Multimorbidity and associated informal care receiving characteristics for US older adults: a latent class analysis.

BACKGROUND: Older adults with varying patterns of multimorbidity may require distinct types of care and rely on informal caregiving to meet their care needs. This study aims to identify groups of older adults with distinct, empirically-determined multimorbidity patterns and compare characteristics of informal care received among estimated classes. METHODS: Data are from the 2011 National Health and Aging Trends Study (NHATS). Ten chronic conditions were included to estimate multimorbidity patterns among 7532 individuals using latent class analysis. Multinomial logistic regression model was estimated to examine the association between sociodemographic characteristics, health status and lifestyle variables, care-receiving characteristics and latent class membership. RESULTS: A four-class solution identified the following multimorbidity groups: some somatic conditions with moderate cognitive impairment (30%), cardiometabolic (25%), musculoskeletal (24%), and multisystem (21%). Compared with those who reported receiving no help, care recipients who received help with household activities only (OR = 1.44, 95% CI 1.05-1.98), mobility but not self-care (OR = 1.63, 95% CI 1.05-2.53), or self-care but not mobility (OR = 2.07, 95% CI 1.29-3.31) had greater likelihood of being in the multisystem group versus the some-somatic group. Having more caregivers was associated with higher odds of being in the multisystem group compared with the some-somatic group (OR = 1.09, 95% CI 1.00-1.18), whereas receiving help from paid helpers was associated with lower odds of being in the multisystem group (OR = 0.36, 95% CI 0.19-0.77). CONCLUSIONS: Results highlighted different care needs among persons with distinct combinations of multimorbidity, in particular the wide range of informal needs among older adults with multisystem multimorbidity. Policies and interventions should recognize the differential care needs associated with multimorbidity patterns to better provide person-centered care.

The importance of chronic conditions for potentially avoidable hospitalizations among non-Hispanic Black and non-Hispanic White older adults in the US: a cross-sectional observational study.

BACKGROUND: Non-Hispanic (NH) Black older adults experience substantially higher rates of potentially avoidable hospitalization compared to NH White older adults. This study explores the top three chronic conditions preceding hospitalization and potentially avoidable hospitalization among NH White and NH Black Medicare beneficiaries in the United States. METHODS: Data on 4993 individuals (4,420 NH White and 573 NH Black individuals) aged ≥ 65 years from 2014 Medicare claims were linked with sociodemographic data from previous rounds of the Health and Retirement Study. Conditional inference random forests were used to rank the importance of chronic conditions in predicting hospitalization and potentially avoidable hospitalization separately for NH White and NH Black beneficiaries. Multivariable logistic regression with the top three chronic diseases for each outcome adjusted for sociodemographic characteristics were conducted to quantify the associations. RESULTS: In total, 22.1% of NH White and 24.9% of NH Black beneficiaries had at least one hospitalization during 2014. Among those with hospitalization, 21.3% of NH White and 29.6% of NH Black beneficiaries experienced at least one potentially avoidable hospitalization. For hospitalizations, chronic kidney disease, heart failure, and atrial fibrillation were the top three contributors among NH White beneficiaries and acute myocardial infarction, chronic obstructive pulmonary disease (COPD), and chronic kidney disease were the top three contributors among NH Black beneficiaries. These chronic conditions were associated with increased odds of hospitalization for both groups. For potentially avoidable hospitalizations, asthma, COPD, and heart failure were the top three contributors among NH White beneficiaries and fibromyalgia/chronic pain/fatigue, COPD, and asthma were the top three contributors among NH Black beneficiaries. COPD and heart failure were associated with increased odds of potentially avoidable hospitalization among NH White beneficiaries, whereas only COPD was associated with increased odds of potentially avoidable hospitalizations among NH Black beneficiaries. CONCLUSION: Having at least one hospitalization and at least one potentially avoidable hospitalization was more prevalent among NH Black than NH White Medicare beneficiaries. This suggests greater opportunity for increasing prevention efforts among NH Black beneficiaries. The importance of COPD for potentially avoidable hospitalizations further highlights the need to focus on prevention of exacerbations for patients with COPD, possibly through greater access to primary care and continuity of care.

Racial and Ethnic Differences in Multimorbidity Changes Over Time.

