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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.

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

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, HRS 1998–2010) of adults 51 years and 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 HRS 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 post-estimation 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 to 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.

Objectives Studies report racial/ethnic disparities in multimorbidity (≥2 chronic conditions) and their rate of accumulation over time as well as differences in physical activity. Our study aimed to investigate whether racial/ethnic differences in the accumulation of multimorbidity were mediated by physical activity among middle-aged and older adults. Method We assessed racial/ethnic differences in the accumulation of multimorbidity (of 9 conditions) over 12 years (2004–2016) in the Health and Retirement Study (N = 18,264, mean age = 64.4 years). Structural equation modeling was used to estimate latent growth curve models of changes in multimorbidity and investigate whether the relationship of race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White participants) to changes in the number of chronic conditions was mediated by physical activity after controlling for age, sex, education, marital status, household wealth, insurance coverage, smoking, alcohol, and body weight. Results There was a significant increase in multimorbidity over time. Initial levels and changes in multimorbidity over time varied significantly across individuals. Indirect effects of the relationship between race/ethnicity and changes in multimorbidity as mediated by physical activity were significant, consistent with the mediational hypothesis. Black respondents engaged in significantly lower levels of physical activity than White respondents after controlling for covariates, but there were no differences between Hispanic and White respondents once education was included. Discussion: These results provide important new information for understanding how modifiable lifestyle factors may help explain disparities in multimorbidity in mid-to-late life, suggesting greater need to intervene to reduce sedentary behavior and increase physical activity.

Background Obesity and multimorbidity are more prevalent among U.S. racial/ethnic minority groups. Evaluating racial/ethnic disparities in disease accumulation according to body mass index (BMI) may guide interventions to reduce multimorbidity burden in vulnerable racial/ethnic groups. Method We used data from the 1998–2016 Health and Retirement Study on 8 106 participants aged 51–55 at baseline. Disease burden and multimorbidity (≥2 co-occurring diseases) were assessed using 7 chronic diseases: arthritis, cancer, heart disease, diabetes, hypertension, lung disease, and stroke. Four BMI categories were defined per convention: normal, overweight, obese class 1, and obese class 2/3. Generalized estimating equations models with inverse probability weights estimated the accumulation of chronic diseases. Results Overweight and obesity were more prevalent in non-Hispanic Black (82.3%) and Hispanic (78.9%) than non-Hispanic White (70.9 %) participants at baseline. The baseline burden of disease was similar across BMI categories, but disease accumulation was faster in the obese class 2/3 and marginally in the obese class 1 categories compared with normal BMI. Black participants across BMI categories had a higher initial burden and faster accumulation of disease over time, while Hispanics had a lower initial burden and similar rate of accumulation, compared with Whites. Black participants, including those with normal BMI, reach the multimorbidity threshold 5–6 years earlier compared with White participants. Conclusions Controlling weight and reducing obesity early in the lifecourse may slow the progression of multimorbidity in later life. Further investigations are needed to identify the factors responsible for the early and progressing nature of multimorbidity in Blacks of nonobese weight.

ObjectivesInvestigate whether combinations of sociodemographic factors, chronic conditions, and other health indicators pose barriers for older adults to access Annual Wellness Visits (AWVs) and influenza vaccinations.MethodsData on 4999 individuals aged ≥65 years from the 2012 wave of the Health and Retirement Study linked with Medicare claims were analyzed. Conditional Inference Tree (CIT) and Random Forest (CIRF) analyses identified the most important predictors of AWVs and influenza vaccinations. Multivariable logistic regression (MLR) was used to quantify the associations.ResultsTwo-year uptake was 22.8% for AWVs and 65.9% for influenza vaccinations. For AWVs, geographical region and wealth emerged as the most important predictors. For influenza vaccinations, number of somatic conditions, race/ethnicity, education, and wealth were the most important predictors.ConclusionsThe importance of geographic region for AWV utilization suggests that this service was unequally adopted. Non-Hispanic black participants and/or those with functional limitations were less likely to receive influenza vaccination.

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.

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-effects models, weight change over five 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 0–1 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 1–3 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 3–5 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.

