Community-level group sports participation and all-cause, cardiovascular disease, and cancer mortality: a 7-year longitudinal study.

BACKGROUND: Community-level group sports participation is a structural aspect of social capital that can potentially impact individual health in a contextual manner. This study aimed to investigate contextual relationship between the community-level prevalence of group sports participation and the risk of all-cause, cardiovascular disease (CVD), and cancer mortality in older adults. METHODS: In this 7-year longitudinal cohort study, data from the Japan Gerontological Evaluation Study, a nationwide survey encompassing 43,088 functionally independent older adults residing in 311 communities, were used. Cause of death data were derived from the Japanese governmental agency, The Ministry of Health, Labour and Welfare, for secondary use. "Participation" was defined as engaging in group sports for one or more days per month. To analyze the data, a two-level survival analysis was employed, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. RESULTS: Among the participants, 5,711 (13.3%) deaths were identified, with 1,311 related to CVD and 2,349 to cancer. The average group sports participation rate was 28.3% (range, 10.0-52.7%). After adjusting for individual-level group sports participation and potential confounders, a higher community-level group sports participation rate was found to be significantly associated with a lower risk of both all-cause mortality (HR: 0.89, 95% CI: 0.83-0.95) and cancer mortality (HR: 0.89, 95% CI: 0.81-0.98) for every 10% point increase in the participation rate. For CVD mortality, the association became less significant in the model adjusted for all covariates (HR: 0.94, 95% CI: 0.82-1.09). CONCLUSIONS: Our findings support the existence of a preventive relationship between community-level group sports participation and the occurrence of all-cause and cancer mortality among older individuals. Promoting group sports within communities holds promise as an effective population-based strategy for extending life expectancy, regardless of individual participation in these groups.

Correcting for Sampling Error in between-Cluster Effects: An Empirical Bayes Cluster-Mean Approach with Finite Population Corrections.

With clustered data, such as where students are nested within schools or employees are nested within organizations, it is often of interest to estimate and compare associations among variables separately for each level. While researchers routinely estimate between-cluster effects using the sample cluster means of a predictor, previous research has shown that such practice leads to biased estimates of coefficients at the between level, and recent research has recommended the use of latent cluster means with the multilevel structural equation modeling framework. However, the latent cluster mean approach may not always be the best choice as it (a) relies on the assumption that the population cluster sizes are close to infinite, (b) requires a relatively large number of clusters, and (c) is currently only implemented in specialized software such as Mplus. In this paper, we show how using empirical Bayes estimates of the cluster means can also lead to consistent estimates of between-level coefficients, and illustrate how the empirical Bayes estimate can incorporate finite population corrections when information on population cluster sizes is available. Through a series of Monte Carlo simulation studies, we show that the empirical Bayes cluster-mean approach performs similarly to the latent cluster mean approach for estimating the between-cluster coefficients in most conditions when the infinite-population assumption holds, and applying the finite population correction provides reasonable point and interval estimates when the population is finite. The performance of EBM can be further improved with restricted maximum likelihood estimation and likelihood-based confidence intervals. We also provide an R function that implements the empirical Bayes cluster-mean approach, and illustrate it using data from the classic High School and Beyond Study.

Comparing individual-, family-, and community-level effects on the oral health of preschool children: a multilevel analysis of national survey data.

