Prevalence and quality of life of the adult population with multiple long-term conditions in an Urban Municipality of Nepal

Prevalence and quality of life of the adult population with multiple long-term conditions in an Urban Municipality of Nepal | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence and quality of life of the adult population with multiple long-term conditions in an Urban Municipality of Nepal Abja Sapkota, Arun Sedhain, Pratima Pathak, Nebina Piya, Pratima Ghimire, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8170865/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background The presence of two or more chronic conditions at the same time in the same individual has been increasing. The presence of chronic conditions will lead to a huge burden on physical and psychological health and poor quality of life. The study aimed to identify the prevalence and quality of life among adult populations living with multiple long-term conditions (MLTC). Methods This was a community-based cross-sectional descriptive study conducted at the urban municipality of Kathmandu, Nepal. A total of 1407 adults aged 20 years and above were included. The assessment of quality of life was done by interviews of the persons living with MLTC with the use of the Nepali version of the European Health Interview Survey - Quality of Life (EUROHIS-QOL8-Item) Index. Results Out of the total participants, 24% had non-communicable disease. The prevalence of hypertension was 14%, diabetes 7.1%, gastritis 3.7%, thyroid disorders 2.6% and COPD 2.5%. The prevalence of MLTC was 7.9% among adults aged ≥ 20 years. The prevalence of MLTC for those with age ≥ 40 years was 14% whereas for those aged 20–39 years it was 1%. Among the people with MLTC, those with chronic backache and COPD had the worst limitation in daily activities. Out of the 8 items of EUROHIS-QOL, the lowest score obtained was on the satisfaction with energy for everyday life, with an average score of 2.8, and satisfaction with finances, with a score of 3.1 out of 4. The overall mean QOL score was 28 out of 40. Conclusions Nursing faculties and nursing student can utilize the findings (evidence based) of these surveys while planning health intervention in community where there is scarcity of resources. Furthermore, the team should aim to address the quality of life of people while planning and implementing micro health project in these community. Multiple long term conditions adult populations quality of life Background Multiple long-term conditions (MLTC) are the coexistence of two or more health conditions at the same time in the same individual [1, 2]. These conditions can be a physical non-communicable disease of long duration, such as cardiovascular disease or cancer or a mental health condition of long duration, such as a mood disorder or dementia or an infectious disease of long duration, such as HIV or hepatitis C [2]. The global prevalence of multiple long-term conditions is 37.2% [3]. Every one in 4 adult populations in England and every one out of five to seven in Nepal has MLTC[2, 4, 5]. Living with MLTC causes a huge burden on physical and psychological health, poor quality of life, and a higher risk of dying. Studies have shown that a combination of long-term conditions leads to a lower quality of life score [2, 6]. World Health Organization (WHO) and the WHOQOL group defined QOL as an “individual’s perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” It covers the physical, psychological, social, and environmental aspects and is considered as important as mortality and morbidity [6, 7]. Multiple long-term conditions affect all aspects of an individual’s life and lead to poor health-related quality of life [5, 8]. Research findings have shown that aspects like advanced age and sex, where many non-modifiable factors co-exist, are associated with poor quality of life [6, 9]. The healthcare system around the world is facing a great challenge in supporting people with MLTC to make their lives better. To support them, the healthcare system needs to first assess the quality of life. In Nepal, studies on MLTC are limited merely to the prevalence and its associated factors and are mainly conducted in hospital settings. Therefore, this study was conducted to explore the quality of life among MLTC in the community settings of Nepal. Methods A community- based cross-sectional descriptive study was carried out in ward number 2 of Kageshwori Manahara municipality of Kathmandu District. Adult population of age 20 years and above was studied. Data collection was done from January to February and November to December in the year 2024. Ethical approval Ethical approval was obtained from the institutional review committee of Nepal Medical College (NMC-IRC, Ref. No. 45-080/081) and permission was taken from the office of the ward no. 2 of Kageshwori Manohara Municipality (Ref. No. 610-2080/081). A total of 400 households were selected based on family members' willingness to provide information. Every member from the selected houses with age of≥20 years was included in the study. According to the census of 2021 of Nepal, the population above 20 years of age at ward number 2 was 2494 [10]. Number of participants in this study was 1407, which was 56.41% of the total adult population. Instrument: Section 1: The family folder designed for undergraduate nursing students for their home visit, as a part of community nursing curriculum, was used as the first part. The socio-demographic information like age, sex, socioeconomic status and the disease related information like presence of morbidity, if any, were collected. With this tool, information about the prevalence of multiple long term conditions could be gathered. Once B.Sc. students identified the chronic conditions then the researcher approached the participants with the second set of instruments. Section II: Once the information on the chronic conditions was collected as per the tool on section I, next part of the tools were used that covered the detail information on people with multiple long term conditions. It included types of problems that were self-reported or reporting by the family members on ever diagnosed with chronic conditions. Conditions having more than or equal to two chronic conditions diagnosed for ≥ 6 months were grouped in MLTC. Disease included in MLTC were arthritis, diabetes mellitus(DM), hypertension, chronic liver disease(CLD), acute peptic disease(APD)/gastritis, chronic back pain(CBP), heart disease(HD), stroke, deafness, chronic obstructive pulmonary disease (COPD) and asthma, chronic kidney disease(CKD), blindness, deafness, alcohol disorder, cancer, epilepsy, thyroid, tuberculosis, filariasis, mental illness (depression, schizophrenia, Mania) and, neurological conditions (parkinsonism and /or Alzheimer’s disease). In this study, chronic liver disease has been added in place of dementia (considering it as symptom not a disease). Furthermore participants were asked how much each problem limited themselves in their daily activities (severity index).This question is a 5 point item with not at all=0, a little, somewhat=2, quite a bit=3, a lot 4. A higher score in each problem indicates higher severity. The types of morbidity and the severity of the conditions have been adopted from the “multimobidity assessment questionnaire for primary care (MAQ-PC)” developed in India [11]. Smoking, alcohol dependency, use of government health insurance was also assessed. Section III: Quality of Life Measurement: In this study, QOL was measured by the researchers by asking 8 sets of questions on how individual participants felt about their lives in the past 4 weeks. QOL was measured by a person’s satisfaction with the shortened version of WHOQOL BREF-8, also called as European Health Interview Survey Quality of Life (EUROHIS-QOL). This measure was published in 2006 by the WHOQOL group. Eight items from different domains were considered. Each item of the WHOQOL-8 is rated on a five-point scale, scored from 1-worst to 5-best. Overall QOL score is formed by a simple summation of scores on the eight items, with higher scores indicating better QOL, and the sum score has a potential range from 8 to 40 [12]. It is a reliable tool with an internal consistency of 0.72 to 0.81 and is recommended for public health research [12]. The tool is available in Nepali version and has an acceptable internal consistency of 0.74 and has been used in Nepal [13, 14]. Statistical analysis was done by using SPSS version 16. Descriptive statistics like frequency, percentage, mean was used. To find the association between age and sex with presence of multiple long term conditions chi square test was used and p value was considered significant at p<0.05 at 95 % CI. Results​ Table 1: Prevalence of MLTC according to age and sex wise (n=1407) Characteristics Multiple long term conditions Total (%) No, n(%) Yes, n(%) p value Age(in completed years) 20 to 40 years 669(47.5) 663(99.0) 6(1.0) 0.001 ≥40 years 738 (52.5) 633(85.8) 105(14.2) Mean±SD (range) 42.64 41.3±15.3 (20-92) 58.9±12.8(25-90) Sex Male 696(49.5) 644(92.5) 52(7.5) 0.565 Female 711(50.5) 652(91.7) 59(8.3) P value obtained from chi square test and considered significant at p<0.05 Altogether, 1407 adults were included in the study, amongst whom 738 (52.5%) were of age ≥ 40 and 711(50.5%) were women. Chronic illness was present in 24% of the participants with overall prevalence of MLTC of 7.9%. Hypertension was present in 14.4%, diabetes in 7.1%, gastritis in 3.7%, thyroid disorders in 2.6%, COPD in 2.5% and heart disease in 1.2%. The conditions that were present in ≤ 1% of the participants were kidney disease, mental illness, deafness, cancer, epilepsy, chronic liver disease, epilepsy, Parkinsonism, chronic back pain and stroke. About six participants (1%) with age < 40 years had presence of the chronic conditions. Only one chronic condition was present in 16%, two in5.5%, and three in 1.8% of the participants. Four chronic conditions were present in 7 participants and 5 and 6 chronic conditions were present in 1 participants each (Table 1 and 2). Table 2: Clinical characteristics of the participants(n=1407) Chronic conditions n(%) Chronic conditions No 1071 (76.1) Yes 336 (23.9) Types*(n=1407) Hypertension 203(14.4) Diabetes 100 ( 7.1) Gastritis 52(3.7) Thyroid disorders 36 (2.6) COPD 35(2.5) Heart disease 17 (1.2) Arthritis 13(0.9) Mental illness 6(0.4) Chronic kidney disease 5(0.4) Deaf 3 (0.2) Cancer 3(0.2) Chronic Liver Disease 2(0.1) Epilepsy 2(0.1) Parkinsonism 2(0.1) Chronic back pain 2(0.1) Stroke 1(0.1) Number of Chronic