Unsafe drinking water is a substantial health risk contributing to child diarrhoea. We investigated impacts of a program that provided a water filter to households in rural Rwandan villages. We assessed drinking water quality and reported diarrhoea 12-24 months after intervention delivery among 269 households in the poorest tertile with a child under 5 from 9 intervention villages and 9 matched control villages. We also documented filter coverage and use. In Round 1 (12-18 months after delivery), 97.4% of intervention households reported receiving the filter, 84.5% were working, and 86.0% of working filters contained water. Sensors confirmed half of households with working filters filled them at least once every other day on average. Coverage and usage was similar in Round 2 (19-24 months after delivery). The odds of detecting faecal indicator bacteria in drinking water were 78% lower in the intervention arm than the control arm (odds ratio (OR) 0.22, 95% credible interval (CrI) 0.10-0.39, p

BACKGROUND: Nurse educators have used peer teaching as a means of providing effective learning to peer learners and enhancing peer teachers’ comfort with teaching. There is a lack of evidence related to providing feedback to peer teachers. Receiving feedback may enhance peer teachers’ knowledge synthesis and understanding of the teaching process. METHODS: We utilized a mixed methods approach to determine if an evaluation instrument was valid and helpful to peer teachers. Both peer learners and educators completed evaluations of peer teachers, which were then compared. After receiving summarized feedback, peer teachers completed a survey regarding their experience. RESULTS: There were no statistical differences between peer learner and educator ratings of peer teachers. Peer learners indicated they found peer teachers to be helpful in the high fidelity simulation setting. Peer teachers indicated satisfaction with the experience. Analysis of qualitative comments on peer-teacher surveys resulted in the identification of three themes: (a) validation of knowledge growth; (b) increased comfort with teaching; and (c) enhanced appreciation of teaching. CONCLUSIONS: Peer teaching may enhance knowledge gain and synthesis for both peer teachers and peer learners. Enhanced comfort with teaching may lead to enhanced comfort in teaching both patients and peers in future practice.

OBJECTIVE This study sought to determine improvements in mental and physical health-related quality of life (HRQOL) following bariatric surgery in Medicaid and commercially insured patients. METHODS Using data from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery (2006-2009), changes in Short Form 36 mental component summary (MCS) and physical component summary (PCS) scores were examined in 1,529 patients who underwent Roux-en-Y gastric bypass, laparoscopic adjustable band, or sleeve gastrectomy and were followed for 5 years. Piecewise linear mixed-effects models estimated MCS and PCS scores as a function of insurance group (Medicaid, N = 177; commercial, N = 1,352) from 0 to 1 year and from 1 to 5 years after surgery, with interactions between insurance group and surgery type. RESULTS Patients with Medicaid had lower PCS and MCS scores at baseline. At 1 year after surgery, patients with Medicaid and commercial insurance experienced similar improvement in PCS scores (commercial-Medicaid difference in PCS change [95% CI]: Roux-en-Y gastric bypass, 1.5 [-0.2, 3.3]; laparoscopic adjustable band, 1.9 [-2.2, 6.0]; sleeve gastrectomy, 6.4 [0.0, 12.8]). One-year MCS score improvement was minimal and similar between insurance groups. In years 1 to 5, PCS and MCS scores were stable in all groups. CONCLUSIONS Both insurance groups experienced improvements in physical HRQOL and minimal changes in mental HRQOL.