BACKGROUND: Early childhood is a critical stage for the prevention of dental caries. The prevalence of caries in preschool children is still high in Taiwan, where National Health Insurance covers 99% of the population. The effort to improve the oral health of preschool children should be based on conceptual model that encompasses more than individual-level factors. This study input nationwide survey data in a conceptual model to evaluate the effects of comprehensive factors related to the high prevalence of caries in preschool children. METHODS: This observation study examined factors related to the oral health of preschool children by employing a comprehensive multilevel model to analyse nationally representative data from the Taiwan Oral Health Survey of Preschool Children (TOHPC) 2017-2018. Individual-level, family-level and community-level contextual effects were evaluated through multilevel analysis in this study. The proportional change in variance (PCV) was used to compare the multilevel model with the null model and individual-level, family-level, and community-level context effects. RESULTS: The estimated deft index for preschool children was 1.34 (1.22-1.47) at age 3, 2.20 (2.08-2.32) at age 4, and 3.05 (2.93-3.18) at age 5. The overall prevalence of caries in preschool children in Taiwan was 34.27% (30.76%, 37.78%) at age 3, 51.67% (48.99%, 54.35%) at age 4, and 62.05% (59.66%, 64.44%) at age 5. The model that included the individual-, family-, and community-context levels exhibited the highest reduction of variance (PCV = 53.98%). The PCV was further reduced to 35.61% when only the level of accessibility to dental services for individuals, families, and the community was considered. For the model in which no community-context cofactors were considered and the model considering only the individual level, the PCVs were 20.37% and 5.52%, respectively. CONCLUSIONS: Our findings indicate the key components that affect oral health in preschool children and can serve as a reference for policy makers. The most notable finding of this study is that to improve the oral health of preschool children, community-level factors should be targeted. To rely solely on dentists for leading oral health education programs for children is impractical and inefficient. Training more professional oral health educators to provide additional community-based oral health promotion campaigns is critical. We suggest training more professional oral health educators to provide more community-based oral health promotion campaigns.

On the Common but Problematic Specification of Conflated Random Slopes in Multilevel Models.

For multilevel models (MLMs) with fixed slopes, it has been widely recognized that a level-1 variable can have distinct between-cluster and within-cluster fixed effects, and that failing to disaggregate these effects yields a conflated, uninterpretable fixed effect. For MLMs with random slopes, however, we clarify that two different types of slope conflation can occur: that of the fixed component (termed fixed conflation) and that of the random component (termed random conflation). The latter is rarely recognized and not well understood. Here we explain that a model commonly used to disaggregate the fixed component-the contextual effect model with random slopes-troublingly still yields a conflated random component. Negative consequences of such random conflation have not been demonstrated. Here we show that they include erroneous interpretation and inferences about the substantively important extent of between-cluster differences in slopes, including either underestimating or overestimating such slope heterogeneity. Furthermore, we show that this random conflation can yield inappropriate standard errors for fixed effects. To aid researchers in practice, we delineate which types of random slope specifications yield an unconflated random component. We demonstrate the advantages of these unconflated models in terms of estimating and testing random slope variance (i.e., improved power, Type I error, and bias) and in terms of standard error estimation for fixed effects (i.e., more accurate standard errors), and make recommendations for which specifications to use for particular research purposes.

Judging emoji by occupation: A case of emoji-based sarcasm interpretation.

The smiling emoji has been claimed to be a marker of sarcastic intention among young Chinese users in computer-mediated communication. However, it is not well understood whether people interpret the emoji differently based on the characteristics or traits of the sender, as conveyed by occupation stereotypes. We investigated the effect of sender occupation on emoji-based sarcasm interpretation in both unambiguous (Experiment 1) and ambiguous (Experiment 2) contexts. The results showed that contextual incongruity was privileged over sender occupation in cueing sarcastic intention. In unambiguous contexts, sender occupation exerted no significant influence on the interpretation of emoji-based sarcastic statements. In contrast, sender occupation played an important role in the interpretation of emoji-based statements in ambiguous contexts. Specifically, emoji-based ambiguous statements delivered by senders in high­irony occupations were more likely to be perceived as sarcastic than by those in low-irony occupations. However, sender occupation did not affect the interpretation of the emoji; instead, it biased the judgment of emoji in sarcasm interpretation. In a follow-up experiment (Experiment 3), we investigated the perceived characteristics of both high- and low-irony occupations. The results demonstrated that individuals in high-irony occupations were stereotyped with characteristics, including being humorous, insincere, easy to setting up close relationships, and of a lower social status. Taken together, our study suggests that stereotypical information about the sender could drive the interpretation of potentially sarcastic statements, and the contextual information modulates the effect of sender occupation on sarcasm interpretation.

