A multilevel investigation of inequalities in clinical and psychosocial outcomes for women after breast cancer

Background In Australia, breast cancer is the most common cancer affecting Australian women. Inequalities in clinical and psychosocial outcomes have existed for some time, affecting particularly women from rural areas and from areas of disadvantage. We have a limited understanding of how individual and area-level factors are related to each other, and their associations with survival and other clinical and psychosocial outcomes. Methods/Design This study will examine associations between breast cancer recurrence, survival and psychosocial outcomes (e.g. distress, unmet supportive care needs, quality of life). The study will use an innovative multilevel approach using area-level factors simultaneously with detailed individual-level factors to assess the relative importance of remoteness, socioeconomic and demographic factors, diagnostic and treatment pathways and processes, and supportive care utilization to clinical and psychosocial outcomes. The study will use telephone and self-administered questionnaires to collect individual-level data from approximately 3, 300 women ascertained from the Queensland Cancer Registry diagnosed with invasive breast cancer residing in 478 Statistical Local Areas Queensland in 2011 and 2012. Area-level data will be sourced from the Australian Bureau of Statistics census data. Geo-coding and spatial technology will be used to calculate road travel distances from patients' residence to diagnostic and treatment centres. Data analysis will include a combination of standard empirical procedures and multilevel modelling. Discussion The study will address the critical question of: what are the individual- or area-level factors associated with inequalities in outcomes from breast cancer? The findings will provide health care providers and policy makers with targeted information to improve the management of women with breast cancer, and inform the development of strategies to improve psychosocial care for women with breast cancer.

Change readiness : a multilevel review

The authors conducted a theoretical review of the change readiness literature and identified two major limitations with this work. First, while there is substantial agreement about the key cognitions that underlie change readiness, researchers have not examined the affective element of this attitude. Second, researchers have not adopted a multilevel perspective when considering change readiness. The authors address these limitations and argue that it is important to incorporate affect into definitions of the change readiness construct and also when measuring this construct. They then develop a multilevel framework that identifies the antecedents and consequences of individual, work group, and organizational change readiness. Next, the authors outline the theoretical processes that lead to the development of individual and collective change readiness. They then review theoretical and empirical evidence to identify the antecedents of change readiness at the three levels of analysis. Finally, the authors identify a number of suggestions to guide future research seeking to adopt a multilevel approach to change readiness.

Academic entrepreneurship: A multilevel examination of individual, subunit and organizational effects

This study utilizes a multilevel approach to both estimate the relative importance of individual, subunit, and organization effects on entrepreneurial intentions in academia, as well as to investigate specific factors within the subunit effect and their interactions with other levels. Using a dataset of 2,652 researchers from 386 departments in 24 European universities, our findings reveal that intra-university differences, caused by the influence of the department, should not be ignored when studying academic entrepreneurship. Whereas researchers’ entrepreneurial intentions are mostly influenced by individual differences, department membership explains more variation than the university as a whole. Furthermore, drawing upon organizational culture literature, we identify a department’s adhocracy culture, characterized by flexibility and an external orientation, to be positively related to entrepreneurial intentions. Finally, consistent with trait activation theory, we find that strong adhocracy cultures reinforce the positive association between proactive personality and entrepreneurial intentions. This effect is further intensified when the university also has a technology transfer office with a substantial size. Our results have relevant implications for both academics and practitioners, including university managers, department heads and policy makers.

Comparing multilevel and Bayesian spatial random effects survival models to assess geographical inequalities in colorectal cancer survival: a case study

Background Multilevel and spatial models are being increasingly used to obtain substantive information on area-level inequalities in cancer survival. Multilevel models assume independent geographical areas, whereas spatial models explicitly incorporate geographical correlation, often via a conditional autoregressive prior. However the relative merits of these methods for large population-based studies have not been explored. Using a case-study approach, we report on the implications of using multilevel and spatial survival models to study geographical inequalities in all-cause survival. Methods Multilevel discrete-time and Bayesian spatial survival models were used to study geographical inequalities in all-cause survival for a population-based colorectal cancer cohort of 22,727 cases aged 20–84 years diagnosed during 1997–2007 from Queensland, Australia. Results Both approaches were viable on this large dataset, and produced similar estimates of the fixed effects. After adding area-level covariates, the between-area variability in survival using multilevel discrete-time models was no longer significant. Spatial inequalities in survival were also markedly reduced after adjusting for aggregated area-level covariates. Only the multilevel approach however, provided an estimation of the contribution of geographical variation to the total variation in survival between individual patients. Conclusions With little difference observed between the two approaches in the estimation of fixed effects, multilevel models should be favored if there is a clear hierarchical data structure and measuring the independent impact of individual- and area-level effects on survival differences is of primary interest. Bayesian spatial analyses may be preferred if spatial correlation between areas is important and if the priority is to assess small-area variations in survival and map spatial patterns. Both approaches can be readily fitted to geographically enabled survival data from international settings