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, Thomas Clasen and colleagues report their trial in which reduced levels of diarrhea in children under 5 result from the introduction of water filters and rocket-style cookstoves in Rwanda., Author summary Why was this study done? Unsafe drinking water and household air pollution are leading health risks for young children in low-income countries and contribute to diarrhea and acute respiratory infections (ARIs), both of which are leading causes of child mortality and major burdens on healthcare systems. Systematic reviews have shown household-based water treatment to be effective in improving water quality and preventing diarrhea in low-income countries, while cooking indoors with solid fuels such as wood is associated with ARI in children. Intervention studies of household-based water treatment and higher-efficiency cookstoves have largely been short-term in duration, and there is limited evidence on intervention use, exposure, and health impacts when delivered programmatically at scale. What did the researchers do and find? In the context of a large-scale intervention program that delivered and promoted the use of an advanced water filter and portable biomass-burning “rocket” cookstove to over 101,000 low-income households in Rwanda, we conducted a cluster-randomized trial to assess intervention use, drinking water quality, and air quality (personal exposure to fine particulate matter, PM2.5) and diarrhea and ARI among children. A total of 1,582 households from 174 village-sized clusters were enrolled and visited approximately every 4 months for a year after receiving the intervention filter and stove. Among children under 5 years of age, the intervention reduced 7-day prevalence of diarrhea by 29% and ARI by 25%, although intervention use decreased throughout follow-up; drinking water quality improved, but adult and child personal exposures to PM2.5 remained unchanged and above WHO’s Air Quality Guideline (10 μg/m3) and Interim Target 1 (35 μg/m3) despite increased outdoor cooking. What do these findings mean? Our results suggest that this program was effective in reaching a vulnerable population, securing sustained use of the intervention, improving drinking water quality, and reducing risk of diarrhea and ARI among children under 5. While there was evidence of nonexclusive and diminished intervention use over time, our results suggest that the programmatic delivery and promotion of a combined household filter and cookstove intervention can provide a scalable interim solution among rural populations that currently lack access to safe piped-in drinking water, although cleaner cooking solutions are likely needed to optimize health benefits. Additional research is necessary to assess sustained benefits and identify effects, if any, on more serious cases of infection, as well as to explore the potential synergistic effects of combined household-level interventions.

Unsafe drinking water is a leading cause of morbidity and mortality, especially among young children in low-income settings. We conducted a national survey in Rwanda to determine the level of faecal contamination of household drinking water and risk factors associated therewith. Drinking water samples were collected from a nationally representative sample of 870 households and assessed for thermotolerant coliforms (TTC), a World Health Organization (WHO)-approved indicator of faecal contamination. Potential household and community-level determinants of household drinking water quality derived from household surveys, the 2012 Rwanda Population and Housing Census, and a precipitation dataset were assessed using multivariate logistic regression. Widespread faecal contamination was present, and only 24.9% (95% CI 20.9-29.4%, n=217) of household samples met WHO Guidelines of having no detectable TTC contamination, while 42.5% (95% CI 38.0-47.1%, n=361) of samples had >100TTC/100mL and considered high risk. Sub-national differences were observed, with poorer water quality in rural areas and Eastern province. In multivariate analyses, there was evidence for an association between detectable contamination and increased open waste disposal in a sector, lower elevation, and water sources other than piped to household or rainwater/bottled. Risk factors for intermediate/high risk contamination (>10TTC/100mL) included low population density, increased open waste disposal, lower elevation, water sources other than piped to household or rainwater/bottled, and occurrence of an extreme rain event the previous day. Modelling suggests non-household-based risk factors are determinants of water quality in this setting, and these results suggest a substantial proportion of Rwanda's population are exposed to faecal contamination through drinking water.

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.

Multimorbidity is widely recognized as having adverse effects on health and wellbeing and may threaten the ability of older adults to live independently. Much of what is known about multimorbidity rests on research that has largely focused on one point in time, or from a static perspective. Given that there remains a lack of agreement in the field on how to standardize multimorbidity definitions and measurement, it is not surprising that analyzing and predicting multimorbidity development, progression over time, and its impact are still largely unaddressed. As a result, there are important gaps and challenges to measuring and studying multimorbidity in a longitudinal context. This Research Practice perspective summarizes pressing challenges and offers practical steps to move the field forward.

