Mind the gap! A multilevel analysis of factors related to variation in published cost-effectiveness estimates within and between countries

Background. Published cost-effectiveness estimates can vary considerably, both within and between countries. Despite extensive discussion, little is known empirically about factors relating to these variations. Objectives. To use multilevel statistical modeling to integrate cost-effectiveness estimates from published economic evaluations to investigate potential causes of variation. Methods. Cost-effectiveness studies of statins for cardiovascular disease prevention were identified by systematic review. Estimates of incremental costs and effects were extracted from reported base case, sensitivity, and subgroup analyses, with estimates grouped in studies and in countries. Three bivariate models were developed: a cross-classified model to accommodate data from multinational studies, a hierarchical model with multinational data allocated to a single category at country level, and a hierarchical model excluding multinational data. Covariates at different levels were drawn from a long list of factors suggested in the literature. Results. We found 67 studies reporting 2094 cost-effectiveness estimates relating to 23 countries (6 studies reporting for more than 1 country). Data and study-level covariates included patient characteristics, intervention and comparator cost, and some study methods (e.g., discount rates and time horizon). After adjusting for these factors, the proportion of variation attributable to countries was negligible in the cross-classified model but moderate in the hierarchical models (14%−19% of total variance). Country-level variables that improved the fit of the hierarchical models included measures of income and health care finance, health care resources, and population risks. Conclusions. Our analysis suggested that variability in published cost-effectiveness estimates is related more to differences in study methods than to differences in national context. Multinational studies were associated with much lower country-level variation than single-country studies. These findings are for a single clinical question and may be atypical

Disentangling the complex association between female genital cutting and HIV among Kenyan women

Female genital cutting (FGC) is a widespread cultural practice in Africa and the Middle East, with a number of potential adverse health consequences for women. It was hypothesised by Kun (1997) that FGC increases the risk of HIV transmission through a number of different mechanisms. Using the 2003 data from the Kenyan Demographic and Health Survey (KDHS), this study investigates the potential association between FGC and HIV. The 2003 KDHS provides a unique opportunity to link the HIV test results with a large number of demographic, social, economic and behavioural characteristics of women, including women’s FGC status. It is hypothesised that FGC increases the risk of HIV infection if HIV/AIDS is present in the community. A multilevel binary logistic regression technique is used to model the HIV status of women, controlling for selected individual characteristics of women and interaction effects. The results demonstrate evidence of a statistically significant association between FGC and HIV, after controlling for the hierarchical structure of the data, potential confounding factors, and interaction effects. The results show that women who had had FGC and a younger or the same age first union partner have higher odds of being HIV positive than women with a younger or same age first union partner but without FGC; whereas women who had had FGC and an older first union partner have lower odds of being HIV positive than women with an older first union partner but without FGC. The findings suggest the behavioural pathway of association between FGC and HIV as well as an underlying complex interplay of bio-behavioural and social variables being important in disentangling the association between FGC and HIV

The use of national datasets to baseline science education reform: exploring value-added approaches

This paper uses data from the National Pupil Database to investigate the differences in ‘performance’ across the range of science courses available following the 2006 Key Stage 4 (KS4) science reforms in England. This is a value-added exploration (from Key Stage 3 [KS3] to KS4) aimed not at the student or the school level, but rather at that of the course. Different methodological approaches to carrying out such an analysis, ranging from simple non-contextualized techniques, to more complex fully contextualized multilevel models, are investigated and their limitations and benefits are evaluated. Important differences between courses are found in terms of the typical ‘value’ they add to the students studying them with particular applied science courses producing higher mean KS4 outcomes for the same KS3 level compared with other courses. The implications of the emergence of such differences, in a context where schools are judged to a great extent on their value-added performance, are discussed. The relative importance of a variety of student characteristics in determining KS4 outcomes are also investigated. Substantive findings are that across all types of course, science prior attainment at KS3, rather than that of mathematics or English, is the most important predictor of KS4 performance in science, and that students of lower socio-economic status consistently make less progress over KS4 than might be expected, despite prior attainment being accounted for in the modelling

Modelling job crafting behaviours: Implications for work engagement

In this study among 206 employees (103 dyads), we followed the job demands–resources approach of job crafting to investigate whether proactively changing one’s work environment influences employee’s (actor’s) own and colleague s (partner’s) work engagement. Using social cognitive theory, we hypothesized that employees would imitate each other’s job crafting behaviours, and therefore influence each other’s work engagement. Results showed that the crafting of social and structural job resources, and the crafting of challenge job demands was positively related to own work engagement, whereas decreasing hindrance job demands was unrelated to own engagement. As predicted, results showed a reciprocal relationship between dyad members’ job crafting behaviours – each of the actor’s job crafting behaviours was positively related to the partner’s job crafting behaviours. Finally, employee’s job crafting was related to colleague’s work engagement through colleague’s job crafting, suggesting a modelling process