conditions (n=1407) One 225 (16) Two 77 (5.5) Three 25 (1.8) Four 7(0.5) Five 1(0.1) Six 1(0.1) Presence of MLTC (n=1407) No 1296(92.1) Yes 111(7.9) *Multiple response Adults with multiple long term conditions available at the time of data collection from 10 am to 2.30 pm were included in further analysis. Among 111 participants with MLTC, 48.6% were available for the assessment of the severity index of disease and for quality of life. Therefore, characteristics like age, sex, marital status, smoking habit, alcohol use, use of government health insurance were presented of these participants only. Among the people with multiple long term conditions with two conditions, 47.7% had both hypertension and diabetes. A second common condition was hypertension and gastritis (22.5%) and the third most was hypertension and COPD (15.3%). Similarly, when the presence of three conditions was explored, hypertension diabetes and gastritis were at the top with 9% and hypertension diabetes and COPD were present in about 5.6% (Table 3). Out of 54 adult populations with MLTC, 38.9% were from age less than 60 years. About 52% were female, 20 % were single, and 79.7 were from middle socioeconomic status. Among the MLTC participants, 18.5% were current smoker and 16.7 % were current alcohol user. About 48%were enrolled in the government health insurance program. Cent percent mentioned that they were prescribed with medicine however 9.3% didn’t take prescribed medicine regularly. (Table 4) Table:3 Distribution of chronic conditions in cluster wise (n=111) Number of conditions n(%) Two conditions HTN, Diabetes 53 (47.7) HTN, gastritis 25(22.5) HTN, COPD 17(15.3) HTN, arthritis 13(11.7) HTN, thyroid disorder 12(10.8) DM, gastritis 12 (10.8) HTN, heart disease 9 (8.1) Three conditions (n=25) HTN, DM, gastritis 10 (9.0) HTN, DM,COPD 6(5.4) HTN DM, arthritis 4(3.6) HTN DM, thyroid 3(2.7) HTN, DM, Heart disease 2(1.8) HTN, COPD, Heart disease 2(2.8) HTN, gastritis, COPD 2(1.8) HTN, DM, KD 2 (1.8) HTN, gastritis, COPD 2(1.8) Table 4: Distribution of multiple long term conditions among adult (n=54) Characteristics n(%) Age (completed years) 20-59 yrs 21(38.9) ≥ 60 years 33(61.1) Mean±SD (Range) 62.8±12.04 (38-90) Sex Male 26(48.0) Female 28(52.0) Marital status Married 43(79.6) single 11(20.4) Socioeconomic status* Middle income 43(79.7) Lower income 11(20.4) Smoking, current smoker Yes 10(18.5) No 44(81.5) Current alcohol user Yes 9(16.7) No 45(83.3) Health Insurance Yes 26(48.1) No 28(51.9) Regular intake of medicine Yes 49(90.7) No 5(9.3) *Kuppuswammy modified scale for Nepalese context [15] Table 4 indicates the characteristics of the participant included for the further analysis of the quality of life score. As quality of life and severity should be identified through direct self-report of the participants, only those adults available at the time of survey were included. Out of 111 participants with MLTC, about 48.7 were available. About 61% of the participants were from age 60 years and above, 52% were female, 79.6% were married. Regarding socioeconomic status 79% were from middle income class and 20% from low socioeconomic status. Table 5: Disease-specific limitation in daily activities (among MLTC only) diseases total n range mean HTN 43 40 0-4 1.6 Diabetes 28 28 0-4 1.6 Gastritis 20 15 0-4 2.1 COPD 13 12 0-4 3.4 Arthritis 8 7 0-4 1.9 Heart disease 7 6 0-4 2.5 Thyroid disorders 10 8 0-4 1.5 Chronic backache 2 2 0-4 3.5 Kidney disease 3 2 0-4 2.5 Table 5 shows the disease severity index among people with multiple long term conditions. When asked about how much each of the problem limit the activities of daily living, the highest limitation noted was due to chronic back pain with mean value 3.5, COPD 3.4, heart disease and chronic kidney disease with mean vale 2.5, and with gastritis 2.1.The disease condition that lead to least limitation in daily activities were diabetes, hypertension and thyroid disorders with a mean score of around 1.5 (Table 5). Table 6: Quality of life score of adults having multiple long term conditions (n=54) Item (range 1-5) very poor n(%) poor n(%) neither poor nor good n(%) good n(%) very good n(%) mean How would you rate your quality of life ? (Rating of Overall QOL) 1(1.9) 3(5.6) 16(29.6) 31(57.3) 3(5.6) 3.6 How satisfied are you with your health?(Satisfaction with health) 4(7.4) 7(13.0) 16(29.6) 24(44.4) 3(5.6) 3.3 How satisfied are you with your ability to perform your daily living activities? (Satisfaction with daily activities) 1(1.9) 7(13.0) 9(16.7) 30(55.6) 7(13.0) 3.7 How satisfied are you with yourself? (Satisfaction with self) 2(3.7) 7(13.0) 10(18.5) 29(53.7) 6(11.1) 3.6 How satisfied are you with your personal relationship? (Satisfaction with relationships) 0(0.0) 8(14.8) 6(11.1) 31(57.4) 9(16.7) 3.7 How satisfied are you with the conditions of your living places?(Satisfaction with living conditions) 1(1.9) 1(1.9) 6(11.1) 36(66.7) 10(18.5) 3.9 Do you have enough energy for everyday life?(Enough energy for everyday life) 1(1.9) 18(33.3) 25(46.3) 9(16.7) 1(1.9) 2.8 you have enough money to meet everyday needs?(Have enough money to meet everyday needs ) 0 13(24.1) 30(55.6) 5(9.3) 6(11.1) 3.1 Mean± SD; Range 27.7±4.3; (18-36) Quality of life was assessed with the European Health Interview Survey Quality of Life (EUROHIS-QOL) scale. About 29.6% rated their quality of life as neither good nor poor, 5.6% rated as poor and 1.9% rated as very poor. About 29.6 had neutral feelings towards satisfaction to life, 13% were dissatisfied, and 7.4 % were very dissatisfied with their health. Equal percentage (13%) was dissatisfied with ability to perform daily activities and with self (self esteem.Fourteen percent were dissatisfied with personnel relationship. Almost 57.4 % and 66.7 percent were satisfied with the personnel relationship and living conditions. About 33.3 percent answered that they had a little energy for everyday life. About 1/4 th of the participants (24.1 %) answered that they had a little money to meet the everyday needs. Out of the total items the leas score was obtained in the items having energy for everyday life with mean score 2.8 and the highest score was in the satisfaction with the living conditions. The overall mean score was 27.7 with standard deviation ±4.3 (Table 6). Discusion In this study, the prevalence of multiple long-term conditions and the quality of life of people with MLTC were identified. Earlier studies in the area focused on the prevalence of the selected chronic conditions and were strict to two conditions (hypertension plus diabetes). The current study mainly focused on the at least 20 multiple long-term conditions (MLTC). The total of 400 household with, 1407 adults with age more than or equals 20 were included. A few more than half aged ≥40 years. Male and female were almost equal in percentage. Out of total adults 1/4 th of them had at least one type of chronic conditions. The top most five common chronic conditions presented were hypertension (14.4), diabetes (7.1), gastritis (3.7), thyroid disorder (2.6) and chronic obstructive pulmonary disease (2.5). This is congruent with the previous studies done in the same area, in which the top five most common conditions were hypertension, diabetes, thyroid, chronic respiratory disease, heart disease, and cancer [16]. However, another study from a nearby urban municipality showed the overall prevalence of hypertension was 24.1% and diabetes 10.5% slightly higher than this [17].This difference might be because difference in area and the difference in the municipal level facilities and difference in recruitment criteria as in our study already diagnosed cases with at least 6 months has been included. Sixteen percentage of the studied population had one chronic condition and the prevalence of multiple long term conditions was 7.9%.This is lower than the findings of national survey of Nepal [18] and systemic review from Nepal [19] and almost consistent with study conducted in South East Asian countries like India and Pakistan [20] and Bangladesh [21]. The lower prevalence may be because of variation in the study populations (age group), difference in the setting, difference in selection criteria, and the difference in time period of the survey. In our survey, the mean age of the population was 42.64 years which is lower than the participants from the previous studies in Nepal [18, 19]. There are variations in the types of conditions majority included hypertension, diabetes, COPD, thyroid disorders and cancers. In this study 5.5% had two conditions present and two had 5 to 6 chronic conditions present. Our findings of presence of 2 and 3 conditions (77 and 25 out of 111 respectively) is in line with the previous study in which 2 and 3 conditions were present in 80.1% and 17.4% of MLTC[18]. The most prevalent MLTC was the combination of hypertension and diabetes which is in line with the study conducted at urban municipality [16, 17]. Combination of hypertension with gastritis and thyroid disorder are other commonest conditions among the MLTC groups. There is wide variation in the inclusion of chronic conditions in multi-morbid studies, majority of which included 4-5 conditions only. Hypertension with COPD constituted 15% of the people with MLTC. The commonest combination of three conditions like hypertension, diabetes and gastritis was at the top followed by the combination of hypertension, diabetes, and COPD (6 out of 1407). This is similar to the study findings from Bangladesh where 14 participants had condition like hypertension, diabetes and COPD out of 3754 [21]. The association of age with presence of multiple long term conditions has been found in this study. MLTC was present in 14% of the adult of ≥40 years of age. There was no any association with the sex of the participants. This is similar to the study by the national representative sample which could not find any association with sex [18]. The total available adults with MLTC at the time of data collection were 48.7% (54 out of 110). The mean age of the studied participants for the QOL survey was 62.8years. Female were predominant. Majority were married. Most of them belonged to middle socioeconomic status. Though the adults were diagnosed with two conditions 18.5 % were current smoker (daily use cigarette) and 16.7% were current alcohol user (consume alcohol in the past 30 days) as per steps survey. This is similar to the findings from the national level survey, which showed the overall prevalence of smoking and alcohol consumption of 14.17% and 15.9% among people with multi-morbid conditions. Previous studies have shown the