Multimorbidity of cardiometabolic diseases and effectiveness of integrated healthcare system response in sub-Saharan Africa

This thesis aims to strengthen the responsiveness of healthcare systems to the management of cardiometabolic multimorbidity in sub-Saharan Africa (SSA). More specifically, four main issues on cardiometabolic multimorbidity in SSA were investigated: the burden of cardiometabolic multimorbidity, chronic care models, the readiness of healthcare facilities to provide integrated care, and the effect of multimorbidity on self-care interventions. A latent class analysis and hierarchical agglomerative cluster analysis in part one show that cardiometabolic diseases occur in distinct clusters of concordant and discordant multimorbidity. These clusters are significant predictors of outpatient visits, hospitalisation, functional disability and quality of life. Multimorbidity is disproportionately highest among persons of high socioeconomic status, women, the middle and old-aged, and those with sedentary lifestyles and obesity. A systematic review and meta-analysis in part two shows that integrated care versus standard care improved systolic blood pressure control in people with multimorbidity. In part three, a national facility assessment survey in Kenya shows that only one in every four healthcare facilities (at all levels) was ready to provide integrated care for cardiovascular diseases and type 2 diabetes. The clinical integration barriers included vertical and unresponsive healthcare services. In part four, a quasi-experimental study of patients with hypertension undergoing a home-based self-care program in Kenya shows that multimorbidity attenuated the effectiveness of patient support groups for hypertension. Overall, the findings of this thesis provide crucial evidence for multimorbidity risk stratification and underscore the importance of tailoring patient-centered care interventions to match the needs of people with cardiometabolic multimorbidity in SSA.