BackgroundMultimorbidity-having two or more coexisting chronic conditions-is highly prevalent, costly, and disabling to older adults. Questions remain regarding chronic diseases accumulation over time and whether this differs by racial and ethnic background. Answering this knowledge gap, this study identifies differences in rates of chronic disease accumulation and multimorbidity development among non-Hispanic white, non-Hispanic black, and Hispanic study participants starting in middle-age and followed up to 16 years.Methods and findingsWe analyzed data from the Health and Retirement Study (HRS), a biennial, ongoing, publicly-available, longitudinal nationally-representative study of middle-aged and older adults in the United States. We assessed the change in chronic disease burden among 8,872 non-Hispanic black, non-Hispanic white, and Hispanic participants who were 51-55 years of age at their first interview any time during the study period (1998-2014) and all subsequent follow-up observations until 2014. Multimorbidity was defined as having two or more of seven somatic chronic diseases: arthritis, cancer, heart disease (myocardial infarction, coronary heart disease, angina, congestive heart failure, or other heart problems), diabetes, hypertension, lung disease, and stroke. We used negative binomial generalized estimating equation models to assess the trajectories of multimorbidity burden over time for non-Hispanic black, non-Hispanic white, and Hispanic participants. In covariate-adjusted models non-Hispanic black respondents had initial chronic disease counts that were 28% higher than non-Hispanic white respondents (IRR 1.279, 95% CI 1.201, 1.361), while Hispanic respondents had initial chronic disease counts that were 15% lower than non-Hispanic white respondents (IRR 0.852, 95% CI 0.775, 0.938). Non-Hispanic black respondents had rates of chronic disease accumulation that were 1.1% slower than non-Hispanic whites (IRR 0.989, 95% CI 0.981, 0.998) and Hispanic respondents had rates of chronic disease accumulation that were 1.5% faster than non-Hispanic white respondents (IRR 1.015, 95% CI 1.002, 1.028). Using marginal effects commands, this translates to predicted values of chronic disease for white respondents who begin the study period with 0.98 chronic diseases and end with 2.8 chronic diseases; black respondents who begin the study period with 1.3 chronic diseases and end with 3.3 chronic diseases; and Hispanic respondents who begin the study period with 0.84 chronic diseases and end with 2.7 chronic diseases.ConclusionsMiddle-aged non-Hispanic black adults start at a higher level of chronic disease burden and develop multimorbidity at an earlier age, on average, than their non-Hispanic white counterparts. Hispanics, on the other hand, accumulate chronic disease at a faster rate relative to non-Hispanic white adults. Our findings have important implications for improving primary and secondary chronic disease prevention efforts among non-Hispanic black and Hispanic Americans to stave off greater multimorbidity-related health impacts.

Background Even among households that have access to improved sanitation, children’s faeces often do not end up in a latrine, the international criterion for safe disposal of child faeces. Methods We collected data on possible determinants of safe child faeces disposal in a cross-sectional study of 851 children 5 y of age using the latrine for defecation and mobility of children

Objective This study sought to determine changes in the prevalence of comorbid disease following bariatric surgery in Medicaid patients compared with commercially insured patients. Methods Data were obtained from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery at one of six geographically diverse centers in the United States. A total of 1,201 patients who underwent Roux-en-Y gastric bypass with 5 years of follow-up were identified. Poisson mixed models were used to estimate relative risks (RRs) and compare changes in common comorbidities between insurance groups within 0-1 and 1-5 years post surgery. Propensity scores were used to achieve balance in the baseline comorbidity burden between Medicaid and commercial patients. Results In the first year, risk of all six comorbidities decreased substantially over time in both groups, ranging from a 32% to a 69% decrease from baseline. After 1 year post surgery, the risk of disease was stable in both groups (RRs ranged from 1.0 to 1.1). After propensity score weighting, the RRs in the first year were more similar in magnitude, while the RRs in the 1- to 5-year period were unchanged. Conclusions These results suggest that Medicaid patients experience a medium-term reduction in comorbid disease after bariatric surgery.

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.