Looking more masculine among females: Spatial context modulates gender perception of face and biological motion.

Perception of visual information highly depends on spatial context. For instance, perception of a low-level visual feature, such as orientation, can be shifted away from its surrounding context, exhibiting a simultaneous contrast effect. Although previous studies have demonstrated the adaptation aftereffect of gender, a high-level visual feature, it remains largely unknown whether gender perception can also be shaped by a simultaneously presented context. In the present study, we found that the gender perception of a central face or a point-light walker was repelled away from the gender of its surrounding faces or walkers. A norm-based opponent model of lateral inhibition, which accounts for the adaptation aftereffect of high-level features, can also excellently fit the simultaneous contrast effect. But different from the reported contextual effect of low-level features, the simultaneous contrast effect of gender cannot be observed when the centre and the surrounding stimuli are from different categories, or when the surrounding stimuli are suppressed from awareness. These findings on one hand reveal a resemblance between the simultaneous contrast effect and the adaptation aftereffect of high-level features, on the other hand highlight different biological mechanisms underlying the contextual effects of low- and high-level visual features.

Contextual fallacy in MLMs with cross-level interaction: A critical review of neighborhood effects on psychiatric resilience.

In the multilevel modeling literature, contextual effect is defined as or identified by the effect of the target group-level variable while controlling for the corresponding individual-level variable. This paper extends the notion of "contextual effects" (or "neighborhood" or "school" effects) to an interaction setting, such that the effect of one explanatory variable Xij on the outcome Yij is modeled as a function of a group-level 'moderating' or predisposing variable Zj* as well as its counterpart at the individual level Zij. Researchers frequently use regression models that only contain a cross-level interaction between Xij and Zj* to test contextual hypotheses in an interaction setting, but this modeling strategy is unable to discriminate the immediate rival hypothesis that attributes a causal role to the corresponding individual-level variable. This paper points out the prevalence of this type of fallacy through a review of past research on contextual determinants of psychiatric resilience. It is argued that the simple step of adding an appropriate individual-level interaction XijZij could help more robustly test substantive hypotheses about how neighborhood context alters the effect of proximal stressors on health outcomes.

Following Other People's Footsteps: A Contextual-Attraction Effect Induced by Biological Motion.

Our visual system is bombarded with numerous social interactions that form intangible social bonds among people, as exemplified by synchronized walking in crowds. Here, we investigated whether these perceived social bonds implicitly intrude on visual perception and induce a contextual effect. Using multiple point-light walkers and a classical contextual paradigm, we tested 72 college-age adults across six experiments and found that the perceived direction of the central walker was attracted toward the direction of the surrounding walkers. The observed contextual-attraction effect occurred even when the surrounding walkers differed from the central walker in gender and walking speed but disappeared when they were asynchronously presented or replaced by inanimate motion. Strikingly, this contextual-attraction effect partially persisted in the context of local motion rather than static figures. These findings, in contrast to the typical contextual-repulsion effect, lend support for the distinctiveness of perceived social bonds on contextual modulation and suggest a specialized contextual mechanism tuned to social factors.

Implicit Counterfactual Effect in Partial Feedback Reinforcement Learning: Behavioral and Modeling Approach.

