Multimorbidity in Africa - Increasing Understanding of the Patient Experience and Epidemiology (MAfricaEE)
Lead Research Organisation:
University of Glasgow
Abstract
Multimorbidity, the presence of 2 or more long-term conditions (LTCs), is an increasing global health challenge. Multimorbidity is increasingly common among younger and middle-aged as well as older people and is associated with adverse effects on health outcomes. Although multimorbidity is increasingly common in low and middle-income countries (LMICs), we have insufficient information on patterns, trends or determinants of multimorbidity in LMICs. Such information is crucial to inform health and social service planning across different LMIC health care systems.
Equally important is the call by the Academy of Medical Sciences to undertake research that includes "studies of the experiences and preferences of patients with different types of multimorbidity" in LMICs. Living with multiple LTCs is hard work and requires people to assume an increasing workload of self-management, something referred to as 'Treatment Burden.' Treatment burden refers to the work that people and their wider support network have to undertake. It covers a variety of activities ranging from: a) the work done to gain an understanding of conditions; b) the effort needed to navigate health and social care systems; c) the work of operationalising self-management such as attending appointments and taking medicines; and d) undertaking self-monitoring activities, such as checking blood sugars. The concept of treatment burden in those with multimorbidity is yet to be investigated in Sub Saharan Africa (SSA).
People can vary in their capacity to cope with any given level of treatment burden depending on a range of factors such as socioeconomic status, health literacy, language, level of educational attainment, location, personal beliefs and physical and mental abilities. As well as personal or individual resources, it is important to consider the role of the persons' wider social support network as well as healthcare organisations and health policy. Gaining an understanding of these concepts in a SSA context and enhancing understanding of the challenges faced by patients and practitioners would inform development of interventions to improve management of multimorbidity. Treatment burden and capacity issues are important as overwhelmed patients are less likely to adhere to therapies, resulting in wasted resources and poor outcomes. This proposal addresses important evidence gaps in multimorbidity research in SSA. Our project will involve 3 work-packages (WPs) and use data sources from 3 African nations (Malawi, Gambia and Uganda). The work represents a collaboration led by the University of Glasgow, which has particular expertise in multimorbidity research, using both data science and qualitative methods, along with partners in Malawi, the MRC Units in Gambia and Uganda and the London School of Hygiene and Tropical Medicine
Our project will address the following questions:
1. What is the prevalence and pattern of multimorbidity across different datasets in Malawi, Uganda and Gambia?
2. What is the cross-sectional relationship between demographic and lifestyle factors with prevalence and pattern of multimorbidity in Malawi, Uganda and Gambia?
3. What are the key similarities and differences in the observed findings across the 3 countries?
4. What are patients' experiences of the effects of multimorbidity on the work of self-management and their capacity to cope with self-management demands?
5. What are healthcare professionals' experiences of treating and managing patients with multimorbidity in each country and what do they see as the main barriers to optimal care provision?
6. What are the key targets for future research?
While this work is primarily exploratory, it will promote development of a new collaboration looking at multimorbidity in SSA and serve to highlight data gaps and opportunities that the team plans to address in future funding applications.
Equally important is the call by the Academy of Medical Sciences to undertake research that includes "studies of the experiences and preferences of patients with different types of multimorbidity" in LMICs. Living with multiple LTCs is hard work and requires people to assume an increasing workload of self-management, something referred to as 'Treatment Burden.' Treatment burden refers to the work that people and their wider support network have to undertake. It covers a variety of activities ranging from: a) the work done to gain an understanding of conditions; b) the effort needed to navigate health and social care systems; c) the work of operationalising self-management such as attending appointments and taking medicines; and d) undertaking self-monitoring activities, such as checking blood sugars. The concept of treatment burden in those with multimorbidity is yet to be investigated in Sub Saharan Africa (SSA).
