Self-management of physical-mental multimorbidity: perspectives and experiences of people with diabetes and depression, and healthcare providers in Pakistan

Background: Multimorbidity is a growing concern in South Asia. There is a need to support self-management among people with physical-mental multimorbidity. However, current knowledge of self-management practices and perspectives is limited. In this thesis, the aim was to develop a better understanding of self-management in physical-mental multimorbidity in a South Asian setting - Pakistan.

Methods: Three research studies were conducted. First, a systematic review was conducted to identify the determinants of NCD self-management in South Asia (objective 1). This was followed by two primary studies conducted in Pakistan. One was a qualitative phenomenological study which explored how people live with and manage physical-mental multimorbidity (objective 2). The other was an exploratory qualitative study which explored healthcare providers’ perspectives and experiences of self-management support in physical-mental multimorbidity (objective 3).

Results: The systematic review identified a range of individual, interpersonal and socio-cultural determinants which were linked to self-management behaviours. The phenomenological study documented the wide-ranging effects of physical-mental multimorbidity, the use of medication, behavioural modification and coping strategies to self-manage, and the challenges faced by individuals in managing complex symptoms and mood/behavioural changes. Discussions with healthcare providers found that self-management support interactions are largely disease-centred, with limited use of behavioural strategies and collaborative approaches. Patient and health-system related factors were also identified as barriers in the provision of self-management support.

Conclusion: This thesis highlights the need for interventions to reduce barriers to self-management, empower individuals with physical-mental multimorbidity to self-manage their illnesses, and strengthen healthcare services to meet the demands of physical-mental multimorbidity. There is a need to further strengthen the existing evidence, and adapt and test culturally appropriate self-management support interventions for people living physical-mental multimorbidity in Pakistan.