Gender differences in response to living with multimorbidity in Malawi

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Spencer, Ben Morton, Deborah Nyirenda, and 20 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7231827/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Multimorbidity is an urgent public health challenge in sub-Saharan Africa (SSA). Gender, defined as the socially constructed roles, behaviours, activities, and attributes that societies deem appropriate for males and females, significantly influences healthcare access and health-seeking behaviours. The aim of this study was to examine gendered experiences of living with multimorbidity (PLWMM) in Malawi. Methods This qualitative study is nested within a broader program of multimorbidity research conducted within two hospitals in Malawi. We recruited patients with ≥ 2 combinations of diabetes, HIV, hypertension and chronic kidney disease, the most common chronic conditions in the Malawi setting. We conducted 32 in-depth-interviews (IDI) and 8 focus group discussions (FGDs) with people living with multimorbidity (PLWMM) and their carers. Baseline data were supplemented with follow-up interviews at 90 days post-admission. Data were thematically analysed using the critical gender theory. Results Three key themes emerged: gendered perceptions of chronic conditions; gendered roles and care-seeking; and decision-making behaviours. Wider structural gender norms informed experiences of living with multimorbidity. Men frequently expressed reluctance to seek care due to societal norms around masculinity and stigma associated with vulnerability, whilst women encountered barriers due to required caregiver roles and limited agency to make health decisions. Limited access to essential resources and reduced physical functionality were common features across both genders. We observed increased propensity toward medical pluralism among females, influenced by their roles as carers and economic factors while males predominantly sought to manage side-effects of treatment. Conclusions Gender shapes the experiences of multimorbidity, with male reluctance to seek care driven by masculinity norms, and females engagement with illness constrained by caregiving responsibilities and limited agency. We recommend health education and peer-to-peer initiatives to reframe gendered healthcare interactions and address perceptions of vulnerability and stigma. Among females, strengthened female agency; increased financial independence; and social support may reduce caregiver burdens and promote shared health responsibility Preventive Medicine Gender Studies Health Policy Multimorbidity Gender HIV Hypertension Chronic Kidney Disease Diabetes Sub-Saharan Africa Decision making Stigma Power Health seeking Figures Figure 1 Figure 2 Introduction Multimorbidity is the presence of two or more long term conditions in a person at the same time ( 1 , 2 ). The prevalence of multimorbidity is increasing in low- and middle- income countries (LMIC) ( 1 , 3 ), and is associated with increased healthcare utilization; increased costs; lower health-related quality of life; and increased mortality ( 2 , 4 ). Existing evidence suggests that women suffer from a higher burden of multimorbidity than men ( 5 , 6 ), possibly due to accumulation of conditions through increased life expectancy ( 7 ). However, there remains a paucity of data on the interaction between gender and multimorbidity in sub Saharan Africa (SSA) ( 8 , 9 ). Understanding the specific challenges faced by people living with multimorbidity (PLWMM), especially in SSA, is crucial to inform targeted healthcare policies and interventions. This study aims to understand gendered responses to experiences of living with multimorbidity in Malawi. Gender plays a critical role in shaping the experiences of individuals living with illness and accessing care ( 10 , 11 ). Critical gender theory examines how gender influences individual experiences and social roles, especially in relation to power dynamics and systems of inequality ( 12 ). Using this approach, gender is not seen as binary or static; but rather as fluid as it intersects with other identities (e.g. race, class, power) to form unique experiences of care, suffering, and survival for different individuals ( 13 ). The approach also seeks to understand how power structures (e.g. patriarchy, societal expectations of gender roles etc.) influence health; access to care; and emotional responses to illness ( 13 , 14 ). Some studies from SSA report that structural factors predominantly favour men, especially when it comes to economic power ( 15 – 17 ). Women, more often involved in informal unpaid work, experience increased vulnerability limiting their access to essential services and economic resources. Evidence suggests that greater autonomy among women enhances their ability to access healthcare, leading to higher utilization of services, particularly in general health care, reproductive health, and child health ( 18 , 19 ). Women of reproductive age frequently visit healthcare facilities for reproductive and child health services but often must navigate non-integrated systems, with associated inefficiencies and increased time burdens ( 