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PubMed2002

Swallowing and speech dysfunction in patients undergoing anterior cervical discectomy and fusion: a prospective, objective preoperative and postoperative assessment.

Swallowing difficulties and dysphonia may occur in patients undergoing anterior cervical discectomy and fusion. The etiology and incidence of these abnormalities, however, are not well defined. In view of this, we performed a prospective, objective analysis of swallowing function and vocal cord approximation in patients undergoing anterior cervical discectomy and fusion. Twenty-three consecutive patients (22 male and one female, mean age 59 years) undergoing anterior cervical discectomy and fusion had standardized modified barium swallow study and videolaryngoendoscopy performed preoperatively and again at 1 week and 1 month postoperatively. Eleven patients (48%) had radiographic evidence of preoperative swallowing abnormalities. The majority of these patients had myelopathic rather than radicular findings (p = 0.03). None, however, had symptoms of swallowing dysfunction. Among these patients, one had worse function postoperatively, three had improvement, and function remained unchanged in seven. The preoperative swallowing assessment was normal in 12 patients (52%). Postoperative radiographic swallowing abnormalities were demonstrated in eight of these patients (67%). Preoperative vocal cord movement was normal in all patients. Postoperatively, vocal cord paresis was detected in two patients. The paresis was transient in one and permanent in the other. Age, previous medical history, operation duration, and spinal level decompressed were not significantly associated with the incidence of swallowing dysfunction. There was, however, a tendency for patients undergoing multilevel surgery to demonstrate an increased incidence of swallowing abnormalities on postoperative radiographic studies. In addition, soft tissue swelling was more frequent in patients whose swallowing function was worse postoperatively (p = 0.007). Postoperative voice and swallowing dysfunction are common complications of anterior cervical discectomy and fusion, although in the majority of patients these abnormalities are not symptomatic. Patients undergoing multilevel procedures are at an increased risk for these complications, in part because of soft tissue swelling in the neck.

Adult↗
PubMed2005

Open vertebral cement augmentation combined with lumbar decompression for the operative management of thoracolumbar stenosis secondary to osteoporotic burst fractures.

Osteoporotic burst fractures with neurologic symptoms are typically treated with neural decompression and multilevel instrumented fusion. These large surgical interventions are challenging because of patients' advanced ages, medical co-morbidities, and poor fixation secondary to osteoporosis. The purpose of this retrospective clinical study was to describe a novel technique for the treatment of osteoporotic burst fractures and symptomatic spinal stenosis via a limited thoracolumbar decompression with open cement augmentation [vertebroplasty (VP) or kyphoplasty (KP)]. Indications for decompression and cement augmentation were intractable pain at the level of a known osteoporotic burst fracture with symptoms of spinal stenosis. As such, 25 patients (mean age, 76.1 years) with low-energy, osteoporotic, thoracolumbar burst fractures (7 males, 18 females; 39 fractures) were included. In all cases, laminectomy of the stenotic level(s) was followed by vertebral cement augmentation (9 VP; 16 KP). When a spondylolisthesis at the decompressed level was present, instrumentation was applied across the listhetic level (n = 9). Clinical outcome (1 = poor to 4 = excellent) was assessed on last clinical follow-up (mean, 44.8 wks). In addition, a modified MacNab's grading criteria was used to objectively assess patient outcomes postoperatively. Radiographic analysis of sagittal contour was assessed preoperatively, immediately postoperatively, and at final follow-up. The average time from onset of symptoms to intervention was 19 weeks (range, 0.3-94 wks). A mean of 1.6 fractures/patient was augmented (range, 1-3 fractures) and 2.8 levels were decompressed (range, 1-6 levels). No statistical difference in anatomic distribution or number of fractures between the VP and KP groups or in the instrumented versus noninstrumented patients was noted (P > 0.05). An overall subjective outcome score of 3.4 was noted. Twenty of 25 patients were graded as excellent/good according to the modified MacNab's criteria. The choice of augmentation procedure or use of instrumentation did not predict outcome (P = 0.08). Overall, 1.7 degrees of sagittal correction was obtained at final follow-up. One patient was noted to have progressive kyphosis after KP. The use of a limited-posterior decompression and open cement augmentation via VP or KP is a safe treatment option for patients who have osteoporotic burst fractures and who are incapacitated from fracture pain and concomitant stenosis. After thoracolumbar decompression, open VP/KP provides direct visualization of the posterior vertebral body wall, allowing for safe cement augmentation of burst fractures, stabilizing the spine, and obviating the need for extensive spinal reconstruction. Although clinically successful, this technique warrants careful patient selection.