People can vary in their capacity to cope with any given level of treatment burden depending on a range of factors such as socioeconomic status, health literacy, language, level of educational attainment, location, personal beliefs and physical and mental abilities. As well as personal or individual resources, it is important to consider the role of the persons' wider social support network as well as healthcare organisations and health policy. Gaining an understanding of these concepts in a SSA context and enhancing understanding of the challenges faced by patients and practitioners would inform development of interventions to improve management of multimorbidity. Treatment burden and capacity issues are important as overwhelmed patients are less likely to adhere to therapies, resulting in wasted resources and poor outcomes. This proposal addresses important evidence gaps in multimorbidity research in SSA. Our project will involve 3 work-packages (WPs) and use data sources from 3 African nations (Malawi, Gambia and Uganda). The work represents a collaboration led by the University of Glasgow, which has particular expertise in multimorbidity research, using both data science and qualitative methods, along with partners in Malawi, the MRC Units in Gambia and Uganda and the London School of Hygiene and Tropical Medicine
Our project will address the following questions:
1. What is the prevalence and pattern of multimorbidity across different datasets in Malawi, Uganda and Gambia?
2. What is the cross-sectional relationship between demographic and lifestyle factors with prevalence and pattern of multimorbidity in Malawi, Uganda and Gambia?
3. What are the key similarities and differences in the observed findings across the 3 countries?
4. What are patients' experiences of the effects of multimorbidity on the work of self-management and their capacity to cope with self-management demands?
5. What are healthcare professionals' experiences of treating and managing patients with multimorbidity in each country and what do they see as the main barriers to optimal care provision?
6. What are the key targets for future research?
While this work is primarily exploratory, it will promote development of a new collaboration looking at multimorbidity in SSA and serve to highlight data gaps and opportunities that the team plans to address in future funding applications.
Technical Summary
Multimorbidity, the presence of 2 or more long-term conditions, is an increasing global health challenge. Although multimorbidity is increasingly common in low and middle-income countries (LMICs), we have insufficient:
1. information on patterns, trends or determinants of multimorbidity in LMICs
2. understanding of patient/health professional perspectives of multimorbidity and barriers/facilitators to optimal care in LMICs.
Such information is crucial to inform health and social services in LMIC contexts.
The collaboration is led by the University of Glasgow, which has particular expertise in multimorbidity research, using both data science and qualitative methods, along with partners in Malawi, the MRC Units in Gambia and Uganda and the London School of Hygiene and Tropical Medicine. Our project involves mixed methods research that will promote capacity building, and involve both primary data collection and secondary analyses of existing cohort and qualitative data to provide important new insights into the challenges posed by multimorbidity. Key research objectives include:
1. Increasing understanding of prevalence and pattern of multimorbidity across different datasets in Malawi/Uganda/Gambia
2. Examining cross-sectional relationship between demographic and lifestyle factors with prevalence and pattern of multimorbidity in Malawi/Uganda/Gambia
3. Exploring patient and professional experiences of the effects of multimorbidity on the work of self-management and barriers and facilitators to optimal care
While the work is primarily exploratory, it will promote capacity building and development of a new collaboration looking at multimorbidity in Sub Saharan Africa. The project will conclude with a research symposium in Malawi involving the research teams and key stakeholders to share experiences of multimorbidity research, opportunities and key challenges, to underpin future work in this sphere.
1. information on patterns, trends or determinants of multimorbidity in LMICs
2. understanding of patient/health professional perspectives of multimorbidity and barriers/facilitators to optimal care in LMICs.
Such information is crucial to inform health and social services in LMIC contexts.
The collaboration is led by the University of Glasgow, which has particular expertise in multimorbidity research, using both data science and qualitative methods, along with partners in Malawi, the MRC Units in Gambia and Uganda and the London School of Hygiene and Tropical Medicine. Our project involves mixed methods research that will promote capacity building, and involve both primary data collection and secondary analyses of existing cohort and qualitative data to provide important new insights into the challenges posed by multimorbidity. Key research objectives include:
1. Increasing understanding of prevalence and pattern of multimorbidity across different datasets in Malawi/Uganda/Gambia
2. Examining cross-sectional relationship between demographic and lifestyle factors with prevalence and pattern of multimorbidity in Malawi/Uganda/Gambia
3. Exploring patient and professional experiences of the effects of multimorbidity on the work of self-management and barriers and facilitators to optimal care
While the work is primarily exploratory, it will promote capacity building and development of a new collaboration looking at multimorbidity in Sub Saharan Africa. The project will conclude with a research symposium in Malawi involving the research teams and key stakeholders to share experiences of multimorbidity research, opportunities and key challenges, to underpin future work in this sphere.