20 , 21 ). Although the lack of integrated care may not reflect a gender bias in the conventional sense, it imposes an additional strain on women, exerting undue pressure on the already limited time and finances ( 21 ). Delayed care seeking is reported to relate to societal expectations for women who must attend to household and care responsibilities ( 22 ). Given these gendered disparities in healthcare access and disease burden, it is crucial to explore how male and females experience and navigate multimorbidity within this context. This study employs a qualitative approach, using in-depth interviews (IDIs) and focus group discussions (FGDs) with PLWMM and carers in Malawi. Through a critical gender lens, it examines how gender shapes lived experiences to provide critical insights to inform development of services that could enhance health-related quality of life for both men and women. Methods Study design We conducted a cross-sectional qualitative study using IDIs and FGDs, applying an iterative approach to data collection and analysis. Insights from early interviews and discussions were used to guide and refine subsequent sessions to enable a deeper understanding of issues. We collected demographic information including age, sex, marital status, education and self-reported conditions: diabetes (DM), hypertension (HTN), chronic kidney disease (CKD) and/or HIV. We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) ( 23 ) to compile and present our findings. The completed checklist is available as supplementary material (Table S1). Study setting We recruited PLWMM and their carers at Queen Elizabeth Central Hospital, Blantyre, and Chiradzulu District Hospital, Chiradzulu, Malawi. According to the World Bank’s Fiscal Year 2024 classification, Malawi is categorized as a lower-middle-income country (LMIC) ( 24 ). The country is experiencing rapid shifts in demographic and disease patterns, characterized by ageing populations and increasing prevalence of non-communicable diseases (NCDs) ( 25 ). Malawi suffers a critical shortage of health care workers and a strained health care system ( 24 , 26 ) similar to other countries in the SSA region. The number of physicians in the country was reported at 0.05 per 1,000 people in 2022 ( 27 ), highlighting the critical shortage in medical personnel. Further details of the facilities where recruitment took place can be found in our a priori published protocol ( 28 ) and report ( 26 ). Sampling and recruitment We purposively recruited PLWMM living with at least two of DM, HTN, HIV and/or CKD (and their carers). All patient participants had been enrolled into an overarching prospective cohort study designed to evaluate prevalence of multimorbidity in people admitted acutely to hospital in Malawi ( 28 ). Whilst there was also recruitment in Tanzania in this overarching study, this report focuses solely on Malawi. Research nurses approached cohort study participants at the point of hospital discharge for additional recruitment to our qualitative study as trusted intermediaries ( 29 ). Researchers for this sub-study had no prior relationships with participants. Patient inclusion criteria: aged ≥ 18; recently discharged alive from one of the two facilities; aware of their multimorbidity diagnosis (DM, HTN, HIV or CKD); capacity to participate in interviews or discussions (were not too acutely ill or debilitated); capable of providing informed consent; and resident within defined facility catchment areas of the two facilities. Carer inclusion criteria: aged ≥ 18 and provides regular care to a PLWMM recruited to the overarching multimorbidity cohort study. To enhance the diversity of insights, we intentionally chose not to pair patients with their carers in this study. Additionally, we categorized the data by participant age, gender, and disease combinations to enrich findings (see Table 1 ). Table 1 Demographic characteristics of PLWMM involved in IDIs Participant ID Sex Age Disease combinations 001 Male 56 HIV, Hypertension 002 Male 37 HIV, Hypertension 003 Male 44 Hypertension, Diabetes 004 Female 53 HIV, Hypertension, Diabetes 005 Female 40 HIV, Hypertension 006 Female 44 HIV, Hypertension 007 Female 50 HIV, Hypertension, Diabetes 008 Female 51 HIV, Hypertension 009 Female 50 HIV, CKD 010 Female 64 Hypertension, Diabetes 011 Female 69 Hypertension, Diabetes 012 Male 54 HIV, Hypertension 013 Male 26 HIV, Hypertension 015 Male 29 HIV, Hypertension, Diabetes 015 Male 57 Hypertension, Diabetes 016 Male 42 Hypertension, Diabetes, CKD Data collection SS, a female PhD student and social scientist with expertise in qualitative methods, facilitated and recorded the IDIs and FGDs. Data collection took place from January 2023 to October 2023, with interviews conducted at hospital discharge and repeated 90 days later. The 90-day interviews primarily occurred during planned visits to the admitting facility, except in 6 cases where patients or carers requested rescheduling, and follow-ups were therefore arranged at alternative times. We scheduled FGDs after hospital discharge and met within the hospital premises for the district facility and at a public school close to the tertiary facility. FGDs at the school took place after school hours or