BACKGROUND: Our understanding of how multimorbidity progresses and changes is nascent. OBJECTIVES: Assess multimorbidity changes among racially/ethnically diverse middle-aged and older adults. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study using latent class analysis to identify multimorbidity combinations over 16 years, and multinomial logistic models to assess change relative to baseline class membership. Health and Retirement Study respondents (age 51 y and above) in 1998 and followed through 2014 (N=17,297). MEASURES: Multimorbidity latent classes of: hypertension, heart disease, lung disease, diabetes, cancer, arthritis, stroke, high depressive symptoms. RESULTS: Three latent classes were identified in 1998: minimal disease (45.8% of participants), cardiovascular-musculoskeletal (34.6%), cardiovascular-musculoskeletal-mental (19.6%); and 3 in 2014: cardiovascular-musculoskeletal (13%), cardiovascular-musculoskeletal-metabolic (12%), multisystem multimorbidity (15%). Remaining participants were deceased (48%) or lost to follow-up (12%) by 2014. Compared with minimal disease, individuals in cardiovascular-musculoskeletal in 1998 were more likely to be in multisystem multimorbidity in 2014 [odds ratio (OR)=1.78, P<0.001], and individuals in cardiovascular-musculoskeletal-mental in 1998 were more likely to be deceased (OR=2.45, P<0.001) or lost to follow-up (OR=3.08, P<0.001). Hispanic and Black Americans were more likely than White Americans to be in multisystem multimorbidity in 2014 (OR=1.67, P=0.042; OR=2.60, P<0.001, respectively). Black compared with White Americans were more likely to be deceased (OR=1.62, P=0.01) or lost to follow-up (OR=2.11, P<0.001) by 2014. CONCLUSIONS AND RELEVANCE: Racial/ethnic older adults are more likely to accumulate morbidity and die compared with White peers, and should be the focus of targeted and enhanced efforts to prevent and/or delay progression to more complex multimorbidity patterns.

Effects of a large-scale distribution of water filters and natural draft rocket-style cookstoves on diarrhea and acute respiratory infection: A cluster-randomized controlled trial in Western Province, Rwanda.

BACKGROUND: Unsafe drinking water and household air pollution (HAP) are major causes of morbidity and mortality among children under 5 in low and middle-income countries. Household water filters and higher-efficiency biomass-burning cookstoves have been widely promoted to improve water quality and reduce fuel use, but there is limited evidence of their health effects when delivered programmatically at scale. METHODS AND FINDINGS: In a large-scale program in Western Province, Rwanda, water filters and portable biomass-burning natural draft rocket-style cookstoves were distributed between September and December 2014 and promoted to over 101,000 households in the poorest economic quartile in 72 (of 96) randomly selected sectors in Western Province. To assess the effects of the intervention, between August and December, 2014, we enrolled 1,582 households that included a child under 4 years from 174 randomly selected village-sized clusters, half from intervention sectors and half from nonintervention sectors. At baseline, 76% of households relied primarily on an improved source for drinking water (piped, borehole, protected spring/well, or rainwater) and over 99% cooked primarily on traditional biomass-burning stoves. We conducted follow-up at 3 time-points between February 2015 and March 2016 to assess reported diarrhea and acute respiratory infections (ARIs) among children <5 years in the preceding 7 days (primary outcomes) and patterns of intervention use, drinking water quality, and air quality. The intervention reduced the prevalence of reported child diarrhea by 29% (prevalence ratio [PR] 0.71, 95% confidence interval [CI] 0.59-0.87, p = 0.001) and reported child ARI by 25% (PR 0.75, 95% CI 0.60-0.93, p = 0.009). Overall, more than 62% of households were observed to have water in their filters at follow-up, while 65% reported using the intervention stove every day, and 55% reported using it primarily outdoors. Use of both the intervention filter and intervention stove decreased throughout follow-up, while reported traditional stove use increased. The intervention reduced the prevalence of households with detectable fecal contamination in drinking water samples by 38% (PR 0.62, 95% CI 0.57-0.68, p < 0.0001) but had no significant impact on 48-hour personal exposure to log-transformed fine particulate matter (PM2.5) concentrations among cooks (ß = -0.089, p = 0.486) or children (ß = -0.228, p = 0.127). The main limitations of this trial include the unblinded nature of the intervention, limited PM2.5 exposure measurement, and a reliance on reported intervention use and reported health outcomes. CONCLUSIONS: Our findings indicate that the intervention improved household drinking water quality and reduced caregiver-reported diarrhea among children <5 years. It also reduced caregiver-reported ARI despite no evidence of improved air quality. Further research is necessary to ascertain longer-term intervention use and benefits and to explore the potential synergistic effects between diarrhea and ARI. TRIAL REGISTRATION: Clinical Trials.gov NCT02239250.