Context remarkably affects learning behavior by adjusting option values according to the distribution of available options. Displaying counterfactual outcomes, the outcomes of the unchosen option alongside the chosen one (i.e., providing complete feedback), would increase the contextual effect by inducing participants to compare the two outcomes during learning. However, when the context only consists of the juxtaposition of several options and there is no such explicit counterfactual factor (i.e., only partial feedback is provided), it is not clear whether and how the contextual effect emerges. In this research, we employ Partial and Complete feedback paradigms in which options are associated with different reward distributions. Our modeling analysis shows that the model that uses the outcome of the chosen option for updating the values of both chosen and unchosen options in opposing directions can better account for the behavioral data. This is also in line with the diffusive effect of dopamine on the striatum. Furthermore, our data show that the contextual effect is not limited to probabilistic rewards, but also extends to magnitude rewards. These results suggest that by extending the counterfactual concept to include the effect of the chosen outcome on the unchosen option, we can better explain why there is a contextual effect in situations in which there is no extra information about the unchosen outcome.

Contextual Information Modulates Pupil Size in Autistic Children.

Recent Bayesian models suggest that perception is more "data-driven" and less dependent on contextual information in autistic individuals than others. However, experimental tests of this hypothesis have given mixed results, possibly due to the lack of objectivity of the self-report methods typically employed. Here we introduce an objective no-report paradigm based on pupillometry to assess the processing of contextual information in autistic children, together with a comparison clinical group. After validating in neurotypical adults a child-friendly pupillometric paradigm, in which we embedded test images within an animation movie that participants watched passively, we compared pupillary response to images of the sun and meaningless control images in children with autism vs. age- and IQ-matched children presenting developmental disorders unrelated to the autistic spectrum. Both clinical groups showed stronger pupillary constriction for the sun images compared with control images, like the neurotypical adults. However, there was no detectable difference between autistic children and the comparison group, despite a significant difference in pupillary light responses, which were enhanced in the autistic group. Our report introduces an objective technique for studying perception in clinical samples and children. The lack of statistically significant group differences in our tests suggests that autistic children and the comparison group do not show large differences in perception of these stimuli. This opens the way to further studies testing contextual processing at other levels of perception.

Disentangling the individual and contextual effects of math anxiety: A global perspective.

Math anxiety is a common affective disorder in students that is characterized by intrusive thoughts that disrupt critical cognitive resources required for math problem-solving. Consistent associations between math anxiety and math achievement have been observed across countries and age groups, placing math anxiety among other important correlates of math achievement, such as socioeconomic status and magnitude representation ability. However, studies examining math anxiety's relation to achievement have largely focused on the effect of students' own math anxiety (individual effect), while little is known regarding the effect of math anxiety in students' educational context (contextual effect). Using three international studies of achievement (n = 1,175,515), we estimated both the individual and contextual effects of math anxiety across the globe. Results suggest that while there are consistent individual effects in virtually all countries examined, the contextual effects are varied, with only approximately half of the countries exhibiting a contextual effect. Additionally, we reveal that teacher confidence in teaching math is associated with a reduction of the individual effect, and country's level of uncertainty avoidance is related to a lessening of the contextual effect. Finally, we uncovered multiple predictors of math anxiety; notably, student perception of teacher competence was negative related with math anxiety, and parental homework involvement was positively related with math anxiety. Taken together, these results suggest that there are significant between-country differences in how math anxiety may be related with math achievement and suggest that education and cultural contexts as important considerations in understanding math anxiety's effects on achievement.

An investigation of cancer survival inequalities associated with individual-level socio-economic status, area-level deprivation, and contextual effects, in a cancer patient cohort in England and Wales.