clear association between MLTC and smoking and alcohol [18, 21]. Since the undergraduate students have a mandatory home visit program under the supervision of the nursing faculty, they can plan the activities to make people aware of the impact of these unhealthy behaviors and plan intervention programs to improve their behaviors. Out of total studied participants with MLTC, 48.1% were enrolled in the government health insurance program. This is similar to the study conducted at Bhaktapur district, where the enrollment rate was 42.4 % [22]. The enrollment percentage is higher than the national coverage, which is 30 %. The difference might be because of the difference in settings as enrollment is higher in urban areas [23]. The health insurance program of Nepal is the government-run policy in order to provide quality health service without having major economic burden to the people [24]. As the people with MLTC have to take medicines on a regular basis for at least 2-3 conditions, it would pose a financial burden that may reduce their satisfaction with finances and decrease the economic quality of life. A study from China showed that the medical insurance led to improvement in health and satisfaction to life among elderly people [25]. Ninety percent of the adults with MLTC mentioned they were taking regular medicine prescribed to them. Studies from Nepal showed that just a few more than forty percent of the people with hypertension are adherent to medicine, whereas adherence to diabetic medicine is 46.3-54% [26–28]. This difference in regular intake of medicine may be due to the socio-cultural difference, perceived threat of the presence of multiple conditions or may be because of different techniques used in information collection. Our findings show that COPD was associated with the highest mean limitation score, followed by chronic backache, and heart disease . In contrast, more prevalent conditions such as hypertension , diabetes , and thyroid disorders showed lower average limitation scores, indicating a relatively lower impact on daily functioning in this multimorbid population. Though, MAQ-PC from India included limitation in daily activities based on each condition, however the researcher couldn’t find out results for each disease condition on the limitation in published studies. Interestingly, despite smaller sample sizes, musculoskeletal conditions such as chronic backache showed high levels of activity limitation. The present study highlights the variations in the quality of life score among people with multiple long term conditions. While a majority of participants rated their overall quality of life as good, specific domains show different findings. Notably, satisfaction with daily activities and living conditions scored relatively high, suggesting a level of functional independence and environmental stability despite the burden of chronic illness. However, energy for everyday life was the most negatively affected domain, with a mean score of 2.8, indicating significant physical limitations, possibly due to fatigue and reduced stamina associated with conditions such as COPD and heart disease. Satisfaction with health (mean: 3.3) and financial adequacy (mean: 3.1) also showed moderate scores. These findings are consistent with earlier studies that have reported the impact of multimorbidity on physical functioning, energy levels, and economic strain. Overall, while individuals with MLTC may adapt to their conditions in some life domains, these people continue to face limitations that warrant integrated, individual-centered interventions. Conclusıon These findings highlight the need to prioritize functional assessment and support for less prevalent but highly disabling conditions like COPD and chronic backache in the large sample. Integrating condition-specific disability management into multimorbidity care could improve overall quality of life and independence. There is challenges of managing chronic conditions in resource-limited settings; therefore, even with the curricular activities done effectively can make people aware on behavior modification activities that can improve the quality of life. There are certain limitations in this study. The study included the conditions on the basis of self-reporting of physicians’ diagnosed conditions for self or for their family members. So there might be information bias (under estimation) in the reporting of the disease conditions. As the data collection was done at a fixed time from 10 am to 2:30 pm, all MLTC participants could not be available for QOL studies, which might have resulted in sampling bias and distorted the results. The major strength of the study is that the researcher was available all the time with the students at the survey; therefore, the result is highly trustworthy. The researcher tried to include almost all the MLTC conditions (20 conditions) that are listed and recommended by the Delphi survey. The uniformity in the conditions involved will help to reach a common consensus and to make data comparable. Furthermore, the researcher used the conditions that has been diagnosed for at least 6 months or more. Abbreviations MLTC Multiple long term conditions (EUROHIS-QOL) European Health Interview Survey - Quality of Life Index COPD Chronic Obstructive Pulmonary Disease QOL Quality of Life WHOQOL World Health Organizations Quality of Life MAQ_PC Multimorbidity Assessment Questionnaire for Primary Care CLD Chronic Liver Disease APD Acute peptic disease CBP Chronic Back Pain CKD Chronic Kidney Disease DM Diabetes Mellitus Declarations Ethical Approval and consent to participate: Ethical approval was obtained from the institutional review committee of Nepal Medical College (NMC-IRC, Ref. No. 45-080/081) and permission was taken from the office of the ward no. 2 of Kageshwori Manohara Municipality (Ref. No. 610-2080/081).The study was conducted in accordance to the Declaration of Helsinki and all the participants gave their informed consent for inclusion before they participated in the study. Consent for publication: All others have given consent for publication and have agreed to the submission of this manuscript to the “ BMC Public Health” Availability of data and materials: The data and materials, like questions, are stored in the computer of the corresponding author and will be available upon request. Competing interests: All the authors declare no competing interests. Funding : There was no funding to conduct this study. Authors’ Contributions: A. Sap. and A. Sed. have made substantial contributions to the conception; P.G., P.P., N.P., S.C., and M.S. did acquisition of the information, A. Sap did analysis and interpretation of data, A. Sap. drafted the work, and A. Sed. and M. S. have substantially revised it. All the authors have revised and approved the submitted version. 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Modification of Kuppuswamy’s Socioeconomic Status Scale in the Context of Nepal, 2019. Kathmandu Univ Med J (KUMJ). 2019;17:1–2. Shrestha N, Shrestha B, Shrestha K. Prevalence of Non-Communicable Diseases in Adult Members in Selected Wards of Kageshwori Manohara Municipality, Kathmandu, Nepal. NMCJ. 2025;27. Silvanus V, Dhakal N, Shrestha N, Kafle PP. Comorbid Diabetes and Hypertension: Gender differences in prevalence and risk factors among adults (≥18 years) in an urban community in Kathmandu District in Nepal. Nepal Medical College Journal. 2023;25:277–89. https://doi.org/10.3126/nmcj.v25i4.60872. Dhungana RR, Karki KB, Bista B, Pandey AR, Dhimal M, Maskey MK. Prevalence, pattern and determinants of chronic disease multimorbidity in Nepal: secondary analysis of a national survey. BMJ Open. 2021;11:e047665. https://doi.org/10.1136/bmjopen-2020-047665. Sinha A, Suman SS, Subedi N, Sahoo KC, Poudel M, Chauhan A, et al. Epidemiology of multimorbidity in Nepal: A systematic review and meta-analysis. Journal of Multimorbidity and Comorbidity. 2024;14:26335565241284022. https://doi.org/10.1177/26335565241284022. Singh K, Patel SA, Biswas S, Shivashankar R, Kondal D, Ajay VS, et al. Multimorbidity in South Asian adults: prevalence, risk factors and mortality. J Public Health (Oxf). 2019;41:80–9. https://doi.org/10.1093/pubmed/fdy017. Khan N, Rahman M, Mitra D, Afsana K. Prevalence of multimorbidity among Bangladeshi adult population: a nationwide cross-sectional study. BMJ Open. 2019;9:e030886. https://doi.org/10.1136/bmjopen-2019-030886. Karanjit P, Mali P, Khadka R, Poudel L. Factors affecting the Utilization of Social Health Insurance by the General Population in Bhaktapur Municipality. Nepal Medical Journal. 2020;3:42–8. Khanal GN, Bharadwaj B, Upadhyay N, Bhattarai T, Dahal M, Khatri RB. Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? Health Res Policy Sys. 2023;21:7. https://doi.org/10.1186/s12961-022-00952-w. स्वास्थ्य बीमा बाेर्ड | Health Insurance Board. https://hib.gov.np/. Accessed 16 Nov 2025. GU L, Feng H, Jin J. Effects of Medical Insurance on the Health Status and Life Satisfaction of the Elderly. Iran J Public Health. 2017;46:1193–203. Dangaura NR, Khanal P, Kuikel BS, Marasini S, Timilsina A, Joshi PC, et al. Impact of National health insurance on medication adherence among hypertensive patients: A hospital-based cross-sectional study from Kailali, Nepal. PLOS ONE. 2025;20:e0332602. https://doi.org/10.1371/journal.pone.0332602. Pandey A, Khanal P, Parajuli S, Neupane S, Bhattarai B, Sharma A. Non-adherence to anti diabetic medication and associated factors in Nepal: a systematic review and meta-analysis. Annals of Medicine and Surgery. 2025;87:5185. https://doi.org/10.1097/MS9.0000000000003563. Shrestha SS, Shakya R, Karmacharya BM, Thapa P. Medication adherence to oral hypoglycemic agents among type II diabetic patients and their clinical outcomes with special reference to fasting blood glucose and glycosylated hemoglobin levels. Kathmandu Univ Med J (KUMJ). 2013;11:226–32. https://doi.org/10.3126/kumj.v11i3.12510. