Adolescents' loneliness in European schools: a multilevel exploration of school environment and individual factors.

BACKGROUND: Loneliness has been recognized as a public health issue and has moved into a number of European countries' policy agendas. Literature examining loneliness in young people (and especially in adolescents) is scarce, but it does show that at this age feelings of loneliness have been increasing in recent decades and are detrimental for both adolescents' current and future well-being. In order to explain loneliness, current literature focuses generally on individual, rather than on broader, environmental characteristics. This study examines school associates of loneliness and compares their importance to those at the individual level because schools are the most important places in which adolescents are socially embedded. In addition, policy interventions on loneliness might be more feasible at the school than the individual level. METHODS: This study uses a single-item measure of adolescents' loneliness feelings in schools and exploits rich data from the Programme for International Student Assessment (PISA 2018) on 23 European countries covering 118,698 students (50.2% female) in 4,819 schools. This study applies multi-level models to investigate school level factors jointly with those at the individual level. RESULTS: Differences between European schools can explain a 20% variation in feelings of loneliness, thereby indicating the importance of the school environment. Furthermore, adolescents' bullying experiences and a bullying climate in school more than doubles incidences of loneliness. In addition, a cooperative climate as well as teacher support can considerably decrease school loneliness. Cross-level interactions do exist: being from a lower socioeconomic background for instance, while not important generally, increases loneliness feelings if most of the school peers are from a better socioeconomic background. School factors appear to be more important for explaining young people's loneliness incidence than individual characteristics. CONCLUSION: This is the first study to compare school level and individual level factors relating to youth loneliness in schools throughout Europe. Results emphasizing the importance of school environment for explaining adolescents' loneliness suggest that school level initiatives may be most appropriate in tackling loneliness when compared to wider and less contextualized national policies that focus on adolescents outside of school.

"An unnecessary cut?" multilevel health systems analysis of drivers of caesarean sections rates in Italy: a systematic review.

BACKGROUND: Improvements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. However, as with any medical procedure, the CS intrinsically carries some risk to its beneficiaries. In recent years, CS rates have risen alarmingly in high-income countries. Many exceeding the World Health Organisation (WHO) recommendation of a 10 to 15% annual CS rate. While this situation poses an increased risk to women and their children, it also represents an excess human and financial burden on health systems. Therefore, from a health system perspective this study systematically summarizes existing evidence relevant to the factors driving the phenomenon of increasing CS rates using Italy as a case study. METHODS: Employing the WHO Health System Framework (WHOHSF), this systematic review used the PRISMA guidelines to report findings. PubMed, SCOPUS, MEDLINE, Cochrane Library and Google Scholar databases were searched up until April 1, 2020. Findings were organised through the six dimensions of the WHOHSF framework: service delivery, health workforce, health system information; medical products vaccine and technologies, financing; and leadership and governance. RESULTS: CS rates in Italy are affected by complex interactions among several stakeholder groups and contextual factors such as the hyper-medicalisation of delivery, differences in policy and practice across units and the national context, issues pertaining to the legal and social environment, and women's attitudes towards pregnancy and childbirth. CONCLUSION: Mitigating the high rates of CS will require a synergistic multi-stakeholder intervention. Specifically, with processes able to attract the official endorsement of policy makers, encourage concensus between regional authorities and local governments and guide the systematic compliance of delivery units with its clinical guidelines.