Diarrhea is a leading contributor to childhood morbidity and mortality in sub-Saharan Africa. Given the challenge of blinding most water, sanitation, and hygiene (WASH) interventions, diarrheal disease outcome measures in WASH intervention trials are subject to potential bias and misclassification. Using the platform of a cluster-randomized controlled trial of a household-based drinking water filter in western province, Rwanda, we assessed the impact of the drinking water filter on enteric seroconversion in young children as a health outcome and examined the association between serologic responses and caregiver-reported diarrhea. Among the 2,179 children enrolled in the trial, 189 children 6–12 months of age were enrolled in a nested serology study. These children had their blood drawn at baseline and 6–12 months after the intervention was distributed. Multiplex serologic assays for Giardia, Cryptosporidium, Entamoeba histolytica, norovirus, Campylobacter, enterotoxigenic Escherichia coli and Vibrio cholerae were performed. Despite imperfect uptake, receipt of the water filter was associated with a significant decrease in seroprevalence of IgG directed against Cryptosporidium parvum Cp17 and Cp23 (relative risk [RR]: 0.62, 95% confidence interval [CI]: 0.44–0.89). Serologic responses were positively associated with reported diarrhea in the previous 7 days for both Giardia intestinalis (RR: 1.94, 95% CI: 1.04–3.63) and C. parvum (RR: 2.21, 95% CI: 1.09–4.50). Serologic responses for all antigens generally increased in the follow-up round, rising sharply after 12 months of age. The water filter is associated with reduced serologic responses against C. parvum, a proxy for exposure and infection; therefore, serologic responses against protozoa may be a suitable health outcome measure for WASH trials among children with diarrhea.

In the general population, bariatric surgery is well documented as the most effective obesity treatment for sustained weight loss and remission of comorbidities. Characterization of the patient populations most likely to benefit from surgical intervention is needed, but the heterogeneity of treatment effects across payer groups has not been reviewed.A systematic review of published studies focusing on bariatric surgery outcomes among Medicaid beneficiaries was conducted. By using PubMed and Scopus, this study searched for studies that quantitatively compared clinical or social bariatric surgery outcomes for United States adult Medicaid recipients and commercially insured patients.Of the 568 titles reviewed, 21 met inclusion criteria. Weight loss and the remission of comorbidities at 1 or 2 years postoperatively were similar between groups despite differences in baseline health status. Short-term health care utilization and mortality outcomes were worse in Medicaid recipients; for instance, Medicaid patients had an average length of stay that was 2 days longer and experienced three more deaths in the first postoperative year.The critical research gaps in the evidence base needed to improve treatment guidelines for Medicaid patients undergoing bariatric surgery include an understanding of the causes of the baseline health differences and how these differences contribute to postoperative outcomes.

The use of sanitary inspections combined with periodic water quality testing has been recommended in some cases as screening tools for fecal contamination. We conducted sanitary inspections and tested for thermotolerant coliforms (TTCs), a fecal indicator bacteria, among 7,317 unique water sources in West Bengal, India. Our results indicate that the sanitary inspection score has poor ability to identify TTC-contaminated sources. Among deep and shallow hand pumps, the area under curve (AUC) for prediction of TTC > 0 was 0.58 (95% confidence interval [CI] = 0.53–0.61) and 0.58 (95% CI = 0.54–0.62), respectively, indicating that the sanitary inspection score was only marginally better than chance in discriminating between contaminated and uncontaminated sources of this type. A slightly higher AUC value of 0.64 (95% CI=0.57–0.71) was observed when the sanitary inspection score was used for prediction of TTC > 0 among the gravity-fed piped sources. Among unprotected springs (AUC = 0.48, 95% CI = 0.38–0.55) and unprotected dug wells (AUC = 0.41, 95% CI = 0.20–0.66), the sanitary inspection score performed more poorly than chance in discriminating between sites with TTC < 1 and TTC > 0. Aggregating over all source types, the sensitivity (true positive rate) of a high/very high sanitary inspection score for TTC contamination (TTC > 1 CFU/100 mL) was 29.4% and the specificity (true negative rate) was 77.9%, resulting in substantial misclassification of the sites when using the established risk categories. These findings suggest that sanitary surveys are inappropriate screening tools for identifying TTC contamination at water points.