Disputes of Self-reported Chronic Disease Over Time: The Role of Race, Ethnicity, Nativity, and Language of Interview.

BACKGROUND: Respondents in longitudinal health interview surveys may inconsistently report their chronic diseases across interview waves. Racial/ethnic minority adults have an increased burden of chronic diseases and may dispute chronic disease reports more frequently. OBJECTIVE: We evaluated the longitudinal association between race/ethnicity, nativity, and language of interview with disputing previously reported chronic diseases. METHODS: We performed secondary data analysis of nationally representative longitudinal data (Health and Retirement Study, 1998-2010) of adults 51 years or older (n=23,593). We estimated multilevel mixed-effects logistic models of disputes of previously reported chronic disease (hypertension, heart disease, lung disease, diabetes, cancer, stroke, arthritis). RESULTS: Approximately 22% of Health and Retirement Study respondents disputed prior chronic disease self-reports across the entire study period; 21% of non-Latino white, 20.5% of non-Latino black, and 28% of Latino respondents disputed. In subgroup comparisons of model-predicted odds using postestimation commands, Latinos interviewed in Spanish have 34% greater odds of disputing compared with non-Latino whites interviewed in English and 35% greater odds of dispute relative to non-Latino blacks interviewed in English. CONCLUSIONS: The odds of disputing a prior chronic disease report were substantially higher for Latinos who were interviewed in Spanish compared with non-Latino white or black counterparts interviewed in English, even after accounting for other sociodemographic factors, cognitive declines, and time-in-sample considerations. Our findings point toward leveraging of multiple sources of data to triangulate information on chronic disease status as well as investigating potential mechanisms underlying the higher probability of dispute among Spanish-speaking Latino respondents.

A cluster-randomized multi-level intervention to increase latrine use and safe disposal of child feces in rural Odisha, India: the Sundara Grama research protocol.

BACKGROUND: Despite health benefits of sanitation, an estimated 12% of the global population practices open defecation, including an estimated 50% of the population of India. Current estimates, however, do not include households that own toilets but do not use them, suggesting that the actual number of people defecating in the open is underestimated. This protocol describes a cluster randomized controlled trial to evaluate an intervention specifically designed to increase latrine use, including the safe disposal of child feces, in rural Odisha, India. METHODS: The trial engages 66 villages in Puri district, 33 randomly allocated to receive the intervention and 33 to serve as controls. The primary outcome is latrine use and is recorded at baseline and endline for all members of all households that own latrines in all trial vilalges. Additional data on determinants of latrine use and safe child feces disposal are also collected to assess change based on the intervetntion. A process evaluation assesses the delivery of the intervention and qualiative research takes place in non-trial villages as well as post-endline in trial villages to help explain trial findings. DISCUSSION: This is one of four trials taking place simultaneously in rural India with latrine use as the primary outcome. All four studies use the same outcome to gerenate comparable data across sites that can serve the government of India. The trial in Odisha is unique in that it collects latrine use data from all potential users in all households that own latrines, enabling a thorough view of the sanitation situation and factors that influence use at the community level. That latrine use is collected via self-report is a limitation, however any bias in reporting should be the same across villages and not impact the overall assessment of intervention impact. TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov: NCT03274245 .

Insurance status differences in weight loss and regain over 5 years following bariatric surgery.

