Clinical management of patients with multimorbidity: A qualitative exploration of healthcare worker perspectives in Malawi and Tanzania

Abstract

Abstract Background Multimorbidity, the coexistence of two or more chronic medical conditions, poses significant challenges for healthcare systems in sub-Saharan Africa (SSA), where single-disease-focused approaches currently predominate. Despite the rising burden of multimorbidity in SSA region, data on its clinical management in hospitals is limited. This study aimed to explore healthcare worker experiences in the management of patients with multimorbidity in Malawi and Tanzania. Methods We conducted in-person in-depth interviews from February 2023 to July 2023. We purposively selected healthcare workers from emergency, outpatient and internal medicine departments in Malawi and Tanzania. Our analysis utilized the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework for integrated care for multimorbidity to categorize codes into corresponding domains and themes. The analysis examines workforce, service delivery, and finance domains, together with the core of the SELFIE framework (patient) factors and generated 11 sub-themes that influence clinical decision-making in these contexts. Results We interviewed 45 healthcare workers including clinicians, nurses and pharmacists involved in the management of patients with multimorbidity in district and tertiary hospitals. Healthcare workers noted that limited patient knowledge of chronic diseases; delayed hospital presentation; inadequate chronic disease training; and a lack of multimorbidity clinical practice guidelines limit high-quality clinical decisions. In addition, restricted access to diagnostics and medicines together with high out-of-pocket costs for chronic disease management further increase the challenge of multimorbidity management. Conclusion This study identified multiple domain factors that influence healthcare workers clinical decisions for the management of patients with multimorbidity revealing gaps in clinical training and clinical practice guidelines. Our findings emphasize the need to strengthen integrated care, expand workforce capacity, update clinical guidelines, and strengthen healthcare financing to address the growing multimorbidity burden in SSA.