Experiences of multimorbidity in urban and rural Malawi: An interview study of burdens of treatment and lack of treatment

**Background** Multimorbidity, defined as the co-occurrence of two or more long-term conditions (LTCs), is a growing global health challenge, particularly in low- and middle-income countries (LMICs). In sub-Saharan Africa, non-communicable diseases (NCDs) are increasingly prevalent alongside infectious diseases like HIV and tuberculosis. Despite this, little is known about the lived experiences of individuals with multimorbidity in these settings. This study aims to explore the experiences of men and women living with multimorbidity in urban and rural Malawi, focusing on the burden of treatment, and to assess the utility of Normalization Process Theory (NPT) and Burden of Treatment Theory (BoTT) for understanding these experiences.

**Methods** The study employed semi-structured in-depth interviews with 32 participants recruited from urban Lilongwe and rural Karonga, Malawi. Participants had at least two of three LTCs: diabetes, hypertension, and HIV. Purposive sampling ensured equal representation by sex (16 males, 16 females) and age (15 under 50 years, 17 over 50 years). Interviews were conducted in Chichewa or Chitumbuka, transcribed verbatim, translated into English, and anonymized. Data were analyzed thematically, with themes then mapped onto the four NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) and further interpreted using BoTT.

**Key Results** Eleven themes emerged from the analysis, ten of which fit within the NPT framework. The theme 'lack' could not be allocated to NPT. Key findings include: - **Making sense of multimorbidity (coherence):** Participants described coming to terms with their conditions, often linking onset to life events. Multimorbidity limited agency and caused disruptions to daily life. - **Engaging with others (cognitive participation):** Family support was crucial, with families adapting diets (e.g., using whole grain maize flour) and providing financial and emotional assistance. Community support varied; women reported both support and stigma, while men faced workplace challenges. Navigating the healthcare system involved long waiting times, medication shortages, and lack of continuity of care, especially in urban settings. - **Enacting management strategies (collective action):** Participants described dietary changes, use of glucometers, and frustration with polypharmacy. Many negotiated medical advice based on financial constraints and personal priorities. - **Reflecting on management (reflexive monitoring):** Successful treatment improved functionality and capacity. Some chose care providers to avoid stigma, and participants suggested improvements in health education and material provision. - **Lack:** A pervasive theme was the burden of lack of treatment, including lack of appropriate food, medications, specialist care, and health system capacity. For example, one participant noted, "The lack of staff and lack of medication led this patient to pursue unsupported management of his conditions."

**Clinical Implications** The study demonstrates that NPT and BoTT are useful frameworks for understanding treatment burden in LMICs, but they must be adapted to include the burden of lack of treatment. Poverty and inadequate healthcare provision constrain patients' capacity to manage their conditions, while supportive social networks enhance capacity. Policy implications include the need for better-resourced healthcare systems with reliable medication supplies, improved continuity of care, enhanced health education, and interventions to reduce poverty and improve living standards. The findings underscore the importance of addressing both treatment burden and the burden of lack of treatment to improve outcomes for individuals with multimorbidity in Malawi and similar settings.