Aged↗
PubMed2005

Quantification of mortality risk after abdominal aortic aneurysm repair.

BACKGROUND: The study was designed to evaluate the Acute Physiology And Chronic Health Evaluation (APACHE) II risk scoring system in abdominal aortic aneurysm (AAA) surgery. The aim was to create an APACHE-based risk stratification model for postoperative death. METHODS: Prospective postoperative APACHE II data were collected from patients undergoing AAA repair over a 9-year interval from 24 intensive care units (ICUs) in the Thames region. A multilevel logistic regression model (APACHE-AAA) for in-hospital mortality was developed to adjust for both case mix and the variation in outcome between ICUs. RESULTS: A total of 1896 patients were studied. The in-hospital mortality rate among the 1289 patients who had elective AAA repair was 9.6 (95 per cent confidence interval (c.i.) 8.0 to 11.2) per cent and that among the 605 patients who had an emergency repair was 46.9 (95 per cent c.i. 43.0 to 50.9) per cent. Four independent predictors of death were identified: age (odds ratio (OR) 1.05 (95 per cent c.i. 1.03 to 1.07) per year increase), Acute Physiology Score (OR 1.14 (95 per cent c.i. 1.12 to 1.17) per unit increase), emergency operation (OR 4.86 (95 per cent c.i. 3.64 to 6.52)) and chronic health dysfunction (OR 1.43 (95 per cent c.i. 1.04 to 1.97)). The APACHE-AAA model was internally valid, as shown by calibration (Hosmer-Lemeshow C statistic: chi(2) = 6.14, 8 d.f., P = 0.632), discrimination properties (area under receiver-operator characteristic curve 0.845) and subgroup analysis. There was no significant variation in outcome between hospitals. CONCLUSION: APACHE-AAA was shown to be an accurate risk-stratification model that could be used to quantify the risk of death after AAA surgery. It might also be used to determine the relative impact of ICU over high-dependency unit care.

APACHE↗
PubMed1994

Biomechanical analysis of cervical stabilization systems. An assessment of transpedicular screw fixation in the cervical spine.

STUDY DESIGN: The biomechanical stability of seven cervical reconstruction methods including the transpedicular screw fixation was evaluated under four instability patterns. These four modalities, based on the range and grade of instability, allowed a reproducible biomechanical assessment to establish the in vitro role of internal fixation in the cervical spine. OBJECTIVES: This study biomechanically investigated the stability of seven reconstruction methods in the cervical spine as influenced by four instability patterns and assessed whether three-column fixation for the cervical spine using transpedicular screw fixation would provide increased stability over that of conventional cervical fixation systems. METHODS: A total of 24 calf cervical spine specimens were divided into four experimental groups. The spinal constructs including seven reconstruction techniques--the posterior AO titanium reconstruction plate, Bohlman's posterior triple-wiring, transpedicular screw fixation, anterior iliac bone graft, anterior AcroMed plate, anterior AO titanium locking plate, and combined fixation with the AO anterior plate and posterior triple-wiring--were tested under four loading modes. RESULTS: Anterior plating methods provided less stability than that of posterior constructs under axial, torsional, and flexural loading conditions. Exclusive posterior procedures provided increased stability compared with the intact spine in one level fixation, however, did not sustain the torsional stability when the anterior and middle column was eliminated in two-level fixation. The stabilizing capabilities of both the combined fixation and transpedicular screw fixation were clearly demonstrated in all loading modes, however, those of the latter were superior in multilevel fixation. CONCLUSION: Front and back approaches, employing the anterior plate and posterior triple-wiring, and transpedicular screw fixation demonstrated clear biomechanical advantages when the extent of instability increased to three-column or multilevel. Three-column fixation for the cervical spine using transpedicular screw fixation offers increased stability over that of conventional cervical fixation systems, particularly in multiple level constructs.

Animals↗
PubMed2006

The prevalence and clustering of four major lifestyle risk factors in an English adult population.