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8170865","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":558178415,"identity":"df710499-8ea1-4d65-af45-c3e535fbf3df","order_by":0,"name":"Abja Sapkota","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDACCYYEEGUAxIwPYCwJ4rSwMTCDVROjhQGmhU2CKC38sxsefvxRc8eYX775WXVhjl2dOQPzwds8+Cy5cyBZmufYMzPJNjaz2zO3JUtYNrAlW+PTwnAjIUGage2wjcExBrPbvNsOSBgc4DGTxqdF/kZC8s8f/0Ba2L8VQ7Twf8OrxeBGQpoEb9thM4NjPGbMUFvY8GoxvHMgzZq375mxZFtOsTTvtmTJDYfZjC3n4NEid7sn+eaPb3cM+5mPb/zMu82O3+B488Mbb/B5n4EnAUgcQBJgxqscBNgPoGkZBaNgFIyCUYAGAG6iTPamj8qUAAAAAElFTkSuQmCC","orcid":"","institution":"Nepal Medical College","correspondingAuthor":true,"prefix":"","firstName":"Abja","middleName":"","lastName":"Sapkota","suffix":""},{"id":558178416,"identity":"4faf290a-f06b-4277-bd7d-3117f647a2c0","order_by":1,"name":"Arun Sedhain","email":"","orcid":"","institution":"National Academy of Medical 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08:55:06","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77664,"visible":true,"origin":"","legend":"","description":"","filename":"5fe294def8f44ec4a45eb3681e4d29f81structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8170865/v1/47a5a15efe59a4331916591a.xml"},{"id":98207190,"identity":"75c4ecc6-a2b1-4ab6-bc00-b202ecd3b3b7","added_by":"auto","created_at":"2025-12-15 08:55:08","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86365,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8170865/v1/5ffc262b21737b59d7f5e375.html"},{"id":98431095,"identity":"b5e81108-e6b5-4a4d-a2fd-e4e3ed879e8a","added_by":"auto","created_at":"2025-12-17 16:47:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1063508,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8170865/v1/23d49408-4724-4a6f-9a0b-a83f0edf0168.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence and quality of life of the adult population with multiple long-term conditions in an Urban Municipality of Nepal","fulltext":[{"header":"Background","content":"\u003cp\u003eMultiple long-term conditions (MLTC) are the coexistence of two or more health conditions at the same time in the same individual [1, 2]. These conditions can be a physical non-communicable disease of long duration, such as cardiovascular disease or cancer or a mental health condition of long duration, such as a mood disorder or dementia or an infectious disease of long duration, such as HIV or hepatitis C [2]. The global prevalence of multiple long-term conditions is 37.2% [3]. Every one in 4 adult populations in England and every one out of five to seven in Nepal has MLTC[2, 4, 5]. Living with MLTC causes a huge burden on physical and psychological health, poor quality of life, and a higher risk of dying. Studies have shown that a combination of long-term conditions leads to a lower quality of life score [2, 6].\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWorld Health Organization (WHO) and the WHOQOL group defined QOL as an \u0026ldquo;individual\u0026rsquo;s perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.\u0026rdquo; It covers the physical, psychological, social, and environmental aspects and is considered as important as mortality and morbidity [6, 7].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMultiple long-term conditions affect all aspects of an individual\u0026rsquo;s life and lead to poor health-related quality of life [5, 8]. Research findings have shown that aspects like advanced age and sex, where many non-modifiable factors co-exist, are associated with poor quality of life [6, 9].\u003c/p\u003e\u003cp\u003eThe healthcare system around the world is facing a great challenge in supporting people with MLTC to make their lives better. To support them, the healthcare system needs to first assess the quality of life. In Nepal, studies on MLTC are limited merely to the prevalence and its associated factors and are mainly conducted in hospital settings. Therefore, this study was conducted to explore the quality of life among MLTC in the community settings of Nepal.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA community- based cross-sectional descriptive study was carried out in ward number 2 of Kageshwori Manahara municipality of Kathmandu District. Adult population of age 20 years and above was studied. Data collection was done from January to February and November to December in the year 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the institutional review committee of Nepal Medical College (NMC-IRC, Ref. No. 45-080/081) and permission was taken from the office of the ward no. 2 of Kageshwori Manohara Municipality (Ref. No. 610-2080/081).\u003c/p\u003e\n\u003cp\u003eA total\u0026nbsp;of 400 households were selected based on family members\u0026apos; willingness to provide information. Every member from the selected houses with age of\u0026ge;20 years was included in the study. According to the census of 2021 of Nepal, the population above 20 years of age at ward number 2 was 2494\u0026nbsp;[10]. Number of participants in this study was 1407, which was 56.41% of the total adult population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstrument:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSection 1:\u0026nbsp;\u003c/strong\u003eThe family folder designed for undergraduate nursing students for their home visit, as a part of community nursing curriculum, was used as the first part. The socio-demographic information like age, sex, socioeconomic status and the disease related information like presence of morbidity, if any, were collected. With this tool, information about the prevalence of multiple long term conditions could be gathered. Once B.Sc. students identified the chronic conditions then the researcher approached the participants with the second set of instruments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSection II:\u0026nbsp;\u003c/strong\u003eOnce the information on the chronic conditions was collected as per the tool on section I, next part of the tools were used that covered the detail information on people with multiple long term conditions. It included types of problems that were self-reported or reporting by the family members on ever diagnosed with chronic conditions. Conditions having more than or equal to two chronic conditions diagnosed for \u0026ge; 6 months were grouped in MLTC. Disease included in MLTC were arthritis, diabetes mellitus(DM), hypertension, chronic liver disease(CLD), acute peptic disease(APD)/gastritis, chronic back pain(CBP), heart disease(HD), stroke, deafness, chronic obstructive pulmonary disease (COPD) and asthma, chronic kidney disease(CKD), \u0026nbsp;blindness, deafness, alcohol disorder, cancer, epilepsy, thyroid, tuberculosis, filariasis, mental illness (depression, schizophrenia, Mania) and, neurological conditions (parkinsonism and /or Alzheimer\u0026rsquo;s disease). In this study, chronic liver disease has been added in place of dementia (considering it as symptom not a disease). Furthermore participants were asked how much each problem limited themselves in their daily activities (severity index).This question is a 5 point item with not at all=0, a little, somewhat=2, quite a bit=3, a lot 4. A higher score in each problem indicates higher severity. The types of morbidity and the severity of the conditions have been adopted from the \u0026ldquo;multimobidity assessment questionnaire for primary care (MAQ-PC)\u0026rdquo; developed in India\u0026nbsp;[11]. Smoking, alcohol dependency, use of government health insurance was also assessed. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSection III: Quality of Life Measurement:\u0026nbsp;\u003c/strong\u003eIn this study, QOL was measured by the researchers by asking 8 sets of questions on how individual participants felt about their lives in the past 4 weeks. QOL was measured by a person\u0026rsquo;s satisfaction with the shortened version of WHOQOL BREF-8, also called as European Health Interview Survey Quality of Life (EUROHIS-QOL). This measure was published in 2006 by the WHOQOL group. Eight items from different domains were considered. Each item of the WHOQOL-8 is rated on a five-point scale, scored from 1-worst to 5-best. \u0026nbsp;Overall QOL score is formed by a simple summation of scores on the eight items, with higher scores indicating better QOL, and the sum score has a potential range from 8 to 40\u0026nbsp;[12].\u003c/p\u003e\n\u003cp\u003eIt is a reliable tool with an internal consistency of 0.72 to 0.81 and is recommended for public health research\u0026nbsp;[12].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThe tool is available in Nepali version and has an acceptable internal consistency of 0.74 and has been used in Nepal\u0026nbsp;[13, 14].\u003c/p\u003e\n\u003cp\u003eStatistical analysis was done by using SPSS version 16. Descriptive statistics like frequency, percentage, mean was used. To find the association between age and sex with presence of multiple long term conditions chi square test was used and p value was considered significant at p\u0026lt;0.05 at 95 % CI.\u003c/p\u003e"},{"header":"Results​","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"631\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 567px;\"\u003e\n \u003cp\u003eTable 1: Prevalence \u0026nbsp;of MLTC according to age and \u0026nbsp;sex wise (n=1407)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 352px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultiple long term conditions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNo, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\n \u003cp\u003eYes, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge(in completed years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 211px;\"\u003e\n \u003cp\u003e20 to 40 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e669(47.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e663(99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\n \u003cp\u003e6(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u0026ge;40 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e738 (52.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e633(85.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\n \u003cp\u003e105(14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 211px;\"\u003e\n \u003cp\u003eMean\u0026plusmn;SD (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e42.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e41.3\u0026plusmn;15.3 (20-92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\n \u003cp\u003e58.9\u0026plusmn;12.8(25-90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 211px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e696(49.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e644(92.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\n \u003cp\u003e52(7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.565\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 211px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e711(50.