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      Chronic multimorbidity among older adults in rural South Africa

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          Abstract

          Introduction

          The rapid ageing of populations around the world is accompanied by increasing prevalence of multimorbidity. This study is one of the first to present the prevalence of multimorbidity that includes HIV in the complex epidemiological setting of South Africa, thus filling a gap in the multimorbidity literature that is dominated by studies in high-income or low-HIV prevalence settings.

          Methods

          Out of the full sample of 5059 people aged 40+, we analysed cross-sectional data on 10 conditions from 3889 people enrolled in the Health and Ageing in Africa: A longitudinal study of an INDEPTH Community in South Africa (HAALSI) Programme. Two definitions of multimorbidity were applied: the presence of more than one condition and the presence of conditions from more than one of the following categories: cardiometabolic conditions, mental disorders, HIV and anaemia. We conducted descriptive and regression analyses to assess the relationship between prevalence of multimorbidity and sociodemographic factors. We examined the frequencies of the most prevalent combinations of conditions and assessed relationships between multimorbidity and physical and psychological functioning.

          Results

          69.4 per cent (95% CI 68.0 to 70.9) of the respondents had at least two conditions and 53.9% (52.4–55.5) of the sample had at least two categories of conditions. The most common condition groups and multimorbid profiles were combinations of cardiometabolic conditions, cardiometabolic conditions and depression, HIV and anaemia and combinations of mental disorders. The commonly observed positive relationships between multimorbidity and age and decreasing wealth were not observed in this population, namelydue to different epidemiological profiles in the subgroups, with higher prevalence of HIV and anaemia in the poorer and younger groups, and higher prevalence of cardiometabolic conditions in the richer and older groups. Both physical functioning and well-being negatively associated with multimorbidity.

          Discussion

          More coordinated, long-term integrated care management across multiple chronic conditions should be provided in rural South Africa.

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          Most cited references28

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          Income, health, and well-being around the world: evidence from the Gallup World Poll.

          Angus Deaton (2008)
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            Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study

            Caroline Bähler, Carola A Huber, Beat Brüngger … (2015)
            Background Chronic conditions and multimorbidity have become one of the main challenges in health care worldwide. However, data on the burden of multimorbidity are still scarce. The purpose of this study is to examine the association between multimorbidity and the health care utilization and costs in the Swiss community-dwelling population, taking into account several sociodemographic factors. Methods The study population consists of 229'493 individuals aged 65 or older who were insured in 2013 by the Helsana Group, the leading health insurer in Switzerland, covering all 26 Swiss cantons. Multimorbidity was defined as the presence of two or more chronic conditions of a list of 22 conditions that were identified using an updated measure of the Pharmacy-based Cost Group model. The number of consultations (total and divided by primary care physicians and specialists), the number of different physicians contacted, the type of physician contact (face-to-face, phone, and home visits), the number of hospitalisations and the length of stay were assessed separately for the multimorbid and non-multimorbid sample. The costs (total and divided by inpatient and outpatient costs) covered by the compulsory health insurance were calculated for both samples. Multiple linear regression modelling was conducted to adjust for influencing factors: age, sex, linguistic region, purchasing power, insurance plan, and nursing dependency. Results Prevalence of multimorbidity was 76.6%. The mean number of consultations per year was 15.7 in the multimorbid compared to 4.4 in the non-multimorbid sample. Total costs were 5.5 times higher in multimorbid patients. Each additional chronic condition was associated with an increase of 3.2 consultations and increased costs of 33%. Strong positive associations with utilization and costs were also found for nursing dependency. Multimorbid patients were 5.6 times more likely to be hospitalised. Furthermore, results revealed a significant age-gender interaction and a socioeconomic gradient. Conclusions Multimorbidity is associated with substantial higher health care utilization and costs in Switzerland. Quantified data on the current burden of multimorbidity are fundamental for the management of patients in health service delivery systems and for health care policy debates about resource allocation. Strategies for a better coordination of multimorbid patients are urgently needed. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0698-2) contains supplementary material, which is available to authorized users.
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              The impact of multimorbidity on adult physical and mental health in low- and middle-income countries: what does the study on global ageing and adult health (SAGE) reveal?