Planned Impact
This project aims to establish a comparative account of multimorbidity in three sub-Saharan African countries which characterises prevalence, patterns and patient experiences. Using datasets from Malawi, The Gambia and Uganda, we will apply data science techniques and statistical methods to offer an account of the relationships between socio-demographic and lifestyle factors and multimorbidity, as well as exploring any differences between these three territories. We will also conduct a secondary analysis of interviews with people living with multimorbidity in Malawi with a focus on exploring the concept of treatment burden. To complement this dataset, we will gather interviews with 30 healthcare professionals, 10 in each of the 3 partner countries, to establish an understanding of practitioner perspectives on treating and managing patients with multimorbidity. Together, these streams of work will provide a rich account of the social patterning, structural determinants and lived experiences of multimorbidity.
The research team plans to publish at least three papers in peer reviewed academic journals from this. The first will present the results from the statistical work carried out in WP1, and will be submitted to a journal such as Plos Medicine. The second will focus on experiences of people living with multimorbidity in Malawi, with special reference to treatment burden, which we intend to submit to Social Science and Medicine. Finally, we aim to publish a paper on clinical perspectives on treatment and management of multimorbidity to a journal such as Journal of Global Health.
Alongside publication activities, the research team will present work at conference within Malawi (e.g. College of Medicine's Annual Research Dissemination Conference), The Gambia (e.g. Annual MRC/Gambian Government Coordinating Meeting) and Uganda. The team will also present work at international conferences such as the Consortium of Universities for Global Health Conference, the British Sociological Association's Medical Sociology Conference and the Society of Academic Primary Care and North American Primary Care Research Group. We are aware of other groups submitting bids to this round from Africa which have synergies with our proposal, and if successful, we will share information about our study with such groups in order to promote learning across Africa.
At the outset of the project, the research team will establish stakeholder networks of policy makers, healthcare service managers and practitioners, who have the capacity to influence approaches to managing multimorbidity in the three partner countries. We will provide regular updates to this network in the form of briefing reports which will outline the work being done, update on progress being made, prime the network for the final symposium we will hold in Malawi as part of Work Package 3 and present the results of the work.
The network will form the basis of invitation lists for the symposium we will undertake as part of Work Package 3. Our final symposium will be designed to ensure participation from a range of stakeholders and that attendees will have the opportunity to explore, interpret and understand the findings generated by the project, as well as consider what action should be taken.
Patient groups from all 3 partner countries will also be invited to join the project's stakeholder network, receive regular reports and, where possible, participate in the Work Package 3 Symposium. Such organisations include Diabetes Association of Malawi, Community Against Hypertension and Diabetes (Lilongwe, Malawi), Gambian Diabetes Association, Uganda Diabetes Association. Regular reports and the final symposium will provide information that informs and empowers these organisations. The final symposium will also offer the platform for these organisations to shape the interpretation of findings and contribute to suggestions of action.
The research team plans to publish at least three papers in peer reviewed academic journals from this. The first will present the results from the statistical work carried out in WP1, and will be submitted to a journal such as Plos Medicine. The second will focus on experiences of people living with multimorbidity in Malawi, with special reference to treatment burden, which we intend to submit to Social Science and Medicine. Finally, we aim to publish a paper on clinical perspectives on treatment and management of multimorbidity to a journal such as Journal of Global Health.
Alongside publication activities, the research team will present work at conference within Malawi (e.g. College of Medicine's Annual Research Dissemination Conference), The Gambia (e.g. Annual MRC/Gambian Government Coordinating Meeting) and Uganda. The team will also present work at international conferences such as the Consortium of Universities for Global Health Conference, the British Sociological Association's Medical Sociology Conference and the Society of Academic Primary Care and North American Primary Care Research Group. We are aware of other groups submitting bids to this round from Africa which have synergies with our proposal, and if successful, we will share information about our study with such groups in order to promote learning across Africa.