Motivation in physical education across the primary-secondary school transition

The purpose of this study was to examine the temporal patterns of approach-avoidance achievement goals, implicit theories of ability and perceived competence in physical education across the transition from primary to secondary school. We also evaluated the predictive utility of implicit theories and perceived competence with regard to achievement goal adoption, and determined the moderating influence of gender on temporal patterns and antecedent–goal relationships. One hundred and forty pupils (mean age at start of study = 11.37 years, SD =.28) completed measures of entity and incremental beliefs, perceived competence and goals on four occasions during a 12-month period. Mastery-approach, performance-approach and perform-ance-avoidance goals, as well as entity and incremental beliefs, exhibited a linear decline over time. Mastery-avoidance goals showed no significant change. Girls exhibited a linear decline in perceived competence, whereas for boys the trajectory was curvilinear. Competence perceptions predicted initial scores, but not rate of change, on mastery-approach and both types of performance goals. Incrementa

Living apart, losing sympathy? How neighbourhood context affects attitudes to redistribution and to welfare recipients

Rising levels of income inequality have been directly linked to rising levels of spatial segregation. In this paper, we explore whether rising segregation may in turn erode support for the redistributive policies of the welfare state, further increasing levels of inequality – a form of positive feedback. The role of the neighbourhood has been neglected in attitudes research but, building on both political geography and ‘neighbourhood effects’ literatures, we theorise that neighbourhood context may shape attitudes through the transmission of attitudes directly and through the accumulation of relevant knowledge. We test this through multilevel modelling of data from England on individual attitudes to redistribution in general and to welfare benefit recipients in particular. We show that the individual factors shaping these attitudes are quite different and that the influence of neighbourhood context also varies as a result. The findings support the idea that neighbourhood context shapes attitudes, with the knowledge accumulation mechanism likely to be the more important. Rising spatial segregation would appear to erode support for redistribution but to increase support for welfare recipients – at least in a context where the dominant media discourse presents such a stigmatising image of those on welfare benefits

Place attachment in deprived neighbourhoods: The impacts of population turnover and social mix

This paper examines the determinants of individual place attachment, focussing in particular on differences between deprived and others neighbourhoods, and on the impacts of population turnover and social mix. It uses a multi-level modelling approach to take account of both individual- and neighbourhood-level determinants. Data are drawn from a large sample government survey, the Citizenship Survey 2005, to which a variety of neighbourhood-level data have been attached. The paper argues that attachment is significantly lower in more deprived neighbourhoods primarily because these areas have weaker social cohesion but that, in other respects, the drivers of attachment are the same. Turnover has modest direct impacts on attachment through its effect on social cohesion. Social mix has very limited impacts on attachment and the effects vary between social groups. In general, higher status or more dominant groups appear less tolerant of social mix

Area and individual differences in personal crime victimization incidence: The role of individual, lifestyle/routine activities and contextual predictors

This article examines how personal crime differences between areas and between individuals are predicted by area and population heterogeneity and their synergies. It draws on lifestyle/routine activities and social disorganization theories to model the number of personal victimization incidents over individuals including routine activities and area characteristics, respectively, as well as their (cross-cluster) interactions. The methodology employs multilevel or hierarchical negative binomial regression with extra binomial variation using data from the British Crime Survey and the UK Census. Personal crime rates differ substantially across areas, reflecting to a large degree the clustering of individuals with measured vulnerability factors in the same areas. Most factors suggested by theory and previous research are conducive to frequent personal victimization except the following new results. Pensioners living alone in densely populated areas face disproportionally high numbers of personal crimes. Frequent club and pub visits are associated with more personal crimes only for males and adults living with young children, respectively. Ethnic minority individuals experience fewer personal crimes than whites. The findings suggest integrating social disorganization and lifestyle theories and prioritizing resources to the most vulnerable, rather than all, residents of poor and densely populated areas to prevent personal crimes

A two-year participatory intervention project with owners to reduce lameness and limb abnormalities in working horses in Jaipur, India

Participatory methods are increasingly used in international human development, but scientific evaluation of their efficacy versus a control group is rare. Working horses support families in impoverished communities. Lameness and limb abnormalities are highly prevalent in these animals and a cause for welfare concern. We aimed to stimulate and evaluate improvements in lameness and limb abnormalities in horses whose owners took part in a 2-year participatory intervention project to reduce lameness (PI) versus a control group (C) in Jaipur, India.In total, 439 owners of 862 horses participated in the study. PI group owners from 21 communities were encouraged to meet regularly to discuss management and work practices influencing lameness and poor welfare and to track their own progress in improving these. Lameness examinations (41 parameters) were conducted at the start of the study (Baseline), and after 1 year and 2 years. Results were compared with control horses from a further 21 communities outside the intervention. Of the 149 horses assessed on all three occasions, PI horses showed significantly (P<0.05) greater improvement than C horses in 20 parameters, most notably overall lameness score, measures of sole pain and range of movement on limb flexion. Control horses showed slight but significantly greater improvements in four parameters, including frog quality in fore and hindlimbs.This participatory intervention succeeded in improving lameness and some limb abnormalities in working horses, by encouraging changes in management and work practices which were feasible within owners’ socioeconomic and environmental constraints. Demonstration of the potentially sustainable improvements achieved here should encourage further development of participatory intervention approaches to benefit humans and animals in other contexts