              Perianayagam Arokiasamy, Uttamacharya Uttamacharya, Kshipra Jain … (2015)
              Background Chronic diseases contribute a large share of disease burden in low- and middle-income countries (LMICs). Chronic diseases have a tendency to occur simultaneously and where there are two or more such conditions, this is termed as ‘multimorbidity’. Multimorbidity is associated with adverse health outcomes, but limited research has been undertaken in LMICs. Therefore, this study examines the prevalence and correlates of multimorbidity as well as the associations between multimorbidity and self-rated health, activities of daily living (ADLs), quality of life, and depression across six LMICs. Methods Data was obtained from the WHO’s Study on global AGEing and adult health (SAGE) Wave-1 (2007/10). This was a cross-sectional population based survey performed in LMICs, namely China, Ghana, India, Mexico, Russia, and South Africa, including 42,236 adults aged 18 years and older. Multimorbidity was measured as the simultaneous presence of two or more of eight chronic conditions including angina pectoris, arthritis, asthma, chronic lung disease, diabetes mellitus, hypertension, stroke, and vision impairment. Associations with four health outcomes were examined, namely ADL limitation, self-rated health, depression, and a quality of life index. Random-intercept multilevel regression models were used on pooled data from the six countries. Results The prevalence of morbidity and multimorbidity was 54.2 % and 21.9 %, respectively, in the pooled sample of six countries. Russia had the highest prevalence of multimorbidity (34.7 %) whereas China had the lowest (20.3 %). The likelihood of multimorbidity was higher in older age groups and was lower in those with higher socioeconomic status. In the pooled sample, the prevalence of 1+ ADL limitation was 14 %, depression 5.7 %, self-rated poor health 11.6 %, and mean quality of life score was 54.4. Substantial cross-country variations were seen in the four health outcome measures. The prevalence of 1+ ADL limitation, poor self-rated health, and depression increased whereas quality of life declined markedly with an increase in number of diseases. Conclusions Findings highlight the challenge of multimorbidity in LMICs, particularly among the lower socioeconomic groups, and the pressing need for reorientation of health care resources considering the distribution of multimorbidity and its adverse effect on health outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12916-015-0402-8) contains supplementary material, which is available to authorized users.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Glob Health
                Journal ID (iso-abbrev): BMJ Glob Health
                Journal ID (hwp): bmjgh
                Journal ID (publisher-id): bmjgh
                Title: BMJ Global Health
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2059-7908
                Publication date Collection: 2019
                Publication date (Electronic): 5 August 2019
                Volume: 4
                Issue: 4
                Electronic Location Identifier: e001386
                Affiliations
                [1 ]departmentDepartment of Global Health and Population , Harvard T H Chan School of Public Health , Boston, Massachusetts, USA
                [2 ]departmentMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) , School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
                [3 ]departmentSchool of Demography , The Australian National University , Canberra, Australian Capital Territory, Australia
                [4 ]Harvard Center for Population and Development Studies, Harvard University , Cambridge, Massachusetts, USA
                [5 ]departmentDivision of Infectious Diseases , Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts, USA
                [6 ]departmentDepartment of Medicine , Stanford University School of Medicine , Palo Alto, California, USA
                Author notes
                [Correspondence to ] Dr Angela Y Chang; angela.chang@ 123456mail.harvard.edu
                Author information
                http://orcid.org/0000-0003-3947-3588
                Article
                Publisher ID: bmjgh-2018-001386
                DOI: 10.1136/bmjgh-2018-001386
                PMC ID: 6688670
                PubMed ID: 31423345
                SO-VID: b824f040-b06f-4925-ac98-4dea0a2fe8af
                Copyright © © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Date received : 31 December 2018
                Date revision received : 17 May 2019
                Date accepted : 01 June 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100004440, Wellcome Trust;
                Award ID: 058893/Z/99/A
                Award ID: 069683/Z/02/Z
                Award ID: 085477/B/08/Z
                Award ID: 085477/Z/08/Z
                Funded by: FundRef http://dx.doi.org/10.13039/100000049, National Institute on Aging;
                Award ID: P01 AG041710
                Categories
                Subject: Research
                Subject: 1506
                Custom metadata
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                Keywords: ageing,multimorbidity,south africa,hiv
                Data availability:
                Keywords: ageing, multimorbidity, south africa, hiv

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