BACKGROUND: People living in more deprived areas of high-income countries have lower cancer survival than those in less deprived areas. However, associations between individual-level socio-economic circumstances and cancer survival are relatively poorly understood. Moreover, few studies have addressed contextual effects, where associations between individual-level socio-economic status and cancer survival vary depending on area-based deprivation. METHODS: Using 9276 individual-level observations from a longitudinal study in England and Wales, we examined the association with cancer survival of area-level deprivation and individual-level occupation, education, and income, for colorectal, prostate and breast cancer patients aged 20-99 at diagnosis. With flexible parametric excess hazard models, we estimated excess mortality across individual-level and area-level socio-economic variables and investigated contextual effects. RESULTS: For colorectal cancers, we found evidence of an association between education and cancer survival in men with Excess Hazard Ratio (EHR) = 0.80, 95% Confidence Interval (CI) = 0.60;1.08 comparing "degree-level qualification and higher" to "no qualification" and EHR = 0.74 [0.56;0.97] comparing "apprenticeships and vocational qualification" to "no qualification", adjusted on occupation and income; and between occupation and cancer survival for women with EHR = 0.77 [0.54;1.10] comparing "managerial/professional occupations" to "manual/technical," and EHR = 0.81 [0.63;1.06] comparing "intermediate" to "manual/technical", adjusted on education and income. For breast cancer in women, we found evidence of an association with income (EHR = 0.52 [0.29;0.95] for the highest income quintile compared to the lowest, adjusted on education and occupation), while for prostate cancer, all three individual-level socio-economic variables were associated to some extent with cancer survival. We found contextual effects of area-level deprivation on survival inequalities between occupation types for breast and prostate cancers, suggesting wider individual-level inequalities in more deprived areas compared to least deprived areas. Individual-level income inequalities for breast cancer were more evident than an area-level differential, suggesting that area-level deprivation might not be the most effective measure of inequality for this cancer. For colorectal cancer in both sexes, we found evidence suggesting area- and individual-level inequalities, but no evidence of contextual effects. CONCLUSIONS: Findings highlight that both individual and contextual effects contribute to inequalities in cancer outcomes. These insights provide potential avenues for more effective policy and practice.

Urban-Rural Differences in Schizophrenia Risk: Multilevel Survival Analyses of Individual- and Neighborhood-Level Indicators, Urbanicity and Population Density in a Danish National Cohort Study.

Background: Urban-rural differences in schizophrenia risk have been widely evidenced across Western countries. However, explanation of these differences is lacking. We aimed to identify contextual risk factors for schizophrenia that explain urban-rural differences in schizophrenia risk. Methods: Utilizing Danish population-based registers, we partitioned Denmark into 1885 geographic "neighborhoods" homogeneously sized in terms of population. Information on the entire Danish population from 1981 to 2016 was used to quantify a spectrum of neighborhood-level domains. We subsequently conducted multilevel survival analyses following persons born in Denmark from 1971 to 1982 for the development of schizophrenia allowing for clustering of people within neighborhoods. We used this method to tease apart the effects of individual, specific, and general contextual risk factors for schizophrenia. Results: A significant general contextual effect in schizophrenia risk across neighborhoods was estimated (Medium Incidence Rate Ratio (MRR):1.41; 95% CI:1.35-1.48). Most of the specific contextual factors examined were associated with schizophrenia risk. For instance, neighborhood-level proportion of lone adult households (Incidence Rate Ratios (IRR):1.53; 95% CI:1.44-1.63) had largest risk estimate. Adjustment for all individual-level and specific contextual constructs reduced the IRR for urbanicity from 1.98 (95% CI:1.77-2.22) to 1.30 (95% CI:1.11-1.51). Conclusions: In the largest prospective multilevel survival analyses of schizophrenia risk conducted to date, multiple neighborhood-level characteristics were associated with raised schizophrenia risk, with these contextual factors explaining most of the elevated risk linked with urbanicity. However, the unexplained heterogeneity that was evident in our multilevel models indicates that our understanding of the role of urbanicity in schizophrenia's etiology remains incomplete.

Study of differences between patients with schizophrenia and healthy people in semantic processing.