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e652(91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 144px;\"\u003e\n \u003cp\u003e59(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"bottom\" style=\"width: 631px;\"\u003e\n \u003cp\u003eP value obtained from chi square test and considered significant at p\u0026lt;0.05\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 211px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 4px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Altogether, 1407 adults were included in the study, amongst whom 738 (52.5%) were of age \u0026ge; 40 and 711(50.5%) were women. Chronic illness was present in 24% of the participants with overall prevalence of MLTC of 7.9%. Hypertension was present in 14.4%, diabetes in 7.1%, gastritis in 3.7%, thyroid disorders in 2.6%, COPD in 2.5% and heart disease in 1.2%. The conditions that were present in \u0026le; 1% of the participants were kidney disease, mental illness, deafness, cancer, epilepsy, chronic liver disease, epilepsy, Parkinsonism, chronic back pain and stroke. About six participants (1%) with age \u0026lt; 40 years had presence of the chronic conditions. Only one chronic condition was present in 16%, two in5.5%, and three in 1.8% of the participants. Four chronic conditions were present in 7 participants and 5 and 6 chronic conditions were present in 1 participants each (Table 1 and 2).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"307\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: Clinical characteristics of the participants(n=1407)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic conditions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic conditions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1071 (76.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e336 (23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTypes*(n=1407)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e203(14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e100 ( 7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eGastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e52(3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eThyroid disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e36 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eCOPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e35(2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e17 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eArthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e13(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eMental illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e6(0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eChronic kidney disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e5(0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eDeaf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e3 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eCancer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e3(0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eChronic Liver Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e2(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eEpilepsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e2(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eParkinsonism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e2(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eChronic back pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e2(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eStroke\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Number of Chronic \u0026nbsp;conditions (n=1407)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;One\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e225 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Two\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e77 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Three\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e25 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e7(0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Five\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Six\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresence of MLTC (n=1407)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1296(92.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 172px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e111(7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*Multiple response\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Adults with multiple long term conditions available at the time of data collection from 10 am to 2.30 pm were included in further analysis. Among 111 participants with MLTC, 48.6% were available for the assessment of the severity index of disease and for quality of life. Therefore, characteristics like age, sex, marital status, smoking habit, alcohol use, use of government health insurance were presented of these participants only.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the people with multiple long term conditions with two conditions, 47.7% had both hypertension and diabetes. \u0026nbsp;A second common condition was hypertension and gastritis (22.5%) and the third most was hypertension and COPD (15.3%). Similarly, when the presence of three conditions was explored, hypertension diabetes and gastritis were at the top with 9% and hypertension diabetes and COPD were present in about 5.6% (Table 3).\u003c/p\u003e\n\u003cp\u003eOut of 54 adult populations with MLTC, 38.9% were from age less than 60 years. About 52% were female, 20 % were single, and 79.7 were from middle socioeconomic status. Among the MLTC participants, 18.5% were current smoker and 16.7 % were current alcohol user. About 48%were enrolled in the government health insurance program. Cent percent mentioned that they were prescribed with medicine however 9.3% didn\u0026rsquo;t take prescribed medicine regularly. (Table 4)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"469\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 469px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable:3 Distribution of chronic conditions in cluster wise \u0026nbsp;(n=111)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of conditions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTwo conditions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e53 (47.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, gastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e25(22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, COPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e17(15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, arthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e13(11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, thyroid disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e12(10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eDM, gastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e12 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e9 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThree conditions (n=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, DM, gastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e10 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, DM,COPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e6(5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN DM, arthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e4(3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN DM, thyroid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e3(2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, DM, Heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e2(1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, COPD, Heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e2(2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, gastritis, COPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e2(1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, DM, KD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e2 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 201px;\"\u003e\n \u003cp\u003eHTN, gastritis, COPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 268px;\"\u003e\n \u003cp\u003e2(1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"402\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 318px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4: Distribution of multiple long term conditions \u0026nbsp;among adult (n=54)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (completed years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e20-59 yrs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e21(38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u0026ge; 60 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e33(61.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eMean\u0026plusmn;SD (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e62.8\u0026plusmn;12.04 (38-90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e26(48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e28(52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e43(79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003esingle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e11(20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocioeconomic status*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eMiddle income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e43(79.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eLower income\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e11(20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking, current smoker\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e10(18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e44(81.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent alcohol user\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e9(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e45(83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth Insurance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e26(48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e28(51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegular intake of medicine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e49(90.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e5(9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 402px;\"\u003e\n \u003cp\u003e*Kuppuswammy modified scale for Nepalese context\u0026nbsp;[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 199px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 4 indicates the characteristics of the participant included for the further analysis of the quality of life score. As quality of life and severity should be identified through direct self-report of the participants, only those adults available at the time of survey were included. Out of 111 participants with MLTC, about 48.7 were available. About 61% of the participants were from age 60 years and above, 52% were female, 79.6% were married. Regarding socioeconomic status 79% were from middle income class and 20% from low socioeconomic status.