BACKGROUND: The aim of this study was to examine the clustering of four major lifestyle risk factors (smoking, heavy drinking, lack of fruit and vegetables consumption, and lack of physical activity), and to examine the variation across different socio-demographic groups in the English adult population. METHODS: The study population was derived from the 2003 Health Survey for England (n=11,492). Clustering was examined by comparing the observed and expected prevalence of the different possible combinations. A multinomial multilevel regression model was conducted to examine the socio-demographic variation in the clustering of the four risk factors. RESULTS: The study found that, when using British health recommendations, a majority of the English population have multiple lifestyle risk factors at the same time. Clustering was found at both ends of the lifestyle spectrum and was more pronounced for women than for men. Overall, multiple risk factors were more prevalent among men, lower social class households, singles, and people who are economically inactive, but less prevalent among home owners and older age groups. CONCLUSIONS: The clustering of multiple risk factors provides support for multiple-behavior interventions as opposed to single-behavior interventions.

Adolescent↗
PubMed2003

Individual unionization decisions: a multilevel model of cost-benefit influences.

An important part of the unionization process is predicting the individual's vote for or against union representation. We proposed and tested a multilevel model based on the relative importance of costs and benefits of representation. Regression statistics from within-person analyses were used to show the influence of perceived costs and benefits on judgment policies about intent to vote in a representation election. Using these statistics as outcome variables, between--person analyses were used to show the influence of decision frame on cost-benefit influences, in which framing a vote as one for or against the union was conceived as a contextual variable in an election. Results were used to extend prior unionization research and to suggest how employers and unions may attend to framing effects in an election.

Adolescent↗
PubMed1998

Cervical interbody fusion cages. An animal model with and without bone morphogenetic protein.

STUDY DESIGN: The Alpine goat model for multilevel anterior cervical discectomy and fusion was used to analyze the use of an intervertebral fusion device to promote an arthrodesis after anterior cervical discectomy. Comparisons were drawn with biomechanical, histologic, and radiographic data. OBJECTIVES: To analyze the use of an intervertebral fusion device, with and without a bone graft substitute, to promote an arthrodesis anterior cervical discectomy. SUMMARY OF BACKGROUND DATA: In previous studies, the goat cervical spine has proven to be an excellent model for examining the healing of fusions using bone grafts, instrumentation, or bone substitutes. METHODS: Three-level anterior cervical dissectomies were performed on 21 mature Alpine goats. Three treatment groups of seven goats each were used. Group I used a standard titanium cervical BAK device filled with autogenous bone graft. Group II used a hydroxyapatite-coated BAK device filled with autogenous bone graft. Group III used a BAK device filled with recombinant human bone morphogenetic protein-2. RESULTS: Radiographically, no cages became displaced. Lucencies were seen around 3 of the 21 cages in Group 1, 4 cages in Group II, and none in Group III. Fluorochrome analysis revealed that the recombinant human bone morphogenetic protein-2-filled cages had an accelerated rate of bone growth around and through each cage-vertebral body interface at 3 weeks. A successful arthrodesis was also more likely with a recombinant human bone morphogenetic protein-2-filled cage (95%) than the hydroxyapatite-coated (62%) or the standard (48%) cage. Biomechanical stiffness testing did not reveal any statistically significant differences between the three groups. There was a tendency for successfully arthrodesed interspaces to be stiffer than those that were not. CONCLUSIONS: The use of a threaded intervertebral fusion cage, with or without hydroxyapatite coating, filled with autogenous bone graft provides a fusion rate that is slightly better than those previously reported using autogenous interbody bone grafts with or without plate stabilization. Recombinant human bone morphogenetic protein-2-filled cages resulted in a much higher arthrodesis rate and accelerated bone formation compared with either autogenous bone-filled BAK devices, or autogenous interbody bone grafts with or without plate stabilization.

Animals↗
PubMed2004

Sex differences in emotional reactivity to daily life stress in psychosis.

BACKGROUND: The expression of schizophrenia has been reported to differ between the sexes. The current study investigates whether these sex differences in clinical expression are reflected in one underlying mechanism that may be causally related to psychosis, namely increases in stress sensitivity in daily life. METHOD: Forty-two participants (22 men, 20 women) with Research Diagnostic Criteria-defined psychotic disorder in a state of clinical remission were studied with the Experience Sampling Method (a structured diary technique assessing current context and mood in daily life) to assess (1) appraised subjective stress related to daily events and activities and (2) emotional reactivity conceptualized as changes in both negative affect and positive affect in relation to the subjective stress. Data were collected from January 1997 to May 1999. RESULTS: Multilevel regression analyses revealed that women reported a significantly (p < .05) increased emotional reactivity to daily life stress compared with men, reflected in both an increase in negative affect and a decrease in positive affect. CONCLUSION: These results suggest that gender differences may not be limited to the characteristics of psychosis but may also be reflected in underlying etiologic mechanisms. Furthermore, these results might strengthen the hypothesis that women are more susceptible than men to a schizoaffective expression of schizophrenia.

