHODS: Baseline data from 52 workplaces was linked to a national absence register. Four hundred twenty-eight persons with more than 2 weeks of sickness absence during a 2-year period were identified. Follow up was 1 year to examine three RTW outcomes. Multilevel logistic and Poisson regression models were used. RESULTS: At the individual level, significant associations were found between one psychosocial and four physical factors and RTW within 4 weeks. Two physical factors predicted RTW within 1 year. Two psychosocial and two physical factors significantly prolonged duration of sickness absence. No significant contextual level risk factors were found. CONCLUSION: At the individual level, both the psychosocial and physical work environment factors are important independent predictors of RTW.

Absenteeism↗
PubMed1997

Neighborhood risk factors for low birthweight in Baltimore: a multilevel analysis.

OBJECTIVES: Past research on low birthweight has focused on individual-level risk factors. We sought to assess the contribution of macrolevel social factors by using census tract-level data on social stratification, community empowerment, and environmental stressors. METHODS: Census tract-level information on social risk was linked to birth certificate records from Baltimore, Md, for the period 1985 through 1989. Individual level factors included maternal education, maternal age, medical assistance health insurance (Medicaid), and trimester of prenatal care initiation. Methods of multilevel modeling using two-stage regression analyses were employed. RESULTS: Macrolevel factors had both direct associations and interactions with low birthweight. All individual risk factors showed interaction with macrolevel variables; that is, individual-level risk factors for low birthweight behaved differently depending upon the characteristics of the neighborhood of residence. For example, women living in high-risk neighborhoods benefited less from prenatal care than did women living in lower-risk neighborhoods. CONCLUSIONS: Multilevel modeling is an important tool that allows simultaneous study of macro- and individual-level risk factors. Multilevel analyses should play a larger role in the formulation of public health policies.

Baltimore↗
PubMed2001

A multilevel analysis of the effects of rurality and social deprivation on premature limiting long term illness.

STUDY OBJECTIVE: To examine the geographical variation in self perceived morbidity in the south west of England, and assess the associations with rurality and social deprivation. DESIGN: A geographically based cross sectional study using 1991 census data on premature Limiting Long Term Illness (LLTI). The urban-rural and intra-rural variation in standardised premature LLTI ratios is described, and correlation and regression analyses explore how well this is explained by generic deprivation indices. Multilevel Poisson modelling investigates whether Customized Deprivation Profiles (CDPs) and area characteristics improve upon the generic indices. SETTING: Nine counties in the south west of England PARTICIPANTS: The population of the south west enumerated in the 1991 census. MAIN RESULTS: Intra-rural variation is apparent, with higher rates of premature LLTI in remoter areas. Together with high rates in urban areas and lower rates in the semi-rural areas this indicates the existence of a U shaped relation with rurality. The generic deprivation indices have strong positive relations with premature LLTI in urban areas, but these are a lot weaker in semi-rural and rural locations. CDPs improve upon the generic indices, especially in the rural settings. A substantial reduction in unexplained variation in rural areas is seen after controlling for the level of local isolation, with higher isolation, at the wider geographical scale, being related to higher levels of LLTI. CONCLUSIONS: This study highlights the need to treat rural areas as heterogeneous, although this has not been the tendency in health research. Generic deprivation indices are unlikely to be a true reflection of levels of deprivation in rural environments. The importance of CDPs that are specific to the area type and health outcome is emphasised. The significance of physical isolation suggests that accessibility to public and health services may be an important issue, and requires further research.

Adolescent↗
PubMed2006

Neighborhood social participation, use of anxiolytic-hypnotic drugs, and women's propensity for disability pension: a multilevel analysis.