Although large-scale programs, like India's Total Sanitation Campaign (TSC), have improved latrine coverage in rural settings, evidence suggests that actual use is suboptimal. However, the reliability of methods to assess latrine use is uncertain. We assessed the reliability of reported use, the standard method, by comparing survey-based responses against passive latrine use monitors (PLUMs) through a cross-sectional study among 292 households in 25 villages in rural Odisha, India, which recently received individual household latrines under the TSC. PLUMs were installed for 2 weeks and householders responded to surveys about their latrine use behavior. Reported use was compared with PLUM results using Bland-Altman (BA) plots and concordance statistics. Reported use was higher than corresponding PLUM-recorded events across the range of comparisons. The mean reported "usual" daily events per household (7.09, 95% confidence interval [CI] = 6.51, 7.68) was nearly twice that of the PLUM-recorded daily average (3.62, 95% CI = 3.29, 3.94). There was poor agreement between "usual" daily latrine use and the average daily PLUM-recorded events (ρc = 0.331, 95% CI = 0.242, 0.427). Moderate agreement (ρc = 0.598, 95% CI = 0.497, 0.683) was obtained when comparing daily reported use during the previous 48 hours with the average daily PLUM count. Reported latrine use, though already suggesting suboptimal adoption, likely exaggerates the actual level of uptake of latrines constructed under the program. Where reliance on self-reports is used, survey questions should focus on the 48 hours prior to the date of the survey rather than asking about "usual" latrine use behavior.

Objectives Chronic disease data from longitudinal health interview surveys are frequently used in epidemiologic studies. These data may be limited by inconsistencies in self-report by respondents across waves. We examined disease inconsistencies in the Health and Retirement Study and investigated a multistep method of adjudication. We hypothesized a greater likelihood of inconsistences among respondents with cognitive impairment, of underrepresented race/ethnic groups, having lower education, or having less income/wealth. Method We analyzed Waves 1995-2010, including adults 51 years and older (N = 24,156). Diseases included hypertension, heart disease, lung disease, diabetes, cancer, stroke, and arthritis. We used questions about the diseases to formulate a multistep adjudication method to resolve inconsistencies across waves. Results Thirty percent had inconsistency in their self-report of diseases across waves, with cognitive impairment, proxy status, age, Hispanic ethnicity, and wealth as key predictors. Arthritis and hypertension had the most frequent inconsistencies; stroke and cancer, the fewest. Using a stepwise method, we adjudicated 60%-75% of inconsistent responses. Discussion Discrepancies in the self-report of diseases across multiple waves of health interview surveys are common. Differences in prevalence between original and adjudicated data may be substantial for some diseases and for some groups, (e.g., the cognitively impaired).

Family members are an important but often underappreciated resource in caring for hospitalized older adults. The Family Preferences Index is a 14-item approach to exploring caregivers' personal choices for participating in the care of hospitalized older adult family members. It can be administered as a structured interview or as a questionnaire. Higher scores indicate a greater preference to participate in care. The nurse can use the responses to the index to plan care that builds a partnership with the family. To watch a free video demonstrating the use of the index, go to http://links.lww.com/A296.

Sleep-disordered breathing (obstructive and central sleep apnea) is common in persons who have had a cerebrovascular accident (CVA). This article describes both sleep-disordered breathing and CVAs and reviews the related risk factors that link them together. In addition, the article discusses sleep-disordered breathing after CVA. The article concludes by presenting the clinical implications of this topic for nurses.

Neighborhood environment is consistently associated with obesity; changes to modifiable aspects of the neighborhood environment may curb the growth of obesity in the US and other developed nations. However, currently the majority of studies are cross-sectional and thus not appropriate for evaluating causality. The goal of this study was to evaluate the effect of a neighborhood-changing intervention on changes in obesity among older women. Over the past 30 years the Portland, Oregon metropolitan region has made significant investments in plans, regulatory structures, and public facilities to reduce sprawl and increase compact growth centers, transit-oriented development approaches, and green space. We used geocoded residential addresses to link data on land-use mix, public transit access, street connectivity, and access to green space from four time points between 1986 and 2004, with longitudinal data on body mass index (BMI) from a cohort of 2003 community-dwelling women aged 66 years and older. Height and weight were measured at clinic visits. Women self-reported demographics, health habits, and chronic conditions, and self-rated their health. Neighborhood socioeconomic status was assessed from census data. Neighborhood walkability and access to green space improved over the 18-year study period. On average there was a non-significant mean weight loss in the cohort between baseline (mean age 72.6 years) and the study's end (mean age 85.0 years). We observed no association between neighborhood built environment or change in built environment and BMI. Greater neighborhood socioeconomic status at baseline was independently associated with a healthier BMI at baseline, and protected against an age-related decline in BMI over time. BMI decreases with age reflect increased frailty, especially among older adults with complex morbidities. Future research should consider the influence of the neighborhood environment on additional relevant health outcomes and should include measures of the social environment in conjunction with built environment measures.