Adult↗
PubMed1990

Multilevel models of fertility determination in four Southeast Asian countries: 1970 and 1980.

Using microdata from the 1970 and 1980 censuses, we specify and test multilevel models of fertility determination for four Southeast Asian societies--Indonesia, Peninsular Malaysia, the Philippines, and Thailand. Social context is indexed by provincial characteristics representing women's status, the roles of children, and infant mortality. These contextual variables are hypothesized to have direct and indirect (through individual socioeconomic characteristics) effects on current fertility. The contextual variables account for a modest but significant share of individual variation in fertility and about one-half of the total between area variation in fertility. The women's status contextual variables, particularly modern sector employment, have the largest and most consistent effect on lowered fertility. The results based on the other contextual variables provide mixed support for the initial hypotheses.

Adolescent↗
PubMed2000

Anterior vertebral screw strain with and without solid interspace support.

STUDY DESIGN: This in vitro biomechanical study examines segmental anterior vertebral screw strain and solid rod construct stiffness with and without the addition of multilevel, threaded cortical bone dowels in a bovine model. OBJECTIVE: To determine whether strain at the bone-screw interface is higher at the end levels during physiologic range loading, and whether solid interspace support decreases segmental strain on the implant. SUMMARY OF BACKGROUND DATA: Anterior instrumentation provides greater correction and preserves distal motion segments. However, nonunion and implant failure are observed more frequently than with posterior segmental instrumentation, and when observed, loss of fixation occurs at the end levels. METHODS: Eight calf spines underwent mechanical testing in the following sequence: 1) intact condition, 2) anterior release with anterior solid rod and bicortical rib grafts, and 3) anterior release with anterior solid rod and threaded cortical bone dowels (L2-L5). Instrumented vertebral screws were used to assess strain within the vertebral body by the near cortex, whereas an anterior extensometer spanning the instrumented segments was used to measure segmental displacements to calculate construct stiffness. The protocol included axial compression (-400 N), right lateral bending (4 Nm (Newton-meter), away from the implant), and left lateral bending (4 Nm, toward the implant). Statistical analysis included a one-way analysis of variance and a Student-Newman-Keuls post hoc test. A pilot study was performed using four additional specimens loaded for 4000 cycles to investigate macroscopic loosening after fatigue loading. RESULTS: In lateral bending toward the implant, the strain was higher at both end levels, with no differences between the rib and dowel reconstructions. The stiffness values were greater than the intact values for both groups. In lateral bending away from the implant, the strain also was higher at both end screws, and the dowel group had less strain at these levels than the rib group. Both groups were stiffer than the intact condition, and the dowel group was stiffer than the rib group. Axial compressive strain also was higher at the end levels, but this difference did not reach statistical significance. The rib group did not reach intact stiffness values, whereas the dowel group was stiffer than the intact condition. The fatigue study showed gross loosening at one or both end levels in all cases. CONCLUSIONS: Higher strain was observed at the bone-screw interface in both end screws of an anterior solid rod construct during lateral bending, which correlates with the clinically observed failure location. This suggests that physiologic range loading may predispose to failure at the end levels. Disc space augmentation with solid implants increased construct stiffness in all three load paths and decreased strain at the end levels in lateral bending away from the implant. Future implant modifications should achieve better fixation at the end screws, and the current model provides a means to compare different strategies to decrease strain at these levels.

Animals↗
PubMed2005

Behavioural sensitization to daily life stress in psychosis.

BACKGROUND: Recent neurobiological models provide a possible mechanism of daily life stress directly affecting the intensity of psychotic experiences in vulnerable individuals. In order to validate such a mechanism, the impact of daily life stress on psychosis intensity was investigated in two groups at increased risk of onset (relatives) and relapse (patients) of psychosis. METHOD: Patients with psychosis in a clinical state of remission (n = 42), first-degree relatives (n = 47), and control subjects (n = 49) were studied with the Experiencing Sampling Method (ESM is a structured diary technique assessing current context and psychopathology in daily life) to assess (1) appraised subjective stress related to daily activities and events, and (2) intensity of subtle psychotic experiences in daily life. RESULTS: Multilevel regression analyses revealed significant increases in psychosis intensity associated with increases in subjective activity--and event-related stress in patients. First-degree relatives reported increases in psychosis intensity in relation to activity-related stress but not event-related stress. No association was found in control subjects. CONCLUSIONS: Subjects at increased risk for psychosis show continuous variation in the intensity of subtle psychotic experiences associated with minor stresses in the flow of daily life. Behavioural sensitization to environmental stress may therefore be a vulnerability marker for schizophrenia, reflecting dopaminergic hyper-responsivity in response to environmental stimuli.