Supportive and palliative care for lung cancer patients

Lung cancer patients face poor survival and experience co-occurring chronic physical and psychological symptoms. These symptoms can result in significant burden, impaired physical and social function and poor quality of life. This paper provides a review of evidence based interventions that support best practice supportive and palliative care for patients with lung cancer. Specifically, interventions to manage dyspnoea, one of the most common symptoms experienced by this group, are discussed to illustrate the emerging evidence base in the field. The evidence base for the pharmacological management of dyspnoea report systemic opioids have the best available evidence to support their use. In particular, the evidence strongly supports systemic morphine preferably initiated and continued as a once daily sustained release preparation. Evidence supporting the use of a range of other adjunctive non-pharmacological interventions in managing the symptom is also emerging. Interventions to improve breathing efficiency that have been reported to be effective include pursed lip breathing, diaphragmatic breathing, positioning and pacing techniques. Psychosocial interventions seeking to reduce anxiety and distress can also improve the management of breathlessness although further studies are needed. In addition, evidence reviews have concluded that case management approaches and nurse led follow-up programs are effective in reducing breathlessness and psychological distress, providing a useful model for supporting implementation of evidence based symptom management strategies. Optimal outcomes from supportive and palliative care interventions thus require a multilevel approach, involving interventions at the patient, health professional and health service level.

Design considerations in an indirectly coupled multilevel motor controller

Permanent magnet (PM) motors utilising ironless stator structures have been incorporated into a wide variety of applications where high efficiency and stringent torque control are required. With recent developments in magnetic materials, improved design strategies, and power outputs of up to 40kW, PM motors have become an attractive candidate for traction drives in electric and hybrid electric vehicles. However, due to their large air gaps and ironless stators these motors can have inductances as low as 2μH, imposing increased requirements on the converter to minimise current ripple. Multilevel converters with n cells can effectively increase the motor inductance by a factor of n2 and are an excellent approach to minimise the motor ripple current. Furthermore by indirectly coupling the outputs of each cell, improvements in converter input and cell ripple current can also be realised. This paper examines the issues in designing a high current indirectly coupled multilevel motor controller for an ironless BLDC traction drive and highlights the limitations of the common ladder core structure.

A state-wide systems approach to embedding the learning and teaching of sustainability in teacher education

Education systems have a key role to play in preparing future citizens to engage in sustainable living practices and help create a more sustainable world. Many schools throughout Australia have begun to develop whole-school approaches to sustainability education that are supported by national and state policies and curriculum frameworks. Preservice teacher education, however, lags behind in building the capacity of new teachers to initiate and implement such approaches (ARIES, 2010). This proposed project seeks to develop a state-wide systems approach to embedding Education for Sustainability (EfS) in teacher education that is aligned with the Australian National Curriculum and the aspirations for EfS in the Melbourne Declaration and other national documents. Representatives from all teacher education institutions and other agents of change in the Queensland education system will be engaged in a multilevel systems approach, involving collaboration at the state, institutional and course levels, to develop curriculum practices that reflect a shared vision of EfS.

