Abstract
BackgroundMultimorbidity is a significant public health threat in sub-Saharan Africa (SSA), but data on the experiences of people living with multimorbidity (PLWMM) are limited. There is a need to explore patient and carer experiences to inform the development of patient-centred interventions for improved management with reduced complications.
Methods
I first conducted a systematic review and meta-synthesis of literature on experiences of self management of HIV, diabetes (DM), hypertension (HTN), and chronic kidney disease (CKD) in Southern Africa to identify current practices in self-management of the four conditions. I used these findings to inform a multi-country qualitative study in Malawi and Tanzania, where I purposively recruited patients, and carers of people with multimorbidity recently discharged from hospital, and conducted longitudinal interviews at discharge and 90 days later. In total, I conducted 32 in-depth interviews (IDIs) and 8 focus group discussions (FGDs) in Malawi, and 21 IDIs and 7 FGDs in Tanzania. I developed and applied a harmonised, context-sensitive, protocol across both countries. I used thematic analysis and mapped results using an Expanded Conceptual Model on Multimorbidity. I also used the Critical Gender Theory to explore gendered dimensions of lived experience in Malawi.
Results
The systematic review and meta-synthesis of literature demonstrated that research on multimorbidity in Southern Africa is limited with most work focused on single chronic conditions. From this work, I demonstrated that intention to self-management among people living with chronic conditions was high, however, individuals face challenges related to lack of access to essentials such as drugs and nutrition, limiting implementation of self-management. Limited access to quality health services and low health literacy also prevailed. I sought to explore these issues further in my primary data collection and found that whilst patients recognised the significance of self-management as central to the control of multimorbidity, implementation was limited by the burden of treatment; financial constraints; and limited health literacy. Patients and carers engaged in diverse self-management strategies including dietary regulation, emotional coping, and symptom monitoring but these were frequently undermined by drug stock-outs, out-of-pocket costs, and poor continuity of care. PLWMM and carers expressed frustration over reduced functionality, economic burdens, and emotional stress, with many identifying trigger events that contributed to disease progression. DM and CKD were seen as especially burdensome while HIV was often deprioritised due to perceived stability or minimal symptoms. In contrast, HTN was commonly associated with stress and treatment lapses. Financial hardship and limited understanding of disease prompted prioritisation based on perceived severity, urgency, and available resources. Females were burdened by caregiving responsibilities, often managing their own illnesses while also supporting others in the household. While PLWMM in Tanzania often had earlier access to screening, particularly for CKD, through insurance-based services, this advantage was short-lived as insurance schemes frequently did not cover the full range of costs. Consequently, many patients were soon required to rely on out-of-pocket payments for consultations, investigations, and medications. This resulted in care-seeking pathways in Tanzania ultimately converging with those in Malawi, where free public services were perceived as inadequate and of poor quality, leaving patients similarly dependent on out-of-pocket expenditure. Younger PLWMM expressed anxiety about reduced physical function and income-earning potential, while older individuals voiced concern over diminished social engagement and a loss of social respect and standing within their communities. While people with single chronic conditions in the meta synthesis faced barriers to self-management, PLWMM in my primary data experienced the added challenge to negotiate competing demands across multiple illnesses; prioritise acute symptoms; ration scarce resources; and adjust strategies in response to shifting risks and treatment demands.
Conclusions
Perceptions of living with multimorbidity in Malawi and Tanzania are shaped by a complex interplay of individual, social, and structural factors. Effective disease management is constrained by the burden of treatment; financial hardship; limited health literacy; and poorly coordinated health systems. PLWMM and carers were keen to self-manage their conditions but were not sufficiently supported to do so. Addressing structural limitations and improving social support can improve experiences of PLWMM and carers. To inform patient-centred care, interventions should enhance self-management support; address medication access barriers; strengthen care coordination; incorporate gender-sensitive approaches; and actively involve patients and carers in intervention design. Addressing these factors could improve experiences and outcomes for PLWMM in low-resource settings. These findings provide empirical evidence on the lived experiences; barriers; and care pathways of PLWMM in Malawi and Tanzania.
| Date of Award | 27 Apr 2026 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Ben Morton (Supervisor), Nicola Desmond (Supervisor) & Deborah Nyirenda (Supervisor) |
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