during school holidays. For FGDs, we recruited participants who were willing to participate in a group discussion; had not participated in IDIs; and lived within predefined facility catchment areas for both facilities ( 28 ). An organizational vehicle was made available to transport participants from (and to) predefined pick-up points if they preferred. We recruited 94 participants, included in 16 IDIs and 8 FGDs. We used data triangulation to leverage both individual and group-level insights to enhance our understanding ( 30 ). IDIs with patients and carers provided detailed insights into lived experiences, including those of patients too ill to participate in FGDs. FGDs facilitated dynamic discussions, to enable participants to share experiences and enhance their collective understanding of living with multimorbidity ( 30 ). Sessions were conducted until theoretical saturation was achieved. These themes included the experiences with gender norms and expectations, and how these dynamics influenced care-seeking behaviour, power distribution, decision-making, and treatment adherence. At the end of each session, the facilitator summarized the key issues and engaged participants to validate and refine interpretations of emerging themes, to ensure that findings accurately captured the gendered dimensions of living with multimorbidity. Only qualitative research facilitators were present during IDIs while research nurses also attended FGDs to support study logistics. Research nurse involvement helped establish familiarity and trust, crucial when recruiting vulnerable populations with complex health needs ( 31 ). This collaboration between researchers and nurses promoted transparency and empowered participants to make informed decisions about their involvement in the study. Data management and analysis All sessions were conducted in Chichewa, the most spoken local language in Malawi, recorded, transcribed verbatim, and anonymized before translation into English. Data analysis followed an interpretive thematic approach using NVivo 12 Pro, (QSR International, Melbourne, Australia, released 2023) underpinned by critical gender theory ( 32 ). This theoretical framework informed the exploration of how gendered power dynamics, social roles, and inequalities shape the experiences of living with multimorbidity. SS read 10 initial transcripts, recording impressions and generated initial codes focused on the experiences of living with multimorbidity. These were discussed with the team of supervisors, with the amended codes subsequently applied to the full dataset. First-order descriptive coding identified surface-level elements such as direct quotes and behaviours. Second-order pattern coding grouped related codes into themes such as impact of multimorbidity on functionality or gender-specific health concerns. Third-order thematic interpretation explored how these themes interacted with broader socio-cultural factors, such as perceptions of multimorbidity ( 33 ). SS coded all data. Positionality As an insider within the research team, SS was able to recognize the unique ways in which gender power relations manifested in that setting. However, insider status also posed a risk of bias due to potential acclimatisation to these issues and unintentional perception as routine, overlooking their significance. To counterbalance this, critical reviews of the raw data and feedback from study supervisors were essential to ensure the analysis remained objective and holistic. As a woman raised in the same context as participants, SS may have been more sensitive to gender power dynamics. Personal experiences with gender roles likely aided empathy with participants, especially women facing similar challenges. However, this could also have introduced bias, as experiences of gender inequality might have shaped interpretations, particularly around power dynamics. Additionally, gender may have influenced participant interaction, either encouraging or hindering open discussions and shaping how topics were approached. To further minimize bias, SS remained vigilant about these potential influences; consistently reflected on her role; and sought feedback from supervisors to ensure balanced interpretations. Ethics approval Ethical approval was obtained from LSTM (21–086) and College of Medicine Research and Ethics Committee (COMREC), Malawi (P.11/21/3462). We obtained written informed consent from all participants. Results Demographic data Of the 94 participants recruited in this qualitative study, 32 were enrolled to IDIs and 62 to FGDs. Of the IDIs, 16 were PLWMM, 16 were carers. The median age for PLWMM was 50 (IQR: 41–55). The youngest person living with multimorbidity was 26 while the oldest was 69. To ensure balanced representation of male and female participants, we conducted an equal number of initial IDIs among carers and PLWMM males (n = 8) and females (n = 8), and organized eight FGDs, divided equally by sex (four with males and four with females) (Figure S1). Of the eight FGDs, four included PLWMM and 4 included carers. We recruited 5–6 male participants and 9–10 female participants for each FGD as there were limited male participants available in from our cohort in both care-seeking and