BACKGROUND: The effectiveness of bariatric surgery among Medicaid beneficiaries, a population with a disproportionately high burden of obesity, remains unclear. We sought to determine if weight loss and regain following bariatric surgery differed in Medicaid patients compared to commercial insurance. SUBJECTS/METHODS: Data from the Longitudinal Assessment of Bariatric Surgery, a ten-site observational cohort of adults undergoing bariatric surgery (2006-2009) were examined for patients who underwent Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Band (LAGB), or Sleeve Gastrectomy (SG). Using piecewise spline linear mixed-effect models, weight change over 5 years was modeled as a function of insurance type (Medicaid, N = 190; commercially insured, N = 1448), time, procedure type, and sociodemographic characteristics; additionally, interactions between all time, insurance, and procedure type indicators allowed time- and procedure-specific associations with insurance type. For each time-spline, mean (kg) difference in weight change in commercially insured versus Medicaid patients was calculated. RESULTS: Medicaid patients had higher mean weight at baseline (138.3 kg vs. 131.2 kg). From 0 to 1 year post-operatively, Medicaid patients lost similar amounts of weight to commercial patients following all procedure types (mean weight Δ difference [95% CI]: RYGB: -0.9 [-3.2, 1.4]; LAGB: -1.5 [-6.7, 3.8]; SG: 5.1 [-4.0, 14.2]). From 1 to 3 years post-operatively Medicaid and commercial patients continued to experience minimal weight loss or began to slowly regain weight (mean weight Δ difference [95% CI]: RYGB: 0.9 [0.0, 2.0]; LAGB: -2.1 [-4.2, 0.1]; SG: 0.7 [-3.0, 4.3]). From 3 to 5 years post-operatively, the rate of regain tended to be faster among commercial patients compared to Medicaid patients (mean weight Δ difference [95% CI]: RYGB: 1.1 [0.1, 2.0]; LAGB: 1.5 [-0.5, 3.5]; SG: 1.0 [-2.5, 4.5]). CONCLUSIONS: Although Medicaid patients had a higher baseline weight, they achieved similar amounts of weight loss and tended to regain weight at a slower rate than commercial patients.

Prevalence and correlates of psychiatric symptoms among first responders in a Southern State.

First responders (FRs) respond to critical incidents as an expectation of their profession, and after years of service, exposure to trauma can accumulate and potentially lead to mental health problems, such as posttraumatic stress disorder (PTSD). A gap persists in the research regarding duty-related risk factors and prevalence of mental health problems among FRs. Guided by existing evidence and in partnerships with the state's FR community, this study assessed the mental health needs of FRs, risk factors that may contribute to these problems, and the associations therein. A convenience sample of firefighters and emergency medical technicians/paramedics (n = 220) were recruited from across Arkansas to complete an online survey. This survey incorporated brief assessment tools to measure various mental health problems, and captured other data regarding possible risk factors. Results found that 14% reported moderate-severe and severe depressive symptoms, 28% reported moderate-severe and severe anxiety symptoms, 26% reported significant symptoms of PTSD, 31% reported harmful/hazardous alcohol use and dependence, 93% reported significant sleep disturbances, and 34% indicated high risk for suicide. Significant group differences were found across measures and gender (female), shift-structure (48 h or more), department setting (rural), relationship status (non-partnered), and having a medical history of hypertension. These findings pose significant implications for mental healthcare providers, as well as other healthcare providers and FR organizations. Findings will guide future research that will address the need for changes in decision-making, funding, and policy regarding FRs' MH and MH services available to them.

Racial and ethnic differences in smoking changes after chronic disease diagnosis among middle-aged and older adults in the United States.

BACKGROUND: Middle-aged and older Americans from underrepresented racial and ethnic backgrounds are at risk for greater chronic disease morbidity than their white counterparts. Cigarette smoking increases the severity of chronic illness, worsens physical functioning, and impairs the successful management of symptoms. As a result, it is important to understand whether smoking behaviors change after the onset of a chronic condition. We assessed the racial/ethnic differences in smoking behavior change after onset of chronic diseases among middle-aged and older adults in the US. METHODS: We use longitudinal data from the Health and Retirement Study (HRS 1992-2010) to examine changes in smoking status and quantity of cigarettes smoked after a new heart disease, diabetes, cancer, stroke, or lung disease diagnosis among smokers. RESULTS: The percentage of middle-aged and older smokers who quit after a new diagnosis varied by racial/ethnic group and disease: for white smokers, the percentage ranged from 14% after diabetes diagnosis to 32% after cancer diagnosis; for black smokers, the percentage ranged from 15% after lung disease diagnosis to 40% after heart disease diagnosis; the percentage of Latino smokers who quit was only statistically significant after stoke, where 38% quit. In logistic models, black (OR = 0.43, 95% CI: 0.19-0.99) and Latino (OR = 0.26, 95% CI: 0.11-0.65) older adults were less likely to continue smoking relative to white older adults after a stroke, and Latinos were more likely to continue smoking relative to black older adults after heart disease onset (OR = 2.69, 95% CI [1.05-6.95]). In models evaluating changes in the number of cigarettes smoked after a new diagnosis, black older adults smoked significantly fewer cigarettes than whites after a new diagnosis of diabetes, heart disease, stroke or cancer, and Latino older adults smoked significantly fewer cigarettes compared to white older adults after newly diagnosed diabetes and heart disease. Relative to black older adults, Latinos smoked significantly fewer cigarettes after newly diagnosed diabetes. CONCLUSIONS: A large majority of middle-aged and older smokers continued to smoke after diagnosis with a major chronic disease. Black participants demonstrated the largest reductions in smoking behavior. These findings have important implications for tailoring secondary prevention efforts for older adults.