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"464\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 464px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 5: Disease-specific limitation in daily activities (among MLTC only)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ediseases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003etotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003erange\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eHTN\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eGastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eCOPD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eArthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eThyroid disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eChronic backache\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 164px;\"\u003e\n \u003cp\u003eKidney disease\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 5 shows the disease severity index among people with multiple long term conditions. When asked about how much each of the problem limit the activities of daily living, the highest limitation noted was due to chronic back pain with mean value 3.5, COPD 3.4, heart disease and chronic kidney disease with mean vale 2.5, and with gastritis 2.1.The disease condition that lead to least limitation in daily activities were diabetes, hypertension and thyroid disorders with a mean score of around 1.5 (Table 5).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"715\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"bottom\" style=\"width: 610px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 6: Quality of life score of \u0026nbsp;adults having multiple long term conditions (n=54)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 105px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem (range 1-5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003every poor n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003epoor n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eneither poor nor good n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003egood n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003every good n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eHow would you rate your quality of life ? (Rating of Overall QOL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e16(29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e31(57.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eHow satisfied are you with your health?(Satisfaction with health)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e4(7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e7(13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e16(29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e24(44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eHow satisfied are you with your ability to perform your daily living activities? (Satisfaction with daily activities)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e7(13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e9(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e30(55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e7(13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eHow satisfied are you with yourself? (Satisfaction with self)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2(3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e7(13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e10(18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e29(53.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e6(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eHow satisfied are you with your personal relationship? (Satisfaction with \u0026nbsp;relationships)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e8(14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e6(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e31(57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eHow satisfied are you with the conditions of your living places?(Satisfaction with living conditions)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e6(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e36(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e10(18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eDo you have enough energy for everyday life?(Enough \u0026nbsp;energy for everyday life)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e18(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e25(46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e9(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eyou have enough money to meet everyday needs?(Have enough money to meet everyday needs )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e13(24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e30(55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e5(9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e6(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003eMean\u0026plusmn; SD; Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" valign=\"bottom\" style=\"width: 481px;\"\u003e\n \u003cp\u003e27.7\u0026plusmn;4.3; (18-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 234px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Quality of life was assessed with the European Health Interview Survey Quality of Life (EUROHIS-QOL) scale. About 29.6% rated their quality of life as neither good nor poor, 5.6% rated as poor and 1.9% rated as very poor. About 29.6 had neutral feelings towards satisfaction to life, 13% were dissatisfied, and 7.4 % were very dissatisfied with their health. Equal percentage (13%) was dissatisfied with ability to perform daily activities and with self (self esteem.Fourteen percent were dissatisfied with personnel relationship. Almost 57.4 % and 66.7 percent were satisfied with the personnel relationship and living conditions. About 33.3 percent answered that they had a little energy for everyday life. About 1/4\u003csup\u003eth\u003c/sup\u003e of the participants (24.1 %) answered that they had a little money to meet the everyday needs. Out of the total items the leas score was obtained in the items having energy for everyday life with mean score 2.8 and the highest score was in the satisfaction with the living conditions. The overall mean score was 27.7 with standard deviation \u0026plusmn;4.3 (Table 6).\u0026nbsp;\u003c/p\u003e"},{"header":"Discusion","content":"\u003cp\u003eIn this study, the prevalence of multiple long-term conditions and the quality of life of people with MLTC were identified. Earlier studies in the area focused on the prevalence of the selected chronic conditions and were strict to two conditions (hypertension plus diabetes). The current study mainly focused on the at least 20 multiple long-term conditions (MLTC). \u0026nbsp;The total of 400 household with, 1407 adults with age more than or equals 20 were included. A few more than half aged \u0026ge;40 years. Male and female were almost equal in percentage. Out of total adults 1/4\u003csup\u003eth\u003c/sup\u003e of them had at least one type of chronic conditions.\u003c/p\u003e\n\u003cp\u003eThe top most five common chronic conditions presented were hypertension (14.4), diabetes (7.1), gastritis (3.7), thyroid disorder (2.6) and chronic obstructive pulmonary disease (2.5). This is congruent with the previous studies done in the same area, in which the top five most common conditions were hypertension, diabetes, thyroid, chronic respiratory disease, heart disease, and cancer\u0026nbsp;[16].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eHowever, another study from a nearby urban municipality showed the overall prevalence of hypertension was 24.1% and diabetes 10.5% slightly higher than this\u0026nbsp;[17].This\u003csup\u003e\u0026nbsp;\u003c/sup\u003edifference\u003csup\u003e\u0026nbsp;\u003c/sup\u003emight be because difference in area and the difference in the municipal level facilities and difference in recruitment criteria as in our study already diagnosed cases with at least 6 months has been included. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSixteen percentage of the studied population had one chronic condition and the prevalence of multiple long term conditions was 7.9%.This is lower than the findings of national survey of Nepal\u0026nbsp;[18]\u003csup\u003e\u0026nbsp;\u003c/sup\u003eand systemic review from Nepal\u0026nbsp;[19]\u003csup\u003e\u0026nbsp;\u003c/sup\u003eand almost consistent with study conducted in South East Asian countries like India and Pakistan\u0026nbsp;[20]\u0026nbsp;and Bangladesh\u0026nbsp;[21]. The lower prevalence may be because of variation in the study populations (age group), difference in the setting, difference in selection criteria, and the difference in time period of the survey. In our survey, the mean age of the population was 42.64 years which is lower than the participants from the previous studies in Nepal\u0026nbsp;[18, 19]. There are variations in the types of conditions majority included hypertension, diabetes, COPD, thyroid disorders and cancers. In this study 5.5% had two conditions present and two had 5 to 6 chronic conditions present. Our findings of presence of 2 and 3 conditions (77 and 25 out of 111 respectively) is in line with the previous study in which 2 and 3 conditions were present in 80.1% and 17.4% of MLTC[18].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The most prevalent MLTC was the combination of hypertension and diabetes which is in line with the study conducted at urban municipality\u0026nbsp;[16, 17]. Combination of hypertension with gastritis and thyroid disorder are other commonest conditions among the MLTC groups. There is wide variation in the inclusion of chronic conditions in multi-morbid studies, majority of which included 4-5 conditions only. Hypertension with COPD constituted 15% of the people with MLTC. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe commonest combination of three conditions like hypertension, diabetes and gastritis was at the top followed by the combination of hypertension, diabetes, and COPD (6 out of 1407). This is similar to the study findings from Bangladesh where 14 participants had condition like hypertension, diabetes and COPD out of 3754\u0026nbsp;[21].