caregiving roles. The most common disease clusters were HIV and HTN (four males, three females), followed by DM and HTN (two males, two females). In total, four PLWMM had three conditions (two versus one male with HIV, HTN and DM) and one female with HTN, DM and CKD (see Fig. 2 A for males and 2B for females). Findings Emerging themes We present our findings under three themes: (i) perceptions of multimorbidity; (ii) gendered roles and care seeking; and (iii) decision-making regarding health seeking (Table 2 ). Table 2 Emerging themes Theme Sub themes Perceptions of multimorbidity • Impact of multimorbidity on functionality • Gender-specific health concerns • Gendered understanding and empathy • Women more likely to use external support networks Gendered roles and care seeking • Balancing caregiving and health-seeking roles for women • Informal caregiving presents an opportunity cost to care seeking • Emotional stress related to informal caregiving Decision making regarding health seeking • Masculinity norms and health seeking behaviour dominate decision making Gendered perceptions of multimorbidity We observed gendered perceptions of multimorbidity among PLWMM and their carers. Females more often associated hypertension comorbidity with feelings of depression. They also displayed a higher tolerance for the side effects of DM, prioritising their own health management while simultaneously shouldering the emotional burden of caregiving. In addition, they expressed concern over males feeling ashamed or burdened by their conditions, acknowledging both the physical and emotional toll alongside their role in providing support. “I feel bad when he feels sorry for himself because he cannot perform as a man. Look at him, they amputated one leg, why does he bother himself like that?” IDI 001 Carer Female. The inability to work and provide for their families due to physical weakness was a major concern for males with diabetes comorbidity, contributing to feelings of inadequacy, distress, and financial instability. This was compounded by sexual dysfunction, which further strained their emotional well-being. The fear of being unable to fulfil both economic and intimate roles led to deep anxieties about abandonment and self-worth. “The relationship between hypertension and diabetes is that sometimes you lose hope because you don’t do the work you used to do previously…. I don’t have the strength to work, I can’t provide for my family,” FGD 001 PLWMM Male. “Diabetes is dangerous; you may feel well like any healthy human, but it also has a downside, an insult…. You lose the intimate spark in bed. Imagine I just got married, she could divorce me, I wouldn’t even re-marry … I would not embarrass myself,” IDI 001 PLWMM Male. In the context of multimorbidity, gender played a significant role in self-management, especially with regards to complementary treatments and herbal remedies. Both males and females recognized the challenges of managing DM, including blood glucose monitoring, lifestyle changes, and insulin therapy. Both perceived DM as more potentially fatal than HTN due to its complexity, which influenced their management strategies. Both genders considered medical pluralism as helpful towards the control of blood sugar, blood pressure, or detoxing the body. However, female perceptions were shaped by their role as keepers of traditional knowledge; active participation in social networks; and limited financial and healthcare access while males were influenced by the impact of side effects of lived conditions. Limited physical ability was a more common driver among all males while and sexual health was more common among younger males in the early stages of multimorbidity. However, this tended to decline over time due to perceived reduced efficacy, changing health priorities, or the increasing reliance on medical treatments. Males were also driven by curiosity and openness to new technologies, associating these with progress and modernity. “We use herbs because our parents used the same,” FGD 002 PLWMM Female. “I used ‘gondolosi’ (an aphrodisiac plant) to control my sugar and give me a boost, but my sugar was still high, now, I just use hospital medicine now,” FGD PLWMM 003 Male. Older females often concealed their use of medical pluralism from healthcare providers for fear of reprisal, while older males viewed it as a private matter and chose not to disclose. Faced with information overload, younger males were more reluctant to use of complimentary treatments for multimorbidity. “ We think they are going to ask us why we go there yet we use herbs, ‘you think herbs help you, then why did you come here?’” IDI 002 Carer Female. “We don’t mention. We have many adverts these days…, sometimes you want to test if what they are saying is helpful…. this one cleanses the body, removes bad minerals etc.,” IDI 002 PLWMM Male. At the same time, males showed scepticism toward traditional remedies, questioning their effectiveness compared to biomedical treatments. “Let me not lie, I have gone through a lot, at the hospital, or traditional…. I have given up about traditional healers,” IDI 003 PLWMM Male. Unspoken depression: how gender shapes emotional distress and resilience in the experience of multