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Background Process evaluations of public health programs are critical to understand if programs were delivered as intended and to identify improvements for future implementations. Here we present a mixed methods process evaluation of the Sundara Grama intervention, which sought to improve latrine use and safe child feces disposal among latrine-owning households in rural Odisha, India. Methods The Sundara Grama intervention was delivered to 36 villages in Puri district by a grassroots non-governmental organization (NGO) and included eight activities: palla performance, transect walk, community meeting, community wall painting, mother’s meeting, positive deviant household recognition, household visit, and latrine repairs. The process evaluation quantitatively assessed fidelity, dose delivered, and reach, and qualitatively examined recruitment, context, and satisfaction. Quantitative data collection included an activity observation survey, activity record, and endline trial survey. Qualitative data collection included an activity observation debrief and in-depth interviews with NGO mobilizers. For the quantitative data, a ‘delivery score’ was calculated for each activity, as well as the proportion of target participants in attendance. Qualitative data were analyzed using thematic analysis. Results Mean delivery scores, reported as a percentage, were moderate to high. Household visit activities (97% general visit, 96% positive deviant visit) and the mother’s meeting (81%) had the highest delivery scores, followed by the palla (77%), transect walk (77%), and community meeting (60%). Activities were attended, on average, by 30% to 73% of latrine-owning households. Several factors aided delivery, including pre-intervention rapport building visits and village stakeholder support. Factors that hindered delivery included inclement weather, certain recruitment strategies, and village social dynamics. Conclusions Overall, the Sundara Grama intervention was implemented as intended and achieved good reach. The findings suggest education-entertainment strategies, like the palla, and multi-level communication approaches are particularly beneficial. The results also showcase the importance of examining the implementer experience and broader context.

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.

OBJECTIVE: This study aims to evaluate the impact of depressive multimorbidity (i.e., 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 non-Hispanic White Americans from the Health & 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 [CES-D] score≥4) vs. somatic (i.e., physical conditions only) multimorbidity vs. those without multimorbidity (no or one 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%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.

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.

BackgroundProcess evaluations of public health programs are critical to understand if programs were delivered as intended and to identify improvements for future implementations. The aim of this paper is to describe a mixed methods process evaluation of the Sundara Grama intervention, which sought to improve latrine use and safe child feces disposal among latrine-owning households in rural Odisha, India.MethodsThe Sundara Grama intervention was delivered to 36 villages in Puri district by a grassroots NGO and included eight activities: palla performance (folk theater ‘edutainment’), transect walk, community meeting, community wall painting, mother’s meeting on child feces disposal, positive deviant household recognition, household visit, and latrine repairs. The process evaluation quantitatively assessed fidelity, dose delivered, and reach, and qualitatively examined recruitment, context, and satisfaction. Quantitative data collection included an activity observation survey, activity record, and endline trial survey. Qualitative data collection included an activity observation debrief and in-depth interviews with NGO mobilizers. Data collection took place during three time periods: during intervention delivery, immediately after, and several months post-implementation. For the quantitative data, a ‘delivery score’ was calculated for each activity, as well as the proportion of target participants in attendance. Qualitative data was analyzed using thematic analysis.ResultsMean delivery scores, reported as a percentage, were moderate to high. Household visit activities (97% general visit, 96% positive deviant visit) and the mother’s meeting (81%) had the highest delivery scores, followed by the palla (77%), transect walk (77%), and community meeting (60%). Activities were attended, on average, by 30–73% of latrine-owning households. Several factors aided delivery, including pre-intervention rapport building visits and village stakeholder support. Factors that hindered delivery included inclement weather, certain recruitment strategies, and village social dynamics related to caste and gender. With regard to satisfaction, participants and NGO mobilizers praised the palla but reported mixed reactions to other activities.ConclusionsOverall, the Sundara Grama intervention was implemented as intended and achieved good reach. The findings suggest edutainment and multi-level communication approaches are particularly beneficial, and offer lessons for community-wide programs on the importance of examining the implementer experience and broader context.Trial RegistrationThis trial is registered at clinicaltrials.gov: NCT03274245.

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.

Background: Uptake of government-promoted sanitation remains a challenge. We evaluated a low-cost, theory-driven behavioural intervention designed to increase latrine use and safe child faeces disposal in India. Methods: We conducted a cluster-randomized controlled trial in 66 rural villages in Puri, Odisha. 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 randomization. The intervention was required to meet a US$20/household threshold and included a folk performance, transect walk, community meeting, positive-deviant banners, community wall painting, mother’s meeting, household visits, and latrine repairs. Control villages received no intervention. Neither participants nor field assessors were blinded to study arm assignment. We estimated intervention effects on reported latrine use and safe child faeces disposal ~4 months following completion of the intervention delivery using a difference-in-difference analysis and stratified results by sex. Clinicaltrials.gov registration: NCT03274245. Findings: We enrolled 3,723 households (1,807 intervention; 1916 control). Analysis included 14,181 individuals (6,921 intervention; 7,260 control). We found a 6·4% (CI: 2·0%-10·7%) increase in latrine use and a 15.2% (CI: 7·9-22.5) increase in safe child faeces disposal. Interpretation: A low-cost behavioural intervention achieved modest increases in latrine use and marked increases safe child faeces disposal, at least in the near term, but was unlikely to reduce exposure to a level necessary to achieve health gains. Trial Registration: NCT03274245 Funding: The Bill & Melinda Gates Foundation and International Initiative for Impact Evaluation. Declaration of Interest: We declare no competing interests. Ethical Approval: The Emory University Institutional Review Board (Atlanta, GA, USA; REF: 00098293), and the London School of Hygiene & Tropical Medicine (London, UK; REF: 14415) and the Xavier Institute of Management (Bhubaneswar, Odisha, India; REF: 131216) Ethics Review Committees approved study protocols. Participants provided oral consent prior to data collection.

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.

OBJECTIVES: To examine the mediating effect of central obesity (measured by waist circumference [WC]) on the relationship between caffeine metabolite (1, 7-dimethylxanthine) and glycohemoglobin level, adjusting for covariates of age, gender, race/ethnicity, smoking, and alcohol intake. METHODS: Design: Publicly available data from the 2009–2010 National Health and Examination Surveys (NHANES) were used to conduct this secondary data analysis. NHANES collected data from respondents using in-home surveys and mobile examination centers. Subjects: For the current study, 1976 respondents were included. Respondents were included if they participated in data collection for caffeine consumption and ≥20 years of age. Respondents were excluded if a proxy was required for data collection or had pregnancy confirmation during the physical examination portion of data collection. Outcome Measures: Original NHANES variables, 1, 7-dimethylxanthine level, glycohemoglobin level, WC, age and gender, were used. Race/ethnicity, smoking, and alcohol were recoded to better address the aim of this study. RESULTS: Structural equation modeling showed that WC mediated the relationship between 1, 7-dimethylxanthine and glycohemoglobin level, adjusting for covariates. The total effect of 1, 7-dimethylxanthine on glycohemoglobin level was -.001 (indirect effect [.029 x .013] + direct effect [–.001]), adjusting for covariates, which suggests that the total effect was minimal. Age (β = .014, P

Background Standardized patient (SP) simulation is used to teach geropsychiatry. This project tested feasibility and effectiveness of video-enabled SP simulation to teach interprofessional (IP) late-life depression screening.Methods and findings Nurse practitioner, pharmacy, and medical students (N=177) participated in remote (n = 27) and on-site (n = 150) SP simulation. Linear mixed-effect model determined the effects of time and setting on pretest and posttest Interprofessional Education Collaborative Competencies Attainment Survey (ICCAS) data. Overall, no significant difference was observed in degree of change on ICCAS domains, indicating both modalities produced equally beneficial outcomes. Small sample size and focus on late-life depression screening limits generalizing results.Conclusions Video-enabled SP simulations can be incorporated to prepare students with IP competencies for late-life depression screening.

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.

Introduction 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. Methods 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. Results 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. Conclusions 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.

Background and objective: Doctorate of Nursing Practice (DNP) students are trained to integrate both clinical care and evidence-based research in order to bring together science with application. However, the educational pathways in DNP programs can be problematic, especially with regards to scholarly writing. While several interventions have been utilized for DNP students, the results show that the intervention(s) used should be tailored to the specific student body being served. However, limited evidence exists regarding the effectiveness of tailored interventions on improving central concepts such as writing self-efficacy. Given these differences in the design and delivery of the DNP curricula, we created a tailored educational-writing curriculum for new DNP students at a medium-sized academic medical center in a Southern state.Methods: We assessed changes in writing self-efficacy over the three measurement intervals using linear mixed effects modeling to account for within-student clustering of writing self-efficacy scores over time.Results: Baseline scores of writing self-efficacy improved immediately after the workshop (Timepoint 2 – immediate post-test) and a full semester later (Timepoint 3 – semester post-test). However, we observed no statistically significant difference between Timepoint 2 (immediate post-test) and Timepoint 3 (semester post-test).Conclusions: We saw a significant benefit in writing self-efficacy among incoming DNP students from baseline scores. The tailored format and integration of real-life anecdotal feedback from faculty may have been fundamental to creating an increase in writing self-efficacy among students—a concept foundational to student, and possibly professional, nursing success.