AIMS: The increasing number of people on disability pension in Sweden is of concern for Swedish policy-makers, and there is a need for a better understanding of the mechanisms behind disability pension. We investigated (i) whether women living in the same neighborhood have a similar propensity for disability pension that relates to neighborhood social participation, and (ii) whether there is an association between anxiolytic-hypnotic drug (AHD) use and disability pension in women that is modified by the neighborhood context. METHODS: We used multilevel logistic regression with 12,156 women aged 45 to 64 (first level) residing in 95 neighborhoods (second level) in the city of Malmö (250,000 inhabitants), Sweden, who participated in the Malmö Diet and Cancer Study (1991-96). RESULTS: Both AHD use (OR = 2.09, 95% CI 1.65, 2.65) and neighborhood rate of low social participation (OR = 11.85, 95% CI 5.09, 27.58) were associated with higher propensity for disability pension. The interval odds ratio indicated that the influence of neighborhood social participation was large compared with the unexplained variance between the neighborhoods. The association between AHD use and disability pension was not modified by the neighborhood context. The median odds ratio was 1.44 after adjusting for individual characteristics and 1.27 after the additional adjusting for neighborhood social participation. CONCLUSIONS: Women living in the same neighborhood appear to have a similar propensity for disability pension, beyond individual characteristics, and this contextual effect seems largely explained by neighborhood social participation. In addition, AHD use might increase the propensity for disability pension in women.

Anti-Anxiety Agents↗
PubMed2005

Multilevel analysis of associations between socioeconomic status and injury among Canadian adolescents.

STUDY OBJECTIVE: To determine the contribution of individual and area level measures of socioeconomic status (SES) to the occurrence of various injury types among Canadian adolescents. DESIGN AND SETTING: Cross sectional Canadian data were used from two sources: (1) the 2001/02 health behaviour in school aged children survey (individual level SES measures, injury measures), and (2) the 2001 Canada census of population (area level SES measures). Injury outcomes included: medically treated injury, injury hospitalisation, sport/recreational injury, and fighting injury. Multilevel logistic regression models were used to examine individual and area level SES measures as potential determinants of adolescent injury. PARTICIPANTS: 7235 students in grades 6-10 from 170 schools across Canada. MAIN RESULTS: Associations between SES and injury were identified for each injury outcome examined, although a clear direction of association was not present for the overall measure of medically treated injury. In general, lower SES was associated with increased risk for hospitalised and fighting injury. Higher SES was associated with increased risks for sport/recreational injury. Independent contributions of individual and area level measures of SES were seen for hospitalised and fighting injury. CONCLUSIONS: Associations between SES and adolescent injury exist; however, the direction of these relations becomes more apparent with particular indicators of SES and when homogenous injury outcomes are evaluated.

Adolescent↗
PubMed2005

Low adherence with antihypertensives in actual practice: the association with social participation--a multilevel analysis.

BACKGROUND: Low adherence is a key factor in explaining impaired effectiveness and efficiency in the pharmacological treatment of hypertension. However, little is known about which factors determine low adherence in actual practice. The purpose of this study is to examine whether low social participation is associated with low adherence with antihypertensive medication, and if this association is modified by the municipality of residence. METHODS: 1288 users of antihypertensive medication were identified from The Health Survey in Scania 2000, Sweden. The outcome was low adherence with antihypertensives during the last two weeks. Multilevel logistic regression with participants at the first level and municipalities at the second level was used for analyses of the data. RESULTS: Low social participation was associated with low adherence with antihypertensives during the last two weeks (OR = 2.05, 95% CI: 1.05-3.99), independently of low educational level. However, after additional adjustment for poor self-rated health and poor psychological health, the association between low social participation and low adherence with antihypertensives during the last two weeks remained but was not conclusive (OR = 1.80, 95% CI: 0.90-3.61). Furthermore, the association between low social participation and low adherence with antihypertensives during the last two weeks varied among municipalities in Scania (i.e., cross-level interaction). CONCLUSION: Low social participation seems to be associated with low adherence with antihypertensives during the last two weeks, and this association may be modified by the municipality of residence. Future studies aimed at investigating health-related behaviours in general and low adherence with medication in particular might benefit if they consider area of residence.

Adult↗