Behavioral Reactivity Associated With Electronic Monitoring of Environmental Health Interventions--A Cluster Randomized Trial with Water Filters and Cookstoves.

Subject reactivity--when research participants change their behavior in response to being observed--has been documented showing the effect of human observers. Electronics sensors are increasingly used to monitor environmental health interventions, but the effect of sensors on behavior has not been assessed. We conducted a cluster randomized controlled trial in Rwanda among 170 households (70 blinded to the presence of the sensor, 100 open) testing whether awareness of an electronic monitor would result in a difference in weekly use of household water filters and improved cookstoves over a four-week surveillance period. A 63% increase in number of uses of the water filter per week between the groups was observed in week 1, an average of 4.4 times in the open group and 2.83 times in the blind group, declining in week 4 to an insignificant 55% difference of 2.82 uses in the open, and 1.93 in the blind. There were no significant differences in the number of stove uses per week between the two groups. For both filters and stoves, use decreased in both groups over four-week installation periods. This study suggests behavioral monitoring should attempt to account for reactivity to awareness of electronic monitors that persists for weeks or more.

Process evaluation and assessment of use of a large scale water filter and cookstove program in Rwanda.

BACKGROUND: In an effort to reduce the disease burden in rural Rwanda, decrease poverty associated with expenditures for fuel, and minimize the environmental impact on forests and greenhouse gases from inefficient combustion of biomass, the Rwanda Ministry of Health (MOH) partnered with DelAgua Health (DelAgua), a private social enterprise, to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households (Ubudehe 1 and 2) nationally, beginning in Western Province under a program branded Tubeho Neza ("Live Well"). The project is privately financed and earns revenue from carbon credits under the United Nations Clean Development Mechanism. METHODS: During a 3-month period in late 2014, over 470,000 people living in over 101,000 households were provided free water filters and cookstoves. Following the distribution, community health workers visited nearly 98 % of households to perform household level education and training activities. Over 87 % of households were visited again within 6 months with a basic survey conducted. Detailed adoption surveys were conducted among a sample of households, 1000 in the first round, 187 in the second. RESULTS: Approximately a year after distribution, reported water filter use was above 90 % (+/-4 % CI) and water present in filter was observed in over 76 % (+/-6 % CI) of households, while the reported primary stove was nearly 90 % (+/-4.4 % CI) and of households cooking at the time of the visit, over 83 % (+/-5.3 % CI) were on the improved stove. There was no observed association between household size and stove stacking behavior. CONCLUSIONS: This program suggests that free distribution is not a determinant of low adoption. It is plausible that continued engagement in households, enabled by Ministry of Health support and carbon financed revenue, contributed to high adoption rates. Overall, the program was able to demonstrate a privately financed, public health intervention can achieve high levels of initial adoption and usage of household level water filtration and improved cookstoves at a large scale.

Evaluating Cellular Instrumentation on Rural Handpumps to Improve Service Delivery-A Longitudinal Study in Rural Rwanda.

In rural sub-Saharan Africa, where handpumps are common, 10-67% are nonfunctional at any one time, and many never get repaired. Increased reliability requires improved monitoring and responsiveness of maintenance providers. In 2014, 181 cellular enabled water pump use sensors were installed in three provinces of Rwanda. In three arms, the nominal maintenance model was compared against a "best practice" circuit rider model, and an "ambulance" service model. In only the ambulance model was the sensor data available to the implementer, and used to dispatch technicians. The study ran for seven months in 2014-2015. In the study period, the nominal maintenance group had a median time to successful repair of approximately 152 days, with a mean per-pump functionality of about 68%. In the circuit rider group, the median time to successful repair was nearly 57 days, with a per-pump functionality mean of nearly 73%. In the ambulance service group, the successful repair interval was nearly 21 days with a functionality mean of nearly 91%. An indicative cost analysis suggests that the cost per functional pump per year is approximately similar between the three models. However, the benefits of reliable water service may justify greater focus on servicing models over installation models.

Mental-somatic multimorbidity in trajectories of cognitive function for middle-aged and older adults.

