Association between physical multimorbidity and common mental health disorders in rural and urban Malawian settings: Preliminary findings from Healthy Lives Malawi long-term conditions survey

Abstract

In low-income Africa, the epidemiology of physical multimorbidity and associated mental health conditions is not well described. We investigated the multimorbidity burden, disease combinations, and relationship between physical multimorbidity and common mental health disorders in rural and urban Malawi using early data from 9,849 adults recruited to an on-going large cross-sectional study on long-term conditions, initiated in 2021. Multimorbidity was defined as having two or more measured (diabetes, hypertension) or self-reported (diabetes, hypertension, disability, chronic pain, HIV, asthma, stroke, heart disease, and epilepsy) conditions. Depression and anxiety symptoms were measured using the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item General Anxiety Disorder scale (GAD-7) and defined by the total score (range 0–27 and 0–21, respectively). We determined age-standardized multimorbidity prevalence and condition combinations. Additionally, we used multiple linear regression models to examine the association between physical multimorbidity and depression and anxiety symptom scores. Of participants, 81% were rural dwelling, 56% were female, and the median age was 30 years (Inter Quartile Range 21–43). The age-standardized urban and rural prevalence of multimorbidity was 14.1% (95% CI, 12.5–15.8%) and 12.2% (95% CI, 11.6–12.9%), respectively. In adults with two conditions, hypertension, and disability co-occurred most frequently (18%), and in those with three conditions, hypertension, disability, and chronic pain were the most common combination (23%). Compared to adults without physical conditions, having one (B-Coefficient (B) 0.79; 95% C1 0.63–0.94%), two- (B 1.36; 95% CI 1.14–1.58%), and three- or more- physical conditions (B 2.23; 95% CI 1.86–2.59%) were associated with increasing depression score, p-trend <0.001. A comparable ‘dose-response’ relationship was observed between physical multimorbidity and anxiety symptom scores. While the direction of observed associations cannot be determined with these cross-sectional data, our findings highlight the burden of multimorbidity and the need to integrate mental and physical health service delivery in Malawi.

Interdisciplinary perspectives on multimorbidity in Africa: Developing an expanded conceptual model

“…Like many intractable health system challenges, multimorbidity can be linked to centuries of colonialisation and racial discrimination that have systematically limited access to educational opportunities, employment, adequate housing, and basic healthcare [ 7 , 8 ]. Chronic infectious diseases including HIV and tuberculosis (TB) that have thrived in such contexts increasingly intersect with non-communicable diseases (NCDs) including diabetes, cardiovascular diseases, and mental illness which have sharply risen due to the expansion of HIV treatment coverage, rising life expectancies, and lifestyles of poverty and urbanisation [ 7 , 9 – 11 ]. The resulting multimorbidity burden has been characterised in terms of the ‘colliding epidemics’ of chronic infectious and NCDs, generally affecting a younger, more economically-active demographic than in HICs, socially patterned along the lines of intersectional inequalities [ 4 , 12 ].…”