Understanding service firms brand value creation : a multilevel perspective including the overarching role of service brand marketing capability

Purpose This study seeks to extend the existing literature on value creation by specifically focusing on service brand value creation (SBVC) and the role of brand marketing. Design/methodology/approach The authors first develop a model of SBVC and simultaneously investigate SBVC from the firm perspective (service brand value offering – SBVO) and from the customer perspective (service brand perceive value-in use – SBPVI). Subsequently, they investigate the effects of SBVO on SBPVI and integrate the moderation role of service brand marketing capability (SBMC) on the relationship between SBVO-SBPVI outcomes. SBVO is viewed as the firms' interpretation of and responsiveness to customer requirements via the delivery of superior performance the value offering through the service brand and SBPVI customers' perceived value from the firms' service brand. The contributions of SBVC to customer-based performance outcomes are then investigated. Hypotheses were tested using a sample of the senior managers of service firms in Cambodia and their customers. A survey was used to gather data via a drop-and-collect approach. Findings Results indicated that SBVO is positively related to SBPVI and SBPVI is positively related to customer-based performance. Noticeably, the results revealed that SBMC enhances the positive relationship between the firm SBVO and the customers SBPVI. Originality/value The paper extends the previous literature on value creation to capture SBVC. More significantly, the premise of the theoretical framework provides a breakthrough in the current SBVC literature which has so far neglected to take into account the dyadic approach (firm-customer) in understanding value creation and more specifically SBVC. The model is expanded by looking at the contingency role of SBMC in communicating value to customers.

Towards a multiple-goal pursuit and multilevel view of continuing information technology usage : a process model integration and a research agenda

The value of information technology (IT) is often realized when continuously being used after users’ initial acceptance. However, previous research on continuing IT usage is limited for dismissing the importance of mental goals in directing users’ behaviors and for inadequately accommodating the group context of users. This in-progress paper offers a synthesis of several literature to conceptualize continuing IT usage as multilevel constructs and to view IT usage behavior as directed and energized by a set of mental goals. Drawing from the self-regulation theory in the social psychology, this paper proposes a process model, positioning continuing IT usage as multiple-goal pursuit. An agent-based modeling approach is suggested to further explore causal and analytical implications of the proposed process model.

A hybrid cascaded multilevel inverter with supercapacitor direct integration for wind power systems

This paper presents a grid-side inverter based supercapacitor direct integration scheme for wind power systems. The inverter used in this study consists of a conventional two-level inverter and three H-bridge modules. Three supercapacitor banks are directly connected to the dc-links of H-bridge modules. This approach eliminates the need for interfacing dc-dc converters and thus considerably improves the overall efficiency. However, for the maximum utilization of super capacitors their voltages should be allowed to vary. As a result of this variable voltage space vectors of the hybrid inverter get distributed unevenly. To handle this issue, a modified PWM method and a space vector modulation method are proposed and they can generate undistorted current even in the presence of unevenly distributed space vectors. A supercapacitor voltage balancing method is also presented in this paper. Simulation results are presented to validate the efficacy of the proposed scheme, modulation methods and control techniques.

Multilevel competing risk models to evaluate the risk of nosocomial infection

Introduction Risk factor analyses for nosocomial infections (NIs) are complex. First, due to competing events for NI, the association between risk factors of NI as measured using hazard rates may not coincide with the association using cumulative probability (risk). Second, patients from the same intensive care unit (ICU) who share the same environmental exposure are likely to be more similar with regard to risk factors predisposing to a NI than patients from different ICUs. We aimed to develop an analytical approach to account for both features and to use it to evaluate associations between patient- and ICU-level characteristics with both rates of NI and competing risks and with the cumulative probability of infection. Methods We considered a multicenter database of 159 intensive care units containing 109,216 admissions (813,739 admission-days) from the Spanish HELICS-ENVIN ICU network. We analyzed the data using two models: an etiologic model (rate based) and a predictive model (risk based). In both models, random effects (shared frailties) were introduced to assess heterogeneity. Death and discharge without NI are treated as competing events for NI. Results There was a large heterogeneity across ICUs in NI hazard rates, which remained after accounting for multilevel risk factors, meaning that there are remaining unobserved ICU-specific factors that influence NI occurrence. Heterogeneity across ICUs in terms of cumulative probability of NI was even more pronounced. Several risk factors had markedly different associations in the rate-based and risk-based models. For some, the associations differed in magnitude. For example, high Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were associated with modest increases in the rate of nosocomial bacteremia, but large increases in the risk. Others differed in sign, for example respiratory vs cardiovascular diagnostic categories were associated with a reduced rate of nosocomial bacteremia, but an increased risk. Conclusions A combination of competing risks and multilevel models is required to understand direct and indirect risk factors for NI and distinguish patient-level from ICU-level factors.