INTRODUCTION: Multimorbidity may confer higher risk for cognitive decline than any single constituent disease. This study aims to identify distinct trajectories of cognitive impairment probability among middle-aged and older adults, and to assess the effect of changes in mental-somatic multimorbidity on these distinct trajectories. METHODS: Data from the Health and Retirement Study (1998-2016) were employed to estimate group-based trajectory models identifying distinct trajectories of cognitive impairment probability. Four time-varying mental-somatic multimorbidity combinations (somatic, stroke, depressive, stroke and depressive) were examined for their association with observed trajectories of cognitive impairment probability with age. Multinomial logistic regression analysis was conducted to quantify the association of sociodemographic and health-related factors with trajectory group membership. RESULTS: Respondents (N = 20,070) had a mean age of 61.0 years (SD = 8.7) at baseline. Three distinct cognitive trajectories were identified using group-based trajectory modelling: (1) Low risk with late-life increase (62.6%), (2) Low initial risk with rapid increase (25.7%), and (3) High risk (11.7%). For adults following along Low risk with late-life increase, the odds of cognitive impairment for stroke and depressive multimorbidity (OR:3.92, 95%CI:2.91,5.28) were nearly two times higher than either stroke multimorbidity (OR:2.06, 95%CI:1.75,2.43) or depressive multimorbidity (OR:2.03, 95%CI:1.71,2.41). The odds of cognitive impairment for stroke and depressive multimorbidity in Low initial risk with rapid increase or High risk (OR:4.31, 95%CI:3.50,5.31; OR:3.43, 95%CI:2.07,5.66, respectively) were moderately higher than stroke multimorbidity (OR:2.71, 95%CI:2.35, 3.13; OR: 3.23, 95%CI:2.16, 4.81, respectively). In the multinomial logistic regression model, non-Hispanic Black and Hispanic respondents had higher odds of being in Low initial risk with rapid increase and High risk relative to non-Hispanic White adults. CONCLUSIONS: These findings show that depressive and stroke multimorbidity combinations have the greatest association with rapid cognitive declines and their prevention may postpone these declines, especially in socially disadvantaged and minoritized groups.

Recommendations on Methods for Assessing Multimorbidity Changes Over Time: Aligning the Method to the Purpose.

BACKGROUND: The rapidly growing field of multimorbidity research demonstrates that changes in multimorbidity in mid- and late-life have far reaching effects on important person-centered outcomes, such as health-related quality of life. However, there are few organizing frameworks and comparatively little work weighing the merits and limitations of various quantitative methods applied to the longitudinal study of multimorbidity. METHODS: We identify and discuss methods aligned to specific research objectives with the goals of (i) establishing a common language for assessing longitudinal changes in multimorbidity, (ii) illuminating gaps in our knowledge regarding multimorbidity progression and critical periods of change, and (iii) informing research to identify groups that experience different rates and divergent etiological pathways of disease progression linked to deterioration in important health-related outcomes. RESULTS: We review practical issues in the measurement of multimorbidity, longitudinal analysis of health-related data, operationalizing change over time, and discuss methods that align with 4 general typologies for research objectives in the longitudinal study of multimorbidity: (i) examine individual change in multimorbidity, (ii) identify subgroups that follow similar trajectories of multimorbidity progression, (iii) understand when, how, and why individuals or groups shift to more advanced stages of multimorbidity, and (iv) examine the coprogression of multimorbidity with key health domains. CONCLUSIONS: This work encourages a systematic approach to the quantitative study of change in multimorbidity and provides a valuable resource for researchers working to measure and minimize the deleterious effects of multimorbidity on aging populations.

A Joint Model for Disability, Self-Rated Health, and Mortality Among Medicare Beneficiaries-Differences by Chronic Disease and Race/Ethnicity.

OBJECTIVES: Quantifying interdependence in multiple patient-centered outcomes is important for understanding health declines among older adults. METHODS: Medicare-linked National Health and Aging Trends Study data (2011-2015) were used to estimate a joint longitudinal logistic regression model of disability in activities of daily living (ADL), fair/poor self-rated health (SRH), and mortality. We calculated personalized concurrent risk (PCR) and typical concurrent risk (TCR) using regression coefficients. RESULTS: For fair/poor SRH, highest odds were associated with COPD. For mortality, highest odds were associated with dementia, hip fracture, and kidney disease. Dementia and hip fracture were associated with highest odds of ADL disability. Hispanic respondents had highest odds of ADL disability. Hispanic and NH Black respondents had higher odds of fair/poor SRH, ADL disability, and mortality. PCRs/TCRs demonstrated wide variability for respondents with similar sociodemographic-multimorbidity profiles. DISCUSSION: These findings highlight the variability of personalized risk in examining interdependent outcomes among older adults.

