Academic journal article Bulletin of the World Health Organization

Multimorbidity and Care for Hypertension, Diabetes and HIV among Older Adults in Rural South Africa/Multimorbidite et Traitement De L'hypertension, Du Diabete et Du VIH Chez Les Personnes Agees Dans Les Zones Rurales d'Afrique Du Sud/Multimorbilidad Y Atencion Para la Hipertension, la Diabetes Y El VIH En Los Adultos De Mayor Edad De Las Zonas Rurales De Sudafrica

Academic journal article Bulletin of the World Health Organization

Multimorbidity and Care for Hypertension, Diabetes and HIV among Older Adults in Rural South Africa/Multimorbidite et Traitement De L'hypertension, Du Diabete et Du VIH Chez Les Personnes Agees Dans Les Zones Rurales d'Afrique Du Sud/Multimorbilidad Y Atencion Para la Hipertension, la Diabetes Y El VIH En Los Adultos De Mayor Edad De Las Zonas Rurales De Sudafrica

Article excerpt

Abstracts in [phrase omitted], Francais, [phrase omitted] and Espanol at the end of each article.

Introduction

Increases in ageing populations in low- and middle-income countries has contributed to a rising prevalence of multimorbidity, commonly defined as persons with more than one medical condition. (1) Previous studies have found that multimorbidity is associated with poorer clinical outcomes, (2) higher health expenditure and frequency of service use, (3-6) higher use of secondary than primary care, (7,8) and higher hospitalization rates among patients. (3,6,9)

One limitation in the existing literature is that studies of multimorbidity often focus on simple counts of medical conditions. However, different combinations of diseases may affect a person's health and health care differently. To account for these differences, disease combinations can be categorized as either concordant (similar in risk profile and management) or discordant (not directly related in pathogenesis or management). (10) Theoretically, concordant conditions are more likely to be diagnosed and treated along with the index condition, because clinical guidelines often incorporate their interactions. For discordant conditions, however, the competing demands of dealing with different conditions may affect the quality of care provided. (11) Previous studies in high-income settings found that patients with diabetes (12,13) or hypertension (14,15) had higher odds of achieving testing and control goals when they had concordant conditions than discordant conditions. Diabetes patients with discordant conditions, on the other hand, had higher unplanned use of hospital services and specialized care than those with concordant conditions. (16)

Little is known about the care of patients with human immunodeficiency virus (HIV) and multimorbidity, although studies in the United States of America found that patients with HIV received poorer care for their coexisting conditions than did those without HIV. (17-19) Much less is known about how the type of multimorbidity (concordant or discordant) affects a person's progression along the continuum of care in low- and middle-income countries. Our study aimed to fill this gap by studying the progression along the care continuum among people in South Africa with hypertension, diabetes or HIV infection, all prominent conditions contributing to the complex health transition underway in the country. Furthermore, this study assessed the effect of the type of multimorbidity on HIV care (and not on non-HIV comorbidities) among patients infected with HIV.

Methods

Study design

We analysed cross-sectional data from patients enrolled in the Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa. The main study is based the sub-district of Agincourt, in the Bush-buckridge area of Mpumalanga province in South Africa. (20) The study enrolled 5059 participants aged 40 years and older. Household-based interviews were completed between November 2014 and November 2015 using a primary survey instrument to collect data about respondents' demographic profile, medical conditions and economic status. More details on data collection are described elsewhere. (21)

The study received ethical approvals from the University of the Witwatersrand human research ethics committee, the Mpumalanga province research and ethics committee, and the Harvard T.H. Chan School of Public Health office of human research administration.

Study setting

The Agincourt sub-district has six clinics and two health centres, and there are three district hospitals located 25-60 km from the study site. (20,22) Primary healthcare services are free of charge and most of out-of-pocket health expenditure for patients is incurred for transport, caregiver costs or private health care.

The Integrated Chronic Disease Management model was recently introduced in South Africa to address several elements of managing multimorbidity, including standardized clinical care based on national treatment protocols, and promotion of disease monitoring and management among patients. …

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