This is the first study to assess the prevalence and correlates of multimorbidity among older adults in rural Nepal. We found that almost half (48.9%) of the older adults had at least one NCD conditions. Approximately, 15% had multimorbidity – most frequently involving osteoarthritis and COPD. Participant’s age and behavioral risk factors (alcohol use and physical inactivity) were associated with multimorbidity.
A sizeable proportion of the older adults had multimorbidity, despite having a mean age of 69.9 years which is low compared to studies in other countries Previous studies of multimorbidity among the Nepalese population are limited, and the only available estimates come from the World Health Survey (2003), which showed a prevalence of 15.2% among the Nepali population, which doubled for the age group 65+ (30.2%) [20]. Since Nepal is in the epidemiologic transition, we would expect to see a higher prevalence of multimorbidity compared to the estimates from 2003 [20]. However, our prevalence estimate (14%) is half that of the 2003 World Health Survey for the older age group. In our study, the possible reasons behind this discrepancy could be due to the measurement of a limited number of common chronic conditions (only four conditions were included) [22], methodological differences, or geographical variation. In this regard, we suggest the need to develop a uniform standardized definition of multimorbidity, including the specific conditions to be included. A study from India showed that illiterate participants tend to overestimate health problems when self-reported [24]. In the present context, illiteracy is high among older Nepali adults [4], which may explain the higher prevalence of multimorbidity in the World Health Survey, resulting from overestimates of self-reported conditions. Second, in the study of multimorbidity, the number, and type of chronic conditions included in the count contributed to greater variability in estimates between the studies [25]. Given that the high prevalence of depression among older Nepali adults (50% )[26], the inclusion of depression (included in World Health Survey but not in our study) is likely to explain the higher prevalence of multimorbidity estimated in that survey.
The finding that one in seven older people in the study had multimorbidity is, however, not surprising given the high prevalence of chronic diseases and the increasing rates of physical inactivity and excessive alcohol consumption [19]. These risk behaviors increase the incidence of chronic conditions as well as the progression into multimorbidity from a single condition. The observed prevalence of multimorbidity is of concern because the impact of multimorbidity is greater than the cumulative effects of single disease [13]. Multimorbidity substantially reduces the quality of life and increases the risk of premature death [11, 14]. It increases the demand for health care and thus adds to the existing challenges faced by health and social services [11, 12].
Significant differences in multimorbidity by ethnicity were noted: minority groups, particularly the Madhesi ethnic group, were slightly more likely to suffer from multimorbidity than the upper caste groups. Our finding is consistent with previous literature from Nepal, which documented a higher burden of chronic disease among the Madhesi ethnic group [22, 27]. Historically, the Madhesi ethnic group was considered disadvantaged in the society as they were discriminated against by the upper caste groups and had limited access to education and employment [28]. As one of the marginalized groups, these groups have a comparatively lower socioeconomic status increasing threats to their poor outcomes in health and wellbeing [29].
The increased risk of multimorbidity among physically inactive individuals is consistent with other research [30–32]. However, surprisingly, study participants with no prior history of alcohol use had 50% higher odds of multimorbidity than those with alcohol use. The literature on the association between alcohol consumption and multimorbidity has been inconsistent since previous studies have reported lower odds of having multimorbidity among those who consumed alcohol daily [30], whereas other studies found no association between alcohol consumption and multimorbidity [31, 33]. Two things may explain the findings. First, in a society where alcohol consumption is prohibited, self-reported measures of alcohol consumption are not reliable, and participants’ responses may be subjected to social desirability bias. Second, in a low-income setting such as ours, the ability to consume alcohol also indicates an individual’s purchase capacity and relative wealth. Hence, older adults who could afford to consume alcohol may have had a relatively better socio-economic status that may have provided an advantage to better health in later life.
In light of our findings, we suggest the need to shift from the approach of treating and management of single conditions to a more integrated approach where patients' needs can be more comprehensively met. Our study demonstrated the strong association between multimorbidity and physical inactivity, which suggests both the opportunity for early prevention and the need for tailoring the physical activity to the level of disability (especially for osteoarthritis). In this regard, our findings have implications at the primary health care level as well as at the secondary/tertiary levels, where health care providers can assess physical activity level among the multimorbidity patients and can tailor interventions accordingly to avert the further health consequences among the people with multimorbidity, especially among socioeconomically deprived communities.., Physical activity needs to be mainstreamed in existing community health programs and at all levels of care. We also underscore the need for the attention of policymakers and the implementors to invest more in the development of multidisciplinary management packages for chronic multimorbid conditions.
Moreover, we suggest the need for a community based longitudinal study that can look at a large number of conditions with a more precise measurement of the lifestyle factors. Further, we also suggest the need for qualitative research to understand the problems at the individual and population levels, community/family level, and organizational level, which might be help to develop a comprehensive intervention package for people with chronic multimorbid conditions.
Some of the strengths of this study include a very high response rate, data collection by trained enumerators who were fluent local languages (Maithili/Tharu/Nepali). Limitations included: a) cross-sectional design that precludes examination of the cause-effect relationship; b) limited generalizability to younger age groups and geography other than Morang and Sunsari districts of Nepal. Additional limitation includes the inclusion of only four chronic conditions in the definition of multimorbidity. Further, our lifestyle measures may be subject to social desirability bias.