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.

Racial/ethnic minority groups in the U.S. are at risk for greater co-existing chronic disease (multimorbidity) burden and experience greater functional limitations relative to non-Hispanic white peers. To target programs designed to preserve functional independence, this study aims to identify temporal trends of functional limitation among race/ethnic groups and within the context of multimorbidity. Data from the Health & Retirement Study (2000-2014, N=16,959, 65 years of age and older, community-dwelling adults) were used in generalized estimating equation (GEE) models to assess changes in functional limitations over time (combined activities of daily living [ADL] and instrumental activities of daily living [IADL], range 0-11). Models were adjusted for race/ethnicity (non-Hispanic black, Hispanic, non-Hispanic white), self-reported chronic disease categories (no/one, ≥2 somatic, somatic-depression; of arthritis, cancer, diabetes, heart disease, high depressive symptoms [CES-D8≥4], hypertension, lung disease, stroke), age at baseline, sex, body-mass index, education, partnered, net worth, and time. In adjusted GEE models, Hispanic and black respondents experience 1.4 times greater counts of functional limitations, respectively, relative to white respondents (incidence rate ratio [IRR]= 1.4, 95% CI[1.17, 1.66], IRR=1.4, CI[1.26, 1.61]); however, temporal trends were similar. With regard to multimorbidity categories, somatic or somatic-depression multimorbidity were each associated with 2.2 or 3.5 times greater functional limitations, respectively, relative to having no/one condition (IRR=2.2, CI[2.06, 2.39], IRR=3.5, CI[3.18, 3.74]). There are marked differences in functional limitation levels between minority ethnic and white groups, as well as among chronic disease combination groups, suggesting the need to intervene in middle-age to reduce disparities.

Racial/ethnic disparities in multimorbidity (≥2 chronic conditions) and their rate of accumulation over time have been established. Studies report differences in physical activity across racial/ethnic groups. We investigated whether racial/ethnic differences in accumulation of multimorbidity over a 10-year period (2004-2014) were mediated by physical activity using data from the Health and Retirement Study (N = 10,724, mean age = 63.5 years). Structural equation modeling was used to estimate a latent growth curve model of changes in the number of self-reported chronic conditions (of nine) and investigate whether the relationship of race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White) to change in the number of chronic conditions was mediated by physical activity after controlling for age, sex, education, marital status, personal wealth, and insurance coverage. Results indicated that Blacks engaged in significantly lower levels of physical activity than Whites (b = -.171, □ = -.153, p < .001), but there were no differences between Hispanics and Whites (b = -.010, □ = -.008, ns). Physical activity also significantly predicted both lower initial levels of multimorbidity (b = -1.437, □ = -.420, p < .001) and greater decline in multimorbidity (b = -.039, □ = -.075, p < .001). The indirect (mediational) effect for the Black vs. White comparison was significant (b = .007, □ = .011, 95% CI [.004,.010]). These results provide important new information for understanding how modifiable lifestyle factors may help explain disparities in multimorbidity in middle and later life, suggesting greater need to reduce sedentary behavior and increase activity.

Obesity and multimorbidity are more prevalent among U.S. racial/ethnic minority groups. Evaluating racial/ethnic disparities in multimorbidity accumulation according to body-mass index (BMI) may guide interventions to reduce multimorbidity burden in vulnerable racial/ethnic groups. Data from the 1998-2016 Health & Retirement Study (N=8,106, 51-55 years at baseline) and generalized estimating equations models with inverse probability weights estimated the accumulation of seven chronic diseases (arthritis, cancer, diabetes, heart disease, hypertension, lung disease, and stroke) between racial/ethnic groups [Non-Hispanic White (reference; 64.2%), Non-Hispanic Black (21.6%), Hispanic (14.2%)]. Overweight and obesity were more prevalent in Black (82.3%) and Hispanic (78.9%) than White (70.9 %) participants at baseline. Initial burden of morbidity was higher among Black participants [risk ratio (RR) =1.3, p