At the outset of the project, the research team will establish stakeholder networks of policy makers, healthcare service managers and practitioners, who have the capacity to influence approaches to managing multimorbidity in the three partner countries. We will provide regular updates to this network in the form of briefing reports which will outline the work being done, update on progress being made, prime the network for the final symposium we will hold in Malawi as part of Work Package 3 and present the results of the work.
The network will form the basis of invitation lists for the symposium we will undertake as part of Work Package 3. Our final symposium will be designed to ensure participation from a range of stakeholders and that attendees will have the opportunity to explore, interpret and understand the findings generated by the project, as well as consider what action should be taken.
Patient groups from all 3 partner countries will also be invited to join the project's stakeholder network, receive regular reports and, where possible, participate in the Work Package 3 Symposium. Such organisations include Diabetes Association of Malawi, Community Against Hypertension and Diabetes (Lilongwe, Malawi), Gambian Diabetes Association, Uganda Diabetes Association. Regular reports and the final symposium will provide information that informs and empowers these organisations. The final symposium will also offer the platform for these organisations to shape the interpretation of findings and contribute to suggestions of action.
Organisations
People |
ORCID iD |
Publications
Chikumbu E
(2022)
Experiences of multimorbidity in urban and rural Malawi: An interview study of burdens of treatment and lack of treatment
in PLOS Global Public Health
Chikumbu E
(2022)
What are the experiences of people living with multimorbidity in Malawi?
Price AJ
(2023)
Epidemiology of multimorbidity in low-income countries of sub-Saharan Africa: Findings from four population cohorts.
in PLOS global public health
Skou ST
(2022)
Multimorbidity.
in Nature reviews. Disease primers
Description | Our work has highlighted how poverty and inadequate healthcare provision constrained capacity to deal with treatment burden for people with multimorbidity in sub saharan Africa (SSA), while supportive social and community networks were important enabling features. Greater access to health information and education would lessen treatment burden as would better resourced healthcare systems and improved standards of living. Our work demonstrates the utility of Normalization Process Theory and Burden of Treatment Theory for aiding conceptualisation of treatment burden issues in LMICs but our findings highlight that 'lack' of access to treatments or services is an important additional burden which must be integrated in accounts of treatment burden in LMICs. Our work has also provided the first three country comparative study of multimorbidity prevalence in rural and urban sub-Saharan Africa. We observed differences in age-standardized multimorbidity burden between urban (22.5%) and rural (11.7%) Malawi, The Gambia (2.9%) and Uganda (8.2%), with the greatest burden observed in urban Malawi. Notably, hypertension comorbid with obesity was one of the most frequent combinations of Long Term Conditions. Furthermore, females were at higher risk of multimorbidity compared to males in all study populations, apart from The Gambia. Gambia cohort, a |
Exploitation Route | This work can be built upon by colleagues in LMICs. In fact, we have colleagues in South Africa who have been shortlisted for further research by Wellcome in this subject area, building on some of the work undertaken in this grant. |
Sectors | Healthcare |
Description | The findings of our research have been shared with policymakers and health service managers in Malawi to inform health service design and policy |
First Year Of Impact | 2022 |
Sector | Healthcare |
Impact Types | Policy & public services |
Title | Indepth interviews on lived experience of multimorbidity, Malawi and Tanzania |
Description | Collection of IDI from three settings Rural Uganda Rural Malawi Urban Malawi Lived experiences of multimorbidity, coded and analysed as a complete dataset for comparability |
Type Of Material | Database/Collection of data |
Year Produced | 2022 |
Provided To Others? | Yes |
Impact | Two publications todate Presentation to policy makers and service providers Agreement that should impact on clinical training in Malawi |
Title | Pooled data on long-term conditions from Malawi, Uganda and the Gambia |
Description | Individual level data Urban and Rural Malawi Rural Uganda Rural Gambia Long-term conditions, including HIV, Hypertension, Obesity, Diabetes |
Type Of Material | Database/Collection of data |
Year Produced | 2022 |
Provided To Others? | No |
Impact | Pooled analysis conducted, paper to be published second quarter 2023 |
