title: Multimorbidity in the Context Of Socioeconomic Deprivation: A mixed methods exploration of how Individual and Community factors interact to influence patient capacity to manage Multimorbidity (MOSAIC)
Creators: name: McCallum, Marianne Rankin
Publisher: name: University of Glasgow
Year: 2024

description: Background: Despite significant investment in research and resource, health inequalities persist and in some cases are worsening. Multimorbidity (presence of two or more long-term conditions in an individual) is more prevalent in areas of high socioeconomic deprivation, where it begins at an earlier age. Burden of Treatment Theory (BOTT) states that where the work of managing chronic conditions (treatment burden) outweighs the capacity to carry out that work, poorer outcomes persist. Preliminary research has explored treatment burden in the context of multimorbidity, but capacity remains under-researched. Given that factors known to reduce capacity cluster in areas of high socioeconomic deprivation, understanding capacity, and how to support and enhance it, has the potential to inform the design of services that may narrow existing health inequalities. This thesis aims to explore, and begin to quantify, the influence of key capacity impacting factors on the ability to self-manage multimorbidity in the context of socio-economic deprivation and to understand how individual and community level factors interact to influence health self-management decisions.

Methods: A multi-methods approach that employed three work packages. 1) A systematic review of existing multimorbidity interventions which employed two methods of data analysis: a meta-ethnography of participant experience and a framework analysis underpinned by BOTT. 2) A quantitative analysis of cohort data exploring the association between individual and community capacity factors, treatment burden and mortality and hospital admissions in people living with multimorbidity 3) A qualitative exploration of the experience of living with multimorbidity in one community experiencing high socioeconomic deprivation. An ethnographically informed approach was taken including 25 in-depth interviews, one focus group, 142 hours of participant observation in four community groups and two participatory workshops. An initial broad thematic descriptive analysis was followed by an analytical synthesis of the themes, exploring how they related to each other and the existing BOTT constructs.

Main Findings: 1) Current multimorbidity interventions focus primarily on practitioner experience or on narrow aspects of participant experiences of interventions. They rarely consider the experience of those who did not benefit. Person-centred care, an objective for several interventions, was often practitioner defined. While interventions could initially shift care to be more person-centred, organisational factors meant this was often not sustained and reverted to usual care. Interventions benefit from a clear evidence-based structure and practitioner training and supervision increase the likelihood of implementation as intended. In addition, interventions that had flexible components, or were able to include flexibility in application, appear to be more effective in engagement. BOTT constructs and social context were not routinely considered by current interventions, and none considered the impact of the work of the intervention for patients with multimorbidity. 2) BOTT constructs can provide a framework to explore capacity variables at the population level. Capacity measures vary over time; not adjusting for this in the analysis could potentially over-estimate or miss associations. As well as expected associations between known individual factors such as literacy, housing tenancy or disability, there was a potential association between mortality and the extent to which people feel they have control over their health, although the exact relationship is unclear (e.g. for the statement “I have little control over what happens to me”: Agree strongly reference group 1; compared to agree 0.51 (0.27,0.98); Disagree 0.47 (0.25,0.90); Disagree strongly 0.57 (0.28,1.14)). In addition, compared to never walking in the dark (reference group 1) there was a protective association with mortality for those who tried to avoid (0.70 (0.57,0.87)), felt uncomfortable (0.66 (0.52,0.84)) or who had no worries (0.63 (0.53,0.76)). This association was also seen for hospital admissions for those who felt uncomfortable (0.61 (0.45,0.83) or who had no worries (0.71 (0.55,0.91)). 3) Qualitative findings demonstrated that BOTT constructs were useful in understanding individual capacity to manage multimorbidity in the context of high socioeconomic deprivation. However, additional components, such as the role of biography (maintaining personal identity) and grounding activities do not fully align with current BOTT constructs. In addition, participants described shared community experiences of “being known” in the community, the experience of stigma , antisocial behaviour, a rundown physical environment, and none of the systems working for them. These experiences influenced how participants accessed healthcare, and their self-management decisions and capabilities. This was summarised as a new construct “community capacity”: the unconscious internalisation of wider shared community experiences. In the context of high socioeconomic deprivation community capacity shaped, and sometimes constrained, individual capacity. Finally, the ethos of community groups (authentic, safe space, peer support, challenge) and high-quality person-centred care were particularly enabling, in part because of their ability to ameliorate the influence of community capacity.

Conclusions: Both individual and community factors have a critical impact on the capacity to manage multimorbidity, and some of these capacity factors are associated with mortality and hospital admissions. BOTT constructs can be used to measure associations between capacity factors at the population level, and this could be built on to create a validated measure of capacity. Health services, and future interventions, should prioritise supporting and optimising person-centred care, work with communities to ensure services are authentic safe spaces and consider utilising peer support for people living with multimorbidity in areas of high socioeconomic deprivation. As community capacity shapes individual capacity, applying BOTT in the context of high socioeconomic deprivation without consideration of wider contextual, community factors, risks perpetuating and widening existing health inequalities. However, an extended BOTT incorporating community capacity, biography and being grounded could be utilised in a high socioeconomic deprivation context to help design health services and interventions for people living with multimorbidity. Such services have the potential to improve outcomes and narrow health inequalities in this setting.