The association of neighborhood built environment with walking activity has received growing attention, although most studies have relied upon subjective measures of the built environment and few have examined the relation between built environment and walking among older adults. This 2001 study examined the relation between objectively measured characteristics of the local neighborhood and walking activity among a sample of 546 community-dwelling older adults in Portland, Oregon. A geographic information system was used to derive measures of the built environment within a quarter-mile (0.4 km) and half-mile (0.8 km) radius around each participant's residence. Multilevel regression analysis was used to examine the association of built environment with walking behavior. No association between built environment and the likelihood of walking or not walking was observed in this cohort of older adults. However, among those participants who reported some degree of walking activity, average time spent walking per week was significantly associated with amount of automobile traffic and number of commercial establishments in their local neighborhood. These findings suggest that built environment may not play a significant role in whether older adults walk, but, among those who do walk, it is associated with increased levels of activity.

Older adult patients often have poor, fragmented sleep when they are in the hospital. The factors contributing to sleep disturbance in hospitalized elders will be explored, and interventions for promoting sleep among these patients will be discussed.

The efficacy of complementary and alternative therapies for sleep promotion in critically ill patients is largely unexamined. We found only seven studies (three on environmental interventions and one each on massage, music therapy, therapeutic touch, and, melatonin) that examined the effect of complementary and alternative therapies. A number of studies, however, have shown that massage, music therapy. and therapeutic touch promote relaxation and comfort in critically ill patients, which likely leads to improved sleep. Massage, music therapy, and therapeutic touch are safe for critically ill patients and should be routinely applied by ICU nurses who have received training on how to administer these specialized interventions. Environmental interventions, such as reducing noise, playing white noise such as ocean sounds, and decreasing interruptions to sleep for care, also are safe and logical interventions that ICU nurses should use to help patients sleep. Progressive muscle relaxation has been extensively studied and shown to be efficacious for improving sleep in persons with insomnia; however, progressive muscle relaxation requires that patients consciously attend to relaxing specific muscle groups and practice these techniques, which may be difficult for critically 11 patients. We do not currently recommend aromatherapy and alternative sedatives, such as valerian and melatonin, for sleep promotion in critically ill patients because the safety of these substances is unclear. In summary, we recommend that ICU nurses implement music therapy, environmental interventions, therapeutic touch, and relaxing massage to promote sleep in critically ill patients. These interventions are safe and may improve patient sleep, although randomized controlled trials are needed to test their efficacy. Aromatherapy and alternative sedatives require further investigation to determine their safety and efficacy.

This descriptive study describes the frequency and severity of sleep-related breathing disorders in men who are hemodynamically stable who have an acute cardiovascular illness and are hospitalized in a critical care unit. Sixty-four males, aged 55-79 years, with an acute cardiovascular illness, stable hemodynamics, and no ongoing chest pain or history of sleep apnea were studied for 1 night in the critical care unit using polysomnography. Forty-seven percent of the sample had an apnea-hypopnea index > or = 5, with events of both obstructive and central etiologies, including Cheyne-Stokes respiration. Oxygen desaturation to < or = 90% occurred in 61% of the sample. There were no episodes of chest pain, ventricular tachycardia, or heart block associated with apneic or hypopneic events; however, dysrhythmias, including sinus bradycardia, supraventricular tachycardia, and premature ventricular beats, were associated with apneic and hypopneic events.

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. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3237-0) contains supplementary material, which is available to authorized users.