Adult↗
PubMed1998

Effects of stressful daily events on mood states: relationship to global perceived stress.

This study used experience sampling methodology to examine the relationship between stressful daily events and mood. Eighty-five male white-collar workers completed self-reports 10 times a day for 5 days. Controlling for individual differences in mood levels, multilevel regression analyses showed that events were followed by increases in negative affect (NA) and agitation (Ag) and by decreases in positive affect (PA). More unpleasant events were associated with greater changes in all three mood dimensions; controllability mitigated the effects of events on NA and PA. Prior events had persistent effects on current mood. High perceived stress (PS) was associated with greater reactivity of NA and PA to current events, whereas trait anxiety moderated reactivity of Ag. Results indicate that PS is related not only to a higher frequency of reported events but also to more intense and prolonged mood responses to daily stress.

Adult↗
PubMedDate not supplied

[Evaluating an internal quality control procedure: application to multidimensional control].

Internal quality control keeps in constant evolution in the industrial world. Introducing in clinical chemistry new QC methods derived from the industrial practice raises the point of the means for their evaluation. The main evaluation criteria are discussed in this paper. The importance of ARL (average run length) as a key-criterion of the efficiency of a quality control procedure is stressed. These principles were applied to the multivariate approach of multilevel control with the Hotelling's T2. This method led to a better detection of random errors than the independently managed conventional Shewhart (Levey- Jennings) charts. Applied to systematic errors, both methods gave similar results with a certain lack of sensitivity. However the multivariate method can be sensitised using EWMA (exponentially weighted moving average), a method specific for improved bias detection. EWMA efficiency outperforms that of the older systems of rules. Moreover, in any kind of error, multivariate approach secures a well-defined false rejection rate, whereas this rate is dependant on unknown inter-level correlation coefficients in conventional QC.

Bias↗
PubMed2003

Emotional reactivity to daily life stress in psychosis and affective disorder: an experience sampling study.

OBJECTIVE: To investigate the emotional reactivity to small disturbances in daily life in patients with non-affective psychosis (NAP), bipolar disorder (BD) and major depression [major depressive disorder (MDD)]. METHOD: Forty-two patients with NAP, 38 with BD, 46 with MDD, and 49 healthy controls were studied with the experience sampling method to assess (i) appraised subjective stress of small disturbances in daily life and (ii) emotional reactivity, reflected in changes in positive affect (PA) and negative affect (NA). RESULTS: Multilevel regression analyses showed an increase in NA in MDD, a decrease in PA in BD and both an increase in NA and a decrease in PA in NAP in association with the subjectively stressful situations, compared with the control subjects. CONCLUSION: Individuals with NAP, MDD and BD display differences in emotional stress reactivity. Type of mood disorder may exert a pathoplastic effect on emotional reactivity in individuals with MDD and BD. Individuals with NAP may be most vulnerable to the effects of daily life stress.

Activities of Daily Living↗
PubMed2004

Vibrational coherence transfer characterized with Fourier-transform 2D IR spectroscopy.

Two-dimensional infrared (2D IR) spectroscopy of the symmetric and asymmetric C[Triple Bond]O stretching vibrations of Rh(CO)(2)acac in hexane has been used to investigate vibrational coherence transfer, dephasing, and population relaxation in a multilevel vibrational system. The transfer of coherence between close-lying vibrational frequencies results in extra relaxation-induced peaks in the 2D IR spectrum, whose amplitude depends on the coherence transfer rate. Coherence transfer arises from the mutual interaction of the bright CO stretches with dark states, which in this case reflects the mutual d-pi(*) back bonding of the Rh center to both the terminal carbonyls and the acetylacenonate ligand. For 2D IR relaxation experiments with variable waiting times, coherent dynamics lead to the modulation of peak amplitudes, while incoherent population relaxation and exchange results in the growth of the relaxation-induced peaks. We have modeled the data by propagating the density matrix with the Redfield equation, incorporating all vibrational relaxation processes during all three experimental time periods and including excitation reorientation effects arising from relaxation. Coherence and population transfer time scales from the symmetric to the asymmetric stretch were found to be 350 fs and 3 ps, respectively. We also discuss a diagrammatic approach to incorporating all vibrational relaxation processes into the nonlinear response function, and show how coherence transfer influences the analysis of structural variables from 2D IR spectroscopy.

