Experiences of people living with multi morbidity in urban and rural Malawi

Context: Multimorbidity (co-occurrence of >2 long-term conditions (LTCs) within the same person), is a pressing global health problem. While there is a growing literature addressing multimorbidity in high income countries, significantly less is known about experiences faced by people in low- and middle-income countries (LMICs).

Objective: To understand the treatment burden experienced by people living in urban and rural Malawi and the factors that influence their capacity to self-manage.

Study Design and Analysis: Qualitative, audio-taped, in-depth interviews. Interview transcripts analysed thematically, following Braun and Clarke’s six steps and data conceptualised through the dual lens of Normalization Process Theory (NPT) and Burden of Treatment Theory (BOTT).

Setting: Urban/rural Malawi

Population Studied: Adults with >2 LTCs located in urban or rural Malawi.

Results: 32 adults interviewed; 16 female; 16 male; 16 under 50; 16 over 50. Participants offered accounts which focused on coming to terms with and reflecting on life with multiple LTCs. The burden of uncertainty relating to the implications of LTCs limited agency and capacity to act in the world. The need for access to informational resources to enhance their capacity for self-care was emphasised. LTCs caused “disruptions to life” (e.g. through amputations) that again could lessen capacity. Interactions with others were important and participants talked of the influence of family assistance and the workplace and the work of navigating health care systems which could all shape their capacity to self-manage. Our analysis of social relationships in the community and workplace suggested a significant gendered divide. Women’s accounts tended to focus on how their illnesses were received by and responded to by members of their community, while younger men spoke about this in relation to work. The routine shortage of vital medicines and “lack of treatment” added to treatment burden as did fragmented care. Participants described in great detail the measures they took in order to stay well (e.g. enacting dietary changes/monitoring glucose), as well as the challenges they faced doing so.

Conclusions: Experiences of multimorbidity in LMICs mirror those experienced in high income countries but participants highlight the burden posed by “lack of treatment” suggesting this as an important new dimension of Treatment Burden worth noting in LMICs