Semantic processing is important in language comprehension and production, and context can facilitate understanding and accelerate processing speed by pre-activating semantically related words. There are many studies suggesting that patients with schizophrenia have inferior language ability. This study was aimed to examine the differences between patients with schizophrenia and healthy people in semantic processing with Chinese classifier-noun pairs rating tasks. Participants were required to finish rating tasks to judge acceptability of classifier-noun pairs. Also, the Positive and Negative Syndrome Scale (PANSS) was conducted in the schizophrenia group. According to results of variance analysis, schizophrenic patients' accuracy of judgment on the acceptability of classifier-noun pairs differed from the control group (F = 4.13, p < .05), and the contextual effect of classifier constraint could be observed in healthy people (F(1, 31) = 5.38, p < .05) but not in patients with schizophrenia (F(1, 25) = 3.55, p = .07), indicating that they failed to use the contextual information to facilitate language comprehension as healthy people. Stepwise linear regression analysis found that hostility, poor impulse control and suspiciousness/persecution and preoccupation in the PANSS may have contributed to the reduced sensitivity in the rating in patients (t = -2.38-3.80, p < .05).

Placebo response and effect in randomized clinical trials: meta-research with focus on contextual effects.

BACKGROUND: Contextual effects (i.e., placebo response) refer to all health changes resulting from administering an apparently inactive treatment. In a randomized clinical trial (RCT), the overall treatment effect (i.e., the post-treatment effect in the intervention group) can be regarded as the true effect of the intervention plus the impact of contextual effects. This meta-research was conducted to examine the average proportion of the overall treatment effect attributable to contextual effects in RCTs across clinical conditions and treatments and explore whether it varies with trial contextual factors. METHODS: Data was extracted from trials included in the main meta-analysis from the latest update of the Cochrane review on "Placebo interventions for all clinical conditions" (searched from 1966 to March 2008). Only RCTs reported in English having an experimental intervention group, a placebo comparator group, and a no-treatment control group were eligible. RESULTS: In total, 186 trials (16,655 patients) were included. On average, 54% (0.54, 95%CI 0.46 to 0.64) of the overall treatment effect was attributable to contextual effects. The contextual effects were higher for trials with blinded outcome assessor and concealed allocation. The contextual effects appeared to increase proportional to the placebo effect, lower mean age, and proportion of females. CONCLUSION: Approximately half of the overall treatment effect in RCTs seems attributable to contextual effects rather than to the specific effect of treatments. As the study did not include all important contextual factors (e.g., patient-provider interaction), the true proportion of contextual effects could differ from the study's results. However, contextual effects should be considered when assessing treatment effects in clinical practice. TRIAL REGISTRATION: PROSPERO CRD42019130257 . Registered on April 19, 2019.

User fees removal and community-based management of undernutrition in Burkina Faso: what effects on children's nutritional status?

OBJECTIVE: To examine the effect of an intervention combining user fees removal with community-based management of undernutrition on the nutrition status in children under 5 years of age in Burkina Faso. DESIGN: The study was a non-equivalent control group post-test-only design based on household survey data collected 4 years after the intervention onset in the intervention and comparison districts. Additionally, we used propensity score weighting to achieve balance on covariates between the two districts, followed by logistic multilevel modelling. SETTING: Two health districts in the Sahel region. PARTICIPANTS: Totally, 1116 children under 5 years of age residing in 41 intervention communities and 1305 from 51 control communities. RESULTS: When comparing children living in the intervention district to children living in a non-intervention district, we determined no differences in terms of stunting (OR = 1·13; 95 % CI 0·83, 1·54) and wasting (OR = 1·21; 95 % CI 0·90, 1·64), nor in severely wasted (OR = 1·27; 95 % CI 0·79, 2·04) and severely stunted (OR = 0·99; 95 % CI 0·76, 1·26). However, we determined that 3 % of the variance of wasting (95 % CI 1·25, 10·42) and 9·4 % of the variance of stunting (95 % CI 6·45, 13·38) were due to systematic differences between communities of residence. The presence of the intervention in the communities explained 2 % of the community-level variance of stunting and 3 % of the community-level variance of wasting. CONCLUSIONS: With the scaling-up of the national free health policy in Africa, we stress the need for rigorous evaluations and the means to measure expected changes in order to better inform health interventions.