OBJECTIVES: To examine if waist circumference mediated the relationship between 1, 7-dimethylxanthine (a caffeine metabolite) and serum LDL level, adjusting for age, gender, race/ethnicity, smoking, and alcohol consumption. METHODS: A secondary data analysis study was conducted using data from the National Health and Examination Survey (NHANES) 2009–2010 data collection wave. The final sample included 1976 weighted respondents. Structural equation modeling was used to examine the objectives of this study. RESULTS: Structural equation modeling found that levels of 1, 7-dimethylxanthine were not associated with levels of LDL, and that WC was not a mediator of the relationship, adjusting for the covariates. None of the covariates were associated with LDL level, controlling for WC. CONCLUSIONS: Further longitudinal studies are needed to more thoroughly examine the role of central obesity on the relationship between caffeine and LDL level. FUNDING SOURCES: None.

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.

Millions of people in the arid regions of Kenya and Ethiopia face water scarcity and frequent drought. Water resource forecasting and reliable operation of groundwater distribution systems may improve drought resilience. In this study, we examined three remote sensing data sets against in-situ sensor-collected groundwater extraction data from 221 water points serving over 1.34 million people across northern Kenya and Afar, Ethiopia between January 1, 2017 and August 31, 2018. In models containing rainfall as a binary variable, we observed an overall 23% increase in borehole runtime following weeks with no rainfall compared to weeks preceded by some rainfall. Further, a 1 mm increase in rainfall was associated with a 1% decrease in borehole use the following week. When surface water availability is reduced during the dry seasons, groundwater demand increases. Our findings emphasize the imperative to maintain functionality of groundwater boreholes in these regions which often suffer drought related emergencies. Funding provided by the United States Agency for International Development, the World Bank, the National Science Foundation, and the Cisco Foundation. The views expressed in this article do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

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

Chronic disease data from longitudinal health interview surveys are used often in epidemiologic studies. Yet, these data may be limited by inaccurate self-reporting of previously diagnosed disease. We examined the agreement between respondent self-report of diabetes, cancer, stroke, heart disease, and lung disease in the Health and Retirement Study (HRS) with diagnostic codes extracted from linked Medicare claims files. Our sample consisted of respondents in the HRS waves 1998–2010 with available Medicare claims (N=21,426). Disease status was derived from Medicare claims using Centers for Medicare and Medicaid Services (CMS) algorithms. We calculated bias and prevalence adjusted kappas to quantify the agreement between CMS-defined disease status and subsequent self-report. We then examined only respondents with CMS-defined disease and calculated the prevalence of negative self-report. Lastly, we modeled respondent factors associated with the probability of not reporting a previously diagnosed disease. The average kappa value across all diseases and waves was .71, indicating good overall agreement. However, among respondents with a history of Medicare claims indicating the presence of chronic disease, 37.4% (diabetes) to 71.3% (lung disease) reported not having that disease at a subsequent survey wave. Characteristics associated with the probability of not reporting previously diagnosed disease included Latino ethnicity, age, cognitive impairment, household wealth, and number Medicare claims. A substantial proportion of individuals with Medicare claims indicative of chronic disease reported having no history of the disease. These findings suggest gaps in patients’ understanding of their chronic disease status and present challenges for researchers designing and using health interview surveys.

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.

Obesity and multimorbidity are more prevalent among underrepresented U.S. racial/ethnic minority groups. Evaluating whether racial/ethnic disparities in multimorbidity accumulation vary according to body-mass index (BMI) may guide interventions aimed at reducing multimorbidity burden in vulnerable racial/ethnic groups. We used 1998-2014 data from the Health & Retirement Study (N=8,635 participants, age 51-55 years old at baseline) and negative binomial models stratified by BMI category to evaluate differences in rates of accumulation of seven chronic conditions (arthritis, cancer, diabetes, heart disease, hypertension, lung disease, and stroke), focusing on differences between racial/ethnic groups [White (reference; 64.7%), Black (21.5%), Hispanic (13.8%)]. Overweight and obesity were more prevalent in Black (80.9%) and Hispanic (78.6%) than White (69.9%) participants at baseline; in all BMI categories, Black participants had higher rates of multimorbidity compared with White participants (normal BMI:β=0.304, p