\u003c/p\u003e\n\u003cp\u003eThe association of age with presence of multiple long term conditions has been found in this study. \u0026nbsp;MLTC was present in 14% of the adult of \u0026ge;40 years of age. There was no any association with the sex of the participants. This is similar to the study by the national representative sample which could not find any association with sex\u0026nbsp;[18].\u003c/p\u003e\n\u003cp\u003eThe total available adults with MLTC at the time of data collection were 48.7% (54 out of 110). The mean age of the studied participants for the QOL survey was 62.8years. Female were predominant. Majority were married. Most of them belonged to middle socioeconomic status. Though the adults were diagnosed with two conditions 18.5 % were current smoker (daily use cigarette) and 16.7% were current alcohol user (consume alcohol in the past 30 days) as per steps survey. This is similar to the findings from the national level survey, which showed the overall prevalence of smoking and alcohol consumption of 14.17% and 15.9% among people with multi-morbid conditions. Previous studies have shown the clear association between MLTC and smoking and alcohol\u0026nbsp;[18, 21]. Since the undergraduate students have a mandatory home visit program under the supervision of the nursing faculty, they can plan the activities to make people aware of the impact of these unhealthy behaviors and plan intervention programs to improve their behaviors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut of total studied participants with MLTC, 48.1% were enrolled in the government health insurance program. This is similar to the study conducted at Bhaktapur district, where the enrollment rate was 42.4 %\u0026nbsp;[22].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThe enrollment percentage is higher than the national coverage, which is 30 %. The difference might be because of the difference in settings as enrollment is higher in urban areas\u0026nbsp;[23]. The health insurance program of Nepal is the government-run policy in order to provide quality health service without having major economic burden to the people\u0026nbsp;[24]. As the people with MLTC have to take medicines on a regular basis for at least 2-3 conditions, it would pose a financial burden that may reduce their satisfaction with finances and decrease the economic quality of life. A study from China showed that the medical insurance led to improvement in health and satisfaction to life among elderly people\u0026nbsp;[25]. Ninety percent of the adults with MLTC mentioned they were taking regular medicine prescribed to them. Studies from Nepal showed that just a few more than forty percent of the people with hypertension are adherent to medicine, whereas adherence to diabetic medicine is 46.3-54%\u0026nbsp;[26\u0026ndash;28]. This difference in regular intake of medicine may be due to the socio-cultural difference, perceived threat of the presence of multiple conditions or may be because of different techniques used in information collection. \u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur findings show that \u003cstrong\u003eCOPD\u003c/strong\u003e was associated with the highest mean limitation score, followed by \u003cstrong\u003echronic backache,\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003eheart disease\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e In contrast, more prevalent conditions such as \u003cstrong\u003ehypertension\u003c/strong\u003e\u003cstrong\u003e, \u003cstrong\u003ediabetes\u003c/strong\u003e,\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003ethyroid disorders\u003c/strong\u003e showed lower average limitation scores, indicating a relatively lower impact on daily functioning in this multimorbid population. Though, MAQ-PC from India included limitation in daily activities based on each condition, however the researcher couldn\u0026rsquo;t find out results for each disease condition on the limitation in published studies. Interestingly, despite smaller sample sizes, \u003cstrong\u003emusculoskeletal conditions\u0026nbsp;\u003c/strong\u003esuch as chronic backache showed high levels of activity limitation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe present study highlights the variations in the quality of life score among people with multiple long term conditions. While a majority of participants rated their overall quality of life as good, specific domains show different findings. Notably, satisfaction with daily activities and living conditions scored relatively high, suggesting a level of functional independence and environmental stability despite the burden of chronic illness. However, \u003cstrong\u003eenergy for everyday life\u003c/strong\u003e was the most negatively affected domain, with a mean score of 2.8, indicating significant physical limitations, possibly due to fatigue and reduced stamina associated with conditions such as COPD and heart disease.\u003c/p\u003e\n\u003cp\u003eSatisfaction with health (mean: 3.3) and financial adequacy (mean: 3.1) also showed moderate scores. These findings are consistent with earlier studies that have reported the impact of multimorbidity on physical functioning, energy levels, and economic strain. Overall, while individuals with MLTC may adapt to their conditions in some life domains, these people continue to face limitations that warrant integrated, individual-centered interventions.\u003c/p\u003e"},{"header":"Conclusıon","content":"\u003cp\u003eThese findings highlight the need to prioritize functional assessment and support for less prevalent but highly disabling conditions like COPD and chronic backache in the large sample. Integrating condition-specific disability management into multimorbidity care could improve overall quality of life and independence. There is challenges of managing chronic conditions in resource-limited settings; therefore, even with the curricular activities done effectively can make people aware on behavior modification activities that can improve the quality of life.\u003c/p\u003e\n\u003cp\u003eThere are certain limitations in this study. The study included the conditions on the basis of self-reporting of physicians\u0026rsquo; diagnosed conditions for self or for their family members. So there might be information bias (under estimation) in the reporting of the disease conditions. As the data collection was done at a fixed time from 10 am to 2:30 pm, all MLTC participants could not be available for QOL studies, which might have resulted in sampling bias and distorted the results. The major strength of the study is that the researcher was available all the time with the students at the survey; therefore, the result is highly trustworthy. The researcher tried to include almost all the MLTC conditions (20 conditions) that are listed and recommended by the Delphi survey. The uniformity in the conditions involved will help to reach a common consensus and to make data comparable. Furthermore, the researcher used the conditions that has been diagnosed for at least 6 months or more.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMLTC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultiple long term conditions\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e(EUROHIS-QOL)\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEuropean Health Interview Survey - Quality of Life Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic Obstructive Pulmonary Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQOL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHOQOL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organizations Quality of Life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMAQ_PC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultimorbidity Assessment Questionnaire for Primary Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCLD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic Liver Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcute peptic disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCBP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic Back Pain\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCKD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic Kidney Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiabetes Mellitus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthical approval was obtained from the institutional review committee of Nepal Medical College (NMC-IRC, Ref. No. 45-080/081) and permission was taken from the office of the ward no. 2 of Kageshwori Manohara Municipality (Ref. No. 610-2080/081).The study was conducted in accordance to the Declaration of Helsinki and all the participants gave their informed consent for inclusion before they participated in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e All others have given consent for publication and have agreed to the submission of this manuscript to the \u0026ldquo; BMC Public Health\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The data and materials, like questions, are stored in the computer of the corresponding author and will be available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eAll the authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: There was no funding to conduct this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u0026nbsp;\u003c/strong\u003eA. Sap. and A. Sed. have made substantial contributions to the conception; P.G., P.P., N.P., S.C., and M.S. did acquisition of the information, A. Sap did analysis and interpretation of data, A. Sap. drafted the work, and A. Sed. and M. S. have substantially revised it. All the authors have revised and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to thank the undergraduate nursing students who identified the participants with chronic conditions and all the participants of the selected municipality who have gave their valuable time by providing information on completion of the study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDambha-Miller H, Cheema S, Saunders N, Simpson G. Multiple Long-Term Conditions (MLTC) and the Environment: A Scoping Review. Int J Environ Res Public Health 2022; 19:11492.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMaking sense of the evidence: Multiple long-term conditions (multimorbidity) - NIHR Evidence. https://evidence.nihr.ac.uk/collection/making-sense-of-the-evidence-multiple-long-term-conditions-multimorbidity/. Accessed 10 Nov 2025.\u003c/li\u003e\n \u003cli\u003eGlobal and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis - eClinicalMedicine. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00037-8/fulltext. Accessed 10 Nov 2025.