Multimorbidity in Africa - Increasing Understanding of the Patient Experience and Epidemiology (MAfricaEE)

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.

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.

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.