Community-Level Sports Group Participation and Health Behaviors Among Older Non-Participants in a Sports Group: A Multilevel Cross-Sectional Study.

This study validates the relationship between community-level sports group participation and the frequency of leaving the house and transtheoretical model stages of behavior change for exercise among older individuals who did not participate in a sports group. We used cross-sectional data from the 2016 Japan Gerontological Evaluation Study. The proportion of sports group participants at the community level was calculated using the data from 157,233 older individuals living in 1000 communities. We conducted a multilevel regression analysis to examine the relationship between the proportion of sports group participants and the frequency of leaving the house (1 day/week or less) and the transtheoretical model stages of behavior change for exercise. A statistically significant relationship was observed between a high prevalence of sports group participation and lower risk of homeboundness (odds ratio: 0.94) and high transtheoretical model stages (partial regression coefficient: 0.06) as estimated by 10 percentage points of participation proportion. Older individuals, even those not participating in a sports group, living in a community with a high prevalence of sports group participation are less likely to be homebound; they are highly interested and have numerous opportunities to engage in exercise.

Assessing the contextual effect of community in the utilization of postnatal care services in Ghana.

BACKGROUND: Inequalities in the use of postnatal care services (PNC) in Ghana have been linked to poor maternal and neonatal health outcomes. This has ignited a genuine concern that PNC interventions with a focus on influencing solely individual-level risk factors do not achieve the desired results. This study aimed to examine the community-level effect on the utilization of postnatal care services. Specifically, the research explored clusters of non-utilization of PNC services as well as the effect of community-level factors on the utilization of PNC services, with the aim of informing equity-oriented policies and initiatives. METHODS: The 2014 Ghana Demographic and Health Survey GDHS dataset was used in this study. Two statistical methods were used to analyze the data; spatial scan statistics were used to identify hotspots of non-use of PNC services and second two-level mixed logistic regression modeling was used to determine community-level factors associated with PNC services usage. RESULTS: This study found non-use of PNC services to be especially concentrated among communities in the Northern region of Ghana. Also, the analyses revealed that community poverty level, as well as community secondary or higher education level, were significantly associated with the utilization of PNC services, independent of individual-level factors. In fact, this study identified that a woman dwelling in a community with a higher concentration of poor women is less likely to utilize of PNC services than those living in communities with a lower concentration of poor women (Adjusted odds ratio (AOR) = 0.60, 95%CI: 0.44-0.81). Finally, 24.0% of the heterogeneity in PNC services utilization was attributable to unobserved community variability. CONCLUSION: The findings of this study indicate that community-level factors have an influence on women's health-seeking behavior. Community-level factors should be taken into consideration for planning and resource allocation purposes to reduce maternal health inequities. Also, high-risk communities of non-use of obstetric services were identified in this study which highlights the need to formulate community-specific strategies that can substantially shift post-natal use in a direction leading to universal coverage.

Understanding the relationships among individual-based momentary measured noise, perceived noise, and psychological stress: A geographic ecological momentary assessment (GEMA) approach.

This study aims to understand how the relationship between individual-based noise exposure and psychological stress is influenced by perceived noise and context. Using geographic ecological momentary assessment, along with activity-travel diaries, GPS tracking, and portable noise sensors, this study collected real-time data of individuals' daily movement, noise exposure, and self-reported noise perception and psychological stress. Structural equation modeling was used to examine the direct and indirect pathways among context, momentary measured noise, perceived noise, and psychological stress. The study finds that momentary measured noise influences psychological stress through the mediating effect of perceived noise. Further, different activity and travel, social, and temporal contexts significantly influence people's momentary measured noise, perceived noise, and psychological stress. These findings advance our understanding of specific contexts, individual-based objectively measured and subjectively perceived environmental exposures, and their effects on psychological health at a high spatiotemporal resolution.