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Multimorbidity-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. We 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. Middle-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.

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

Patterns of development of cardiometabolic multimorbidity (CMM) and the impact of specific cardiometabolic disease combinations on cognitive function are not well understood. This study utilizes sequence analysis to describe the ordering and timing of cardiometabolic disease accumulation over a five-year period and to assess both sociodemographic predictors and cognitive outcomes of typical cardiometabolic disease sequences. We analyzed data from the National Health and Aging Trends Study (2011-2022), including respondents aged ≥65 years without CMM or cognitive impairment at baseline (N = 4956). We used sequence analysis with optimal matching and hierarchical cluster analysis to describe temporal patterns of cardiometabolic disease accumulation and to construct a typology by clustering similar sequences. Sociodemographic predictors of CMM cluster membership were assessed using multinomial logistic regression and discrete time survival analysis was used to examine the association of CMM clusters with subsequent dementia development. 11.8% of respondents developed CMM within 5-years. From a total of 366 distinct cardiometabolic disease sequences, we identified eight cardiometabolic sequence clusters. The first five clusters, \"No Cardiometabolic Disease\" (N = 2283, 46.1%); \"Diabetes Only\" (N=642, 13.0%); Heart Disease Only\" (N = 297, 6.0%); \"MI Only\" (N = 145, 2.9%); \"Stroke Only\" (N = 132, 2.7%), were composed of persons who did not develop CMM over the observation period. The sixth cluster, \"Incident CVD with Multimorbidity\" (N = 656, 13.2%), was largely composed of persons with no conditions at baseline who developed incident cardiometabolic disease and/or CMM during the observation period (N = 477, 72.7%) and the seventh cluster, \"Diabetes Multimorbidity\" (N = 333, 6.7%), primarily consisted of persons with diabetes who developed incident CMM. Finally, the eight cluster (N = 468, 9.4%) was characterized by mortality early in the observation period with minimal CMM development during the observation period. Black and Hispanic race/ethnicity, lower wealth, and obesity were associated with increased likelihood of membership in one or both of the clusters characterized by CMM development. We observed increased dementia risk among persons in the Incident CVD with Multimorbidity cluster (HR = 1.32, 95% CI = 1.04-1.67) and the Diabetes MM cluster (HR = 1.88, 95% CI = 1.44,2.44). Development of cardiometabolic multimorbidity is more likely among minoritized and/or low-income older adults and is associated with increased risk of subsequent dementia. Targeted approaches to cardiometabolic disease prevention and risk reduction may be an effective means of slowing or preventing the onset of cognitive decline among these groups.

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

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

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.

Background Inter-relationships between multimorbidity and geriatric syndromes are poorly understood. This study assesses heterogeneity in joint trajectories of somatic disease, functional status, cognitive performance, and depressive symptomatology. Methods We analyzed 16 years of longitudinal data from the Health and Retirement Study (HRS, 1998-2016) for n = 11,565 older adults (≥65 years) in the United States. Group-based mixture modeling identified latent clusters of older adults following similar joint trajectories across domains. Results We identified four distinct multidimensional trajectory groups: (1) Minimal Impairment with Low Multimorbidity (32.7% of the sample; mean = 0.60 conditions at age 65, 2.1 conditions at age 90) had limited deterioration; (2) Minimal Impairment with High Multimorbidity (32.9%; mean = 2.3 conditions at age 65, 4.0 at age 90) had minimal deterioration; (3) Multidomain Impairment with Intermediate Multimorbidity (19.9%; mean = 1.3 conditions at age 65, 2.7 at age 90) had moderate depressive symptomatology and functional impariments with worsening cognitive performance; (4) Multidomain Impairment with High Multimorbidity (14.1%; mean = 3.3 conditions at age 65; 4.7 at age 90) had substantial functional limitation and high depressive symptomatology with worsening cognitive performance. Black and Hispanic race/ethnicity, lower wealth, lower education, male sex, and smoking history were significantly associated with membership in the two Multidomain Impairment classes. Conclusions There is substantial heterogeneity in combined trajectories of interrelated health domains in late life. Membership in the two most impaired classes was more likely for minoritized older adults.

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

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

Impact evaluations of water, sanitation, and hygiene interventions have demonstrated lower than expected health gains, in some cases due to low uptake and sustained adoption of interventions at a community level. These findings represent common challenges for public health and development programmes relying on collective action. One possible explanation may be low collective efficacy (CE)—perceptions regarding a group’s ability to execute actions related to a common goal. The purpose of this study was to develop and validate a metric to assess factors related to CE. We conducted this research within a cluster-randomised sanitation and hygiene trial in Amhara, Ethiopia. Exploratory and confirmatory factor analyses were carried out to examine underlying structures of CE for men and women in rural Ethiopia. We produced three CE scales: one each for men and women that allow for examinations of gender-specific mechanisms through which CE operates, and one 26-item CE scale that can be used across genders. All scales demonstrated high construct validity. CE factor scores were significantly higher for men than women, even among household-level male-female dyads. These CE scales will allow implementers to better design and target community-level interventions, and examine the role of CE in the effectiveness of community-based programming.