Interprofessional Naloxone Student Training to Manage Suspected Opioid Overdose.

PURPOSE: The study purpose was to examine the effect of interprofessional naloxone training on students' knowledge, confidence, and interprofessional collaboration competency. The overarching goal was to decrease mortality related to opioid overdoses. DESIGN/METHODS: A training session for interprofessional students consisted of a lecture presentation, demonstration, and hands-on practice regarding appropriate administration of naloxone for suspected opioid overdose. A questionnaire elicited baseline and change in knowledge, confidence, and interprofessional collaboration competency scores at pretraining and posttraining. In addition, changes in knowledge and confidence were also measured 3 weeks after the training. Thematic analysis explored training components that students perceived as valuable or needing improvement. RESULTS: Participants (N = 100) were nursing (n = 33), physician assistant (n = 37), and pharmacy (n = 30) students. Pretraining and posttraining comparison demonstrated increased knowledge (P < .001), confidence (P < .001), and collaboration scores (P < .001). At 3 weeks, knowledge and confidence remained higher than pretraining (P < .001). Knowledge was trending downward compared with posttraining (P = .09). Thematic analysis identified 4 themes: (a) indications for administration of different naloxone types, (b) learning modalities, (c) knowledge application, and (d) improvements. CONCLUSIONS: An interprofessional naloxone administration training resulted in increased knowledge, confidence, and interprofessional teamwork. Educators can adapt this training for a variety of future or current healthcare professionals to improve immediate intervention and outcomes in suspected opioid overdoses.

Depressive Multimorbidity and Trajectories of Functional Status among Older Americans: Differences by Racial/Ethnic Group.

OBJECTIVE: This study aims to evaluate the impact of depressive multimorbidity (ie, including depressive symptoms) on the long-term development of activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations according to racial/ethnic group in a representative sample of US older adults. DESIGN: Prospective, observational, population-based 16-year follow-up study of nationally representative sample. SETTING AND PARTICIPANTS: Sample of older non-Hispanic Black, Hispanic, and nonHispanic White Americans from the Health and Retirement Study (2000‒2016, N = 16,364, community-dwelling adults ≥65 years of age). METHODS: Data from 9 biennial assessments were used to evaluate the accumulation of ADL-IADL limitations (range 0‒11) among participants with depressive (8-item Center for Epidemiologic Studies Depression score≥4) vs somatic (ie, physical conditions only) multimorbidity vs those without multimorbidity (no or 1 condition). Generalized estimating equations included race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White), baseline age, sex, body mass index, education, partnered, and net worth. RESULTS: Depressive and somatic multimorbidity were associated with 5.18 and 2.95 times greater accumulation of functional limitations, respectively, relative to no disease [incidence rate ratio (IRR) = 5.18, 95% confidence interval, CI (4.38,6.13), IRR = 2.95, 95% CI (2.51,3.48)]. Hispanic and Black respondents experienced greater accumulation of ADL-IADL limitations than White respondents [IRR = 1.27, 95% CI (1.14, 1.41), IRR = 1.31, 95% CI (1.20, 1.43), respectively]. CONCLUSIONS AND IMPLICATIONS: Combinations of somatic diseases and high depressive symptoms are associated with greatest accumulation of functional limitations over time in adults ages 65 and older. There is a more rapid growth in functional limitations among individuals from racial/ethnic minority groups. Given the high prevalence of multimorbidity and depressive symptomatology among older adults and the availability of treatment options for depression, these results highlight the importance of screening/treatment for depression, particularly among older adults with socioeconomic vulnerabilities, to slow the progression of functional decline in later life.

Study design and baseline to evaluate water service provision among peri-urban communities in Kasai Oriental, Democratic Republic of the Congo.