\u003c/li\u003e\n \u003cli\u003eBalakrishnan S, Karmacharya I, Ghimire S, Mistry SK, Singh DR, Yadav OP, et al. Prevalence of multimorbidity and its correlates among older adults in Eastern Nepal. BMC Geriatr. 2022;22:425. https://doi.org/10.1186/s12877-022-03115-2.\u003c/li\u003e\n \u003cli\u003eYadav UN, Ghimire S, Mistry SK, Shanmuganathan S, Rawal LB, Harris M. Prevalence of non-communicable chronic conditions, multimorbidity and its correlates among older adults in rural Nepal: a cross-sectional study. BMJ Open. 2021;11:e041728. https://doi.org/10.1136/bmjopen-2020-041728.\u003c/li\u003e\n \u003cli\u003eSum G, Salisbury C, Koh GC-H, Atun R, Oldenburg B, McPake B, et al. Implications of multimorbidity patterns on health care utilisation and quality of life in middle-income countries: cross-sectional analysis. J Glob Health. 9:020413. https://doi.org/10.7189/jogh.09.020413.\u003c/li\u003e\n \u003cli\u003eThe World Health Organization quality of life assessment (WHOQOL): Position paper from the World Health Organization. Social Science \u0026amp; Medicine. 1995;41:1403\u0026ndash;9. https://doi.org/10.1016/0277-9536(95)00112-K.\u003c/li\u003e\n \u003cli\u003ePati S, Swain S, Knottnerus JA, Metsemakers JFM, van den Akker M. Health related quality of life in multimorbidity: a primary-care based study from Odisha, India. Health Qual Life Outcomes. 2019;17:116. https://doi.org/10.1186/s12955-019-1180-3.\u003c/li\u003e\n \u003cli\u003eEyowas FA, Schneider M, Balcha SA, Pati S, Getahun FA. Multimorbidity and health-related quality of life among patients attending chronic outpatient medical care in Bahir Dar, Northwest Ethiopia: The application of partial proportional odds model. PLOS Global Public Health. 2022;2:e0001176. https://doi.org/10.1371/journal.pgph.0001176.\u003c/li\u003e\n \u003cli\u003ePopulation | National Population and and Housing Census 2021 Results. https://censusnepal.cbs.gov.np/results/population?province=3\u0026amp;district=28\u0026amp;municipality=2. Accessed 14 Nov 2025.\u003c/li\u003e\n \u003cli\u003eDevelopment and Validation of a Questionnaire to Assess Multimorbidity in Primary Care: An Indian Experience - Pati - 2016 - BioMed Research International - Wiley Online Library. https://onlinelibrary.wiley.com/doi/full/10.1155/2016/6582487. Accessed 14 Nov 2025.\u003c/li\u003e\n \u003cli\u003eda Rocha NS, Power MJ, Bushnell DM, Fleck MP. The EUROHIS-QOL 8-item index: comparative psychometric properties to its parent WHOQOL-BREF. Value Health. 2012;15:449\u0026ndash;57. https://doi.org/10.1016/j.jval.2011.11.035.\u003c/li\u003e\n \u003cli\u003eRisal A, Manandhar S, Manandhar K, Manandhar N, Kunwar D, Holen A. Quality of life and its predictors among aging people in urban and rural Nepal. Qual Life Res. 2020;29:3201\u0026ndash;12. https://doi.org/10.1007/s11136-020-02593-4.\u003c/li\u003e\n \u003cli\u003eRisal A, Kunwar D, Karki E, Adhikari SP, Bimali I, Shrestha B, et al. Adapting World Health Organization Disability Assessment Schedule 2.0 for Nepal. BMC Psychology. 2021;9:45. https://doi.org/10.1186/s40359-021-00550-5.\u003c/li\u003e\n \u003cli\u003eJoshi SK, Acharya K. Modification of Kuppuswamy\u0026rsquo;s Socioeconomic Status Scale in the Context of Nepal, 2019. Kathmandu Univ Med J (KUMJ). 2019;17:1\u0026ndash;2.\u003c/li\u003e\n \u003cli\u003eShrestha N, Shrestha B, Shrestha K. Prevalence of Non-Communicable Diseases in Adult Members in Selected Wards of Kageshwori Manohara Municipality, Kathmandu, Nepal. NMCJ. 2025;27.\u003c/li\u003e\n \u003cli\u003eSilvanus V, Dhakal N, Shrestha N, Kafle PP. Comorbid Diabetes and Hypertension: Gender differences in prevalence and risk factors among adults (\u0026ge;18 years) in an urban community in Kathmandu District in Nepal. Nepal Medical College Journal. 2023;25:277\u0026ndash;89. https://doi.org/10.3126/nmcj.v25i4.60872.\u003c/li\u003e\n \u003cli\u003eDhungana RR, Karki KB, Bista B, Pandey AR, Dhimal M, Maskey MK. Prevalence, pattern and determinants of chronic disease multimorbidity in Nepal: secondary analysis of a national survey. BMJ Open. 2021;11:e047665. https://doi.org/10.1136/bmjopen-2020-047665.\u003c/li\u003e\n \u003cli\u003eSinha A, Suman SS, Subedi N, Sahoo KC, Poudel M, Chauhan A, et al. Epidemiology of multimorbidity in Nepal: A systematic review and meta-analysis. Journal of Multimorbidity and Comorbidity. 2024;14:26335565241284022. https://doi.org/10.1177/26335565241284022.\u003c/li\u003e\n \u003cli\u003eSingh K, Patel SA, Biswas S, Shivashankar R, Kondal D, Ajay VS, et al. Multimorbidity in South Asian adults: prevalence, risk factors and mortality. J Public Health (Oxf). 2019;41:80\u0026ndash;9. https://doi.org/10.1093/pubmed/fdy017.\u003c/li\u003e\n \u003cli\u003eKhan N, Rahman M, Mitra D, Afsana K. Prevalence of multimorbidity among Bangladeshi adult population: a nationwide cross-sectional study. BMJ Open. 2019;9:e030886. https://doi.org/10.1136/bmjopen-2019-030886.\u003c/li\u003e\n \u003cli\u003eKaranjit P, Mali P, Khadka R, Poudel L. Factors affecting the Utilization of Social Health Insurance by the General Population in Bhaktapur Municipality. Nepal Medical Journal. 2020;3:42\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eKhanal GN, Bharadwaj B, Upadhyay N, Bhattarai T, Dahal M, Khatri RB. Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? Health Res Policy Sys. 2023;21:7. https://doi.org/10.1186/s12961-022-00952-w.\u003c/li\u003e\n \u003cli\u003eस्वास्थ्य\u0026nbsp;बीमा\u0026nbsp;बाेर्ड\u0026nbsp;| Health Insurance Board. https://hib.gov.np/. Accessed 16 Nov 2025.\u003c/li\u003e\n \u003cli\u003eGU L, Feng H, Jin J. Effects of Medical Insurance on the Health Status and Life Satisfaction of the Elderly. Iran J Public Health. 2017;46:1193\u0026ndash;203.\u003c/li\u003e\n \u003cli\u003eDangaura NR, Khanal P, Kuikel BS, Marasini S, Timilsina A, Joshi PC, et al. Impact of National health insurance on medication adherence among hypertensive patients: A hospital-based cross-sectional study from Kailali, Nepal. PLOS ONE. 2025;20:e0332602. https://doi.org/10.1371/journal.pone.0332602.\u003c/li\u003e\n \u003cli\u003ePandey A, Khanal P, Parajuli S, Neupane S, Bhattarai B, Sharma A. Non-adherence to anti diabetic medication and associated factors in Nepal: a systematic review and meta-analysis. Annals of Medicine and Surgery. 2025;87:5185. https://doi.org/10.1097/MS9.0000000000003563.\u003c/li\u003e\n \u003cli\u003eShrestha SS, Shakya R, Karmacharya BM, Thapa P. Medication adherence to oral hypoglycemic agents among type II diabetic patients and their clinical outcomes with special reference to fasting blood glucose and glycosylated hemoglobin levels. Kathmandu Univ Med J (KUMJ). 2013;11:226\u0026ndash;32. https://doi.org/10.3126/kumj.v11i3.12510.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Multiple long term conditions, adult populations, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-8170865/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8170865/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe presence of two or more chronic conditions at the same time in the same individual has been increasing. The presence of chronic conditions will lead to a huge burden on physical and psychological health and poor quality of life. The study aimed to identify the prevalence and quality of life among adult populations living with multiple long-term conditions (MLTC).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis was a community-based cross-sectional descriptive study conducted at the urban municipality of Kathmandu, Nepal. A total of 1407 adults aged 20 years and above were included. The assessment of quality of life was done by interviews of the persons living with MLTC with the use of the Nepali version of the European Health Interview Survey - Quality of Life (EUROHIS-QOL8-Item) Index.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOut of the total participants, 24% had non-communicable disease. The prevalence of hypertension was 14%, diabetes 7.1%, gastritis 3.7%, thyroid disorders 2.6% and COPD 2.5%. The prevalence of MLTC was 7.9% among adults aged\u0026thinsp;\u0026ge;\u0026thinsp;20 years. The prevalence of MLTC for those with age\u0026thinsp;\u0026ge;\u0026thinsp;40 years was 14% whereas for those aged 20\u0026ndash;39 years it was 1%. Among the people with MLTC, those with chronic backache and COPD had the worst limitation in daily activities. Out of the 8 items of EUROHIS-QOL, the lowest score obtained was on the satisfaction with energy for everyday life, with an average score of 2.8, and satisfaction with finances, with a score of 3.1 out of 4. The overall mean QOL score was 28 out of 40.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eNursing faculties and nursing student can utilize the findings (evidence based) of these surveys while planning health intervention in community where there is scarcity of resources. Furthermore, the team should aim to address the quality of life of people while planning and implementing micro health project in these community.\u003c/p\u003e","manuscriptTitle":"Prevalence and quality of life of the adult population with multiple long-term conditions in an Urban Municipality of Nepal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 08:54:45","doi":"10.21203/rs.3.rs-8170865/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-26T04:39:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-25T17:21:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-23T07:24:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69390442095871732343453092176615081318","date":"2026-02-23T06:49:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158730877155753566319180179433947684115","date":"2026-02-19T17:53:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134333108936657319041121308508016485419","date":"2026-02-19T15:24:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264293208153811151133095409003133885166","date":"2026-02-19T11:43:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-10T10:43:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-24T07:57:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-24T07:37:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-24T07:33:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-21T07:32:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5ac2932e-0d28-4c2d-b286-48adbfbb497a","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T08:54:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-15 08:54:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8170865","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8170865","identity":"rs-8170865","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}