Multilevel Modeling in Epidemiologic Studies

Multilevel modeling has been used in the fields of sociology, education and demography. More recently, it has become popular in epidemiologic studies due in part to the increasing interest in analyzing the environment and ecologic-level determinants of risk factors of the diseases and its practical implications for prevention of diseases. The epidemiology of infectious diseases cannot dismiss the influence of the environment in the etiology. As a result, any individual-level analysis of the risk factors of infectious disease must include the environmental attributes where the individuals reside, and unlike the individual-level characteristics, these attributes is similar to all individuals.

An individual-level analysis of infectious diseases that include the environment and ecologic characteristics are usually data with hierarchical structure. Since the data includes the environment or ecologic characteristics that are similar among individuals, the assumption of independent observation is violated. A multilevel analysis (MLA) is the suitable technique for this kind of data because it recognizes the existence of clustering of individuals. In addition, MLA models the variability at different levels of the data by simultaneously examining the effects of factors at different levels to the individual-level outcome. Unlike MLA, the

conventional regression models can only utilize one of either individual- or group-level factors when examining effects and random variation. The analytic model of individual-level studies can only incorporate the individual-level explanatory variables in explaining the individual health outcome and its variance. While the ecologic studies, where the unit of analysis is the group, the analytical model includes only group-level explanatory variables with the outcome variable measured also at the group-level. A multilevel model is constructed either by including random intercepts only or by including both random intercepts and random slopes. Variables may also be added to the model to explain variability at the individual and group levels, and to explain the differences in slopes.

An individual-level analysis that ignores the hierarchical structure of the data can force the observations of group-level variables to be aggregated or disaggregated. Suppose that the grouplevel characteristics when incorporated in the model through disaggregation of the higher-level

variables to the individual-level then the sample size of the higher-level variables will radically increase. The disaggregation of the higher-level variables will treat the individual outcome as independent from each other even if the individual outcome within groups may actually be correlated, and this violates the basic assumption of independence of observations in traditional regression. Hence, imposing the assumption that these observations are independent would lead to complacency in the estimated level of significance arising out of the underestimation of standard errors. The consequence is an inflated probability of type 1 error when examining between-group differences and conservative tests when examining within-group differences.

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