An investigation of the interrelationships between multibehaviours and multimorbidity

This thesis addresses the complex interplay between multimorbidity and multibehaviours at theoretical and practical levels. Grounded primarily in pragmatic philosophy and influenced by the interpretive turn of postmodernism, this thesis adopted a mixed-method methodology. The primary aim was twofold: to establish a scientifically supported association between multimorbidity and multibehaviours to inform the development of future guidelines; to enhance our understanding of patient- centred care, focusing on the combined impact of multimorbidity and multibehaviours on the relationship between healthcare providers and people with multimorbidity.

These aims were addressed through four main studies. First, a systematic review and meta-analysis provided novel evidence by quantifying the dose-response association between various types of combined and accumulative SNAP health risk behaviours and multimorbidity using various operational definitions for multimorbidity (MM2+ and MM3+).
Second, an epidemiological study of electronic health records for 21,079 adults in Staffordshire corroborated these findings and extended the research to encompass complex multimorbidity (three or more conditions affecting at least three different organ systems), and stricter cutoff points. Analyses also identified interchangeable sex-specific patterns that varied with definition of multimorbidity applied and with the number of SNAP health risk behaviours. This underscored both the clinical significance of the identified outcomes for promoting tailored multimorbidity guidelines and the need for further sex-sensitive research.

Third, factorial analysis of electronic health record data focused on the 7,560 adults with multimorbidity who engaged with multiple lifestyle behaviours that pose a health risk (‘multibehaviours’). Again, differential patterns of associative multimorbidity emerged, indicating statistical clustering of multimorbidities in people who have engaged with multibehaviours. However, only a cardiovascular pattern commonly emerged in both sexes, further highlighting the importance of sex differences in this area.

The final study examined the novel application of a qualitative methodology, Situational Analysis, to explore the combined impact of multimorbidity-multibehaviours on the
healing relationship. This addressed a significant gap in the literature, contributing to a deeper understanding of adequate healthcare provision for people with multimorbidity under the conceptual framework of the salutogenesis-iatrogenesis dipole.

In summary, the thesis scrutinised the complex dynamics of multimorbidity and multibehaviours, advocating for the integration of behavioural change theories into multimorbidity care. Recognising the importance of addressing health risk behaviours and the evolving needs of postmodern patients, healthcare providers can tailor interventions to enhance patient outcomes effectively. Efforts to reform healthcare systems should prioritise a person-centred care shift in multimorbidity management toward a more salutogenic approach in order the specific health phenomenon to be address comprehensively. Central to this is the incorporation of behavioural change strategies as a counterbalance factor against current medicalisation of multimorbidity management.