Description | @UofGMAfricaEE twitter account - social media engagement. |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Public/other audiences |
Results and Impact | The twitter feed has been used to introduce team members and to advertise our work including presentations at international meetings. The twitter feed has resulted in requests for further information and enquiries about future collaborations. |
Year(s) Of Engagement Activity | 2021,2022 |
URL | https://twitter.com/UofGMAfricaEE |
Description | A talk on qualitative research from MAFRICAEE project at North American Primary Care Research Group |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Our group gave a talk titled: Experiences of people living with multi morbidity in urban and rural Malawi to the North American Primary Care Research Group (NAPCRG) which sparked questions and discussion afterwards.. |
Year(s) Of Engagement Activity | 2021 |
URL | https://napcrg.org/conferences/annualpastmeetingarchives/ |
Description | International conference presentation |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Undertook poster presentation titled: Title: Understanding Health Professional Experiences of Managing Multimorbidity in Africa at the North American Primary Care Research Group meeting in November 2022. Interactive poster session. |
Year(s) Of Engagement Activity | 2022 |
Description | Multimorbidity Workshop, Lilongwe Malawi |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | Policymakers and researchers in the field of NCD were invited to a workshop to review the findings from the studies, and other findings related to multimorbidity from the Malawi Epidemiology and Intervention Research Unit and the Multilink Project. There were discussions on the context and utility of the findings and an invitation from the Malawi Ministry of Health (the lead of the NCDI&MH Dept) to prepare a policy brief to support the work of the dept in lobbying for support for integration of services for long-term conditions. |
Year(s) Of Engagement Activity | 2022 |
Description | Public Engagement - Schools activity on NCD and adolescents role in their community and own future health |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Schools |
Results and Impact | As part of public engagement work supported through a direct grant from Wellcome, we are building on the relationships with primary schools and education authorities and established during the N2N Trial and the evidence that the school & communities respond to engagement around NCD, to deliver a programme where school children access simplified data from all our NCD work including the N2N trial to draw their own conclusions and to express their understanding of their own role in their future health and that of their communities. |
Year(s) Of Engagement Activity | 2023 |
Description | Social media /Twitter for research project |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Public/other audiences |
Results and Impact | We have started a twitter account to share information about the project and its aims as well as to share findings as they arise |
Year(s) Of Engagement Activity | 2021 |
URL | https://twitter.com/UofGMAfricaEE |
Description | Talk on Quantitative Research from the MAFRICAEE project at North American Primary Care Research Group (NAPCRG) |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Gave a talk titled: Burden of multimorbidity in sub-Saharan Africa: preliminary findings from three community studies to NAPCRG attendees. The conference is international and in 2021 was held as a virtual meeting. (https://napcrg.org/conferences/annualpastmeetingarchives/). The talk sparked questions and discussion afterwards. |
Year(s) Of Engagement Activity | 2021 |
URL | https://napcrg.org/conferences/annualpastmeetingarchives/ |
Description | Website |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Public/other audiences |
Results and Impact | Development of our project website provides a project Summary, information about our team and international advisory group and how to contact us. All important to raise awareness of our project to future potential collaborators, researchers, public and other stakeholders. |
Year(s) Of Engagement Activity | 2021 |
URL | https://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/research/multimorb... |
Description | Website - titled: MULTIMORBIDITY IN AFRICA - INCREASING UNDERSTANDING OF THE PATIENT EXPERIENCE AND EPIDEMIOLOGY (MAFRICAEE) |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Our web-site titled: MULTIMORBIDITY IN AFRICA - INCREASING UNDERSTANDING OF THE PATIENT EXPERIENCE AND EPIDEMIOLOGY (MAFRICAEE) describes the project and partners and is used to raise awareness of the research. |
Year(s) Of Engagement Activity | 2021,2022 |
URL | https://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/research/multimorb... |