We present a study design and baseline results to establish the impact of interventions on peri-urban water access, security and quality in Kasai Oriental province of the Democratic Republic of the Congo. In standard development practice, program performance is tracked via monitoring and evaluation frameworks of varying sophistication and rigor. Monitoring and evaluation, while usually occurring nearly concurrently with program delivery, may or may not measure parameters that can identify performance with respect to the project's overall goals. Impact evaluations, often using tightly controlled trial designs and conducted over years, challenge iterative program evolution. This study will pilot an implementation science impact evaluation approach in the areas immediately surrounding 14 water service providers, at each surveying 100 randomly-selected households and conducting water quality assessments at 25 randomly-selected households and five water points every three months. We present preliminary point-of-collection and point-of-use baseline data. This study is utilizing a variety of short- and medium-term monitoring and impact evaluation methods to provide feedback at multiple points during the intervention. Rapid feedback monitoring will assess the continuity of water services, point-of-consumption and point-of-collection microbial water quality, household water security, household measures of health status, ability and willingness to pay for water and sanitation service provision, and service performance monitoring. Long-term evaluation will focus on the use of qualitative comparative analysis whereby we will investigate the combination of factors that lead to improved water access, security and quality.

Racial, ethnic, and socioeconomic disparities in trajectories of morbidity accumulation among older Americans.

Introduction: Multimorbidity, the presence of multiple chronic health conditions, generally starts in middle and older age but there is considerable heterogeneity in the trajectory of morbidity accumulation. This study aimed to clarify the number of distinct trajectories and the potential associations between race/ethnicity and socioeconomic status and these trajectories. Methods: Data from 13,699 respondents (age ≥51) in the Health and Retirement Study between 1998 and 2016 were analyzed with growth mixture models. Nine prevalent self-reported morbidities (arthritis, cancer, cognitive impairment, depressive symptoms, diabetes, heart disease, hypertension, lung disease, stroke) were summed for the morbidity count. Results: Three trajectories of morbidity accumulation were identified: low [starting with few morbidities and accumulating them slowly (i.e., low intercept and low slope); 80% of sample], increasing (i.e., low intercept and high slope; 9%), and high (i.e., high intercept and low slope; 11%). Compared to non-Hispanic (NH) White adults in covariate-adjusted models, NH Black adults had disadvantages while Hispanic adults had advantages. Our results suggest a protective effect of education for NH Black adults (i.e., racial health disparities observed at low education were ameliorated and then eliminated at increasing levels of education) and a reverse pattern for Hispanic adults (i.e., increasing levels of education was found to dampen the advantages Hispanic adults had at low education). Compared with NH White adults, higher levels of wealth were protective for both NH Black adults (i.e., reducing or reversing racial health disparities observed at low wealth) and Hispanic adults (i.e., increasing the initial health advantages observed at low wealth). Conclusion: These findings have implications for addressing health disparities through more precise targeting of public health interventions. This work highlights the imperative to address socioeconomic inequalities that interact with race/ethnicity in complex ways to erode health.

Effect of a low-cost, behaviour-change intervention on latrine use and safe disposal of child faeces in rural Odisha, India: a cluster-randomised controlled trial.

BACKGROUND: Uptake of Government-promoted sanitation remains a challenge in India. We aimed to investigate a low-cost, theory-driven, behavioural intervention designed to increase latrine use and safe disposal of child faeces in India. METHODS: We did a cluster-randomised controlled trial between Jan 30, 2018, and Feb 18, 2019, in 66 rural villages in Puri, Odisha, India. Villages were eligible if not adjacent to another included village and not designated by the Government to be open-defecation free. All latrine-owning households in selected villages were eligible. We assigned 33 villages to the intervention via stratified randomisation. The intervention was required to meet a limit of US$20 per household and included a folk performance, transect walk, community meeting, recognition banners, community wall painting, mothers' meetings, household visits, and latrine repairs. Control villages received no intervention. Neither participants nor field assessors were masked to study group assignment. We estimated intervention effects on reported latrine use and safe disposal of child faeces 4 months after completion of the intervention delivery using a difference-in-differences analysis and stratified results by sex. This study is registered at ClinicalTrials.gov, NCT03274245. FINDINGS: We enrolled 3723 households (1807 [48·5%] in the intervention group and 1916 [51·5%] in the control group). Analysis included 14 181 individuals (6921 [48·8%] in the intervention group and 7260 [51·2%] in the control group). We found an increase of 6·4 percentage points (95% CI 2·0-10·7) in latrine use and an increase of 15·2 percentage points (7·9-22·5) in safe disposal of child faeces. No adverse events were reported. INTERPRETATION: A low-cost behavioural intervention achieved modest increases in latrine use and marked increases in safe disposal of child faeces in the short term but was unlikely to reduce exposure to faecal pathogens to a level necessary to achieve health gains. FUNDING: The Bill & Melinda Gates Foundation and International Initiative for Impact Evaluation.