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 cost-effectiveness and reliability of waste collection services in informal settlements can be difficult to optimize given the geospatial and temporal variability of latrine use. Daily servicing to avoid overflow events is inefficient, but dynamic scheduling of latrine servicing could reduce costs by providing just-in-time servicing for latrines. This study used cellular-connected motion sensors and machine learning to dynamically predict when daily latrine servicing could be skipped with a low risk of overflow. Sensors monitored daily latrine activity, and enumerators collected solid and liquid waste weight data. Given the complex relationship between latrine use and the need for servicing, an ensemble machine learning algorithm (Super Learner) was used to estimate waste weights and predict overflow events to facilitate dynamic scheduling. Accuracy of waste weight predictions based on sensor and historical weight data was adequate for estimating latrine fill levels (mean error of 20% and 22% for solid and liquid wastes), but there was greater accuracy in predicting overflow events (area under the receiver operating characteristic curve of 0.90). Although our simulations indicate that dynamic scheduling could substantially reduce costs for lower use latrines, we found that cost reduction was more modest for higher use latrines and that there was a significant gap between the simulated and implemented results.

Multimorbidity (multiple co-occurring chronic conditions), which is associated with poor quality of life, increased risk of disability, service utilization, and mortality, is important to understanding racial and ethnic disparities in health. Latent class analysis was used to explore multimorbidity combinations and to compare multimorbidity classes among Black, Hispanic, and White middle-aged and older adult participants in the 1998 Health and Retirement Study (N = 18,917, mean age = 65.45). Latent class models examined race/ethnic group differences in class membership and response probabilities with Mplus Version 8. Results suggested four latent classes, characterized by individuals who are relatively disease free, individuals with a high number of chronic conditions (high multimorbidity), individuals with hypertension and diabetes (early risk condition), and individuals with arthritis (musculoskeletal only). Significant differences across the three race/ethnicity groups suggested Hispanics were at the highest risk among the three groups. Hispanic participants had approximately twice the odds of predicted class membership in the high multimorbidity group than Whites (OR = 1.929, p < .001) or Blacks (OR = 2.522, p < .001) and were twice as likely to be predicted members of the early risk group than Blacks (OR = 2.053, p < .005). Blacks and Hispanics were also significantly more likely than Whites to fall into the predicted multimorbidity class than the musculoskeletal only class (OR = 1.72, p < .05, and OR = 1.51, p < .05, respectively). These results provide important new information for understanding disparities in disability, service utilization, and mortality.

Introduction: Older adults experience multiple health problems necessitating medical care. However, studies have shown that healthcare is not equally accessible for older adults in the US. In 2011, Medicare introduced Annual Wellness Visits to improve access to preventive healthcare including influenza vaccination. Objectives: Ascertain whether sociodemographic factors, multimorbidity, and other health indicators pose a barrier for older adults to access Annual Wellness Visits and influenza vaccination. Methods: We analyzed data from the 2012 and 2014 waves of the Health and Retirement Study linked with Medicare records. 4,858 older adults aged 65+ years were included in Conditional Random Forests to identify the most important predictors of Annual Wellness Visits and influenza vaccination during this two-year period. The predictors included: age, sex, race/ethnicity, partnered, geographical region, wealth, educational level, Medicaid coverage, body mass index, activities and instrumental activities of daily living, proxy interview, cognitive impairment, dementia diagnosis, and multimorbidity. Results: In total, 1,142 (23.6%) older adults had an Annual Wellness Visit and 3,316 (68.4%) older adults received an influenza vaccination. 11.9% were non-Hispanic black, 6.3% were Hispanic, with a median of 6 chronic conditions and 16.9% had dementia. The most important predictors of Annual Wellness Visits were region, wealth, dementia diagnosis, and race/ethnicity. The most important predictors of influenza vaccination were multimorbidity, race/ethnicity, educational level, and wealth. Conclusion: The importance of geographical region for Annual Wellness Visits suggests that the service has not been adopted equally throughout the US, whereas multimorbidity is the most important factor for receiving influenza vaccination.

Multimorbidity is widely recognized as having adverse effects on health and wellbeing above and beyond the risk attributable to individual chronic disease. Much of what is known about multimorbidity rests on research that has largely focused on one point-in-time, or from a static perspective, with little consideration to issues involved in assessing longitudinal changes in multimorbidity. In addition, less focus has been placed on assessing racial and ethnic variations in longitudinal changes of multimorbidity. Addressing this knowledge gap, we highlight important issues and considerations in addressing multimorbidity research from a longitudinal perspective and present findings from longitudinal models that examine differences in the rate of chronic disease accumulation and multimorbidity onset between non-Hispanic white (white), non-Hispanic black (black), and Hispanic study participants in the Health and Retirement Study starting in middle-age and followed for up to 16 years.