Journal Article↗
PubMed2004

Elbow flexion and extension strength relative to body or muscle size in children.

PURPOSE: The purpose of this study was to examine gender- and age-related differences in elbow flexion and extension strength in children, when linear size measurements and actual measurements of muscle size were used as explanatory variables in a multilevel model. METHODS: Thirty-seven children participated in a 3-yr longitudinal study (18 boys and 19 girls). The average age +/- SD at the first test occasion was 13.0 +/- 0.3 yr. Stature, arm length, isokinetic concentric and isometric elbow extension and flexion torques, and MRI-determined elbow flexor and extensor muscle cross-sectional areas (CSAs) were assessed annually. Multilevel modeling was used to describe the relationship between the measured torques and body/muscle size variables, incorporating age, age by gender, and gender as additional explanatory variables. RESULTS: When muscle CSA was included in the static and dynamic torque multilevel models, gender differences in strength were nonsignificant. In contrast, use of stature or arm length alone, suggested gender differences in strength that could not be explained by differences in body size. All torque measures were best explained by inclusion of muscle CSA and a linear dimension in the models. Age also explained additional variance in torque, but the influence of age was action and muscle specific. CONCLUSION: Use of only linear dimensions rather than muscle CSA to account for differences in size may have clouded our understanding of strength development in children.

Adolescent↗
PubMed2001

Perceived job stress but not individual cardiovascular reactivity to stress is related to higher blood pressure at work.

Psychological stress has been reported to be related to higher blood pressure (BP) and unfavorable cardiovascular profile. However, because of the complexity of personal stress management, a multilevel stress measurement strategy is needed. The aim of this cross-sectional study was to analyze the respective influences of the subjective perception of professional strain (high demand and low latitude) and cardiovascular reactivity to a stress test (Stroop stress test) on BP. Worksite BP was measured in 303 healthy normotensive subjects, 18 to 55 years of age, who worked in the same chemical company. In a subset of 70 randomly selected subjects, 24-hour ambulatory BP was performed to assess BP during working hours. The 20% of subjects who reported the highest job strain (high-strain group) or the highest BP stress reactivity (high-responder group) were compared with the remaining subjects (80%) (non-high-strain or low-responder groups). Subjects who submitted to the highest job strain had significantly higher ambulatory diastolic BP (4.5 mm Hg, P=0.015) during only working hours, whereas BP was similar during the remaining hours. Worksite BP and stress cardiovascular reactivity were similar between job strain groups. BP stress reactivity did not influence worksite and ambulatory BP. Spontaneous BP variability assessed by standard deviation and spectral analysis was equivalent between complementary groups. Prevalence of microalbuminuria was significantly higher in the high-responder group (8.2% versus 2.5% in low responders) and only slightly higher in the high-strain group (6.2% versus 3.2% in non-high strain). Potential confounding factors, such as age, gender, alcohol consumption, salt intake, body mass index, and occupation, which were equivalent between groups, did not interfere with our results. Our study quantifies high-professional strain effects on BP levels that appear to be higher only during the working period and to be independent from spontaneous BP variability and stress BP reactivity.

Adolescent↗
PubMed2005

Socioeconomic inequalities in early childhood malnutrition and morbidity: modification of the household-level effects by the community SES.

This paper examines variations among communities in childhood malnutrition and diarrhea morbidity, explores the influences of socioeconomic status (SES) on child health, and investigates how the SES of families and that of communities interact in this process. Using multilevel modelling and data from Demographic and Health Surveys of five African countries, it shows evidence of contextual effects and a strong patterning in childhood malnutrition and morbidity along SES lines, with community SES having an independent effect in some instances. It also reveals that living in poorest conditions increases the odds of suffering from both malnutrition and diarrhea, as opposed to experiencing only one of the two outcomes. Importantly, community SES significantly modifies the effects of the household SES, suggesting that measures to improve access of mothers and children to basic community resources may be necessary preconditions for higher levels of familial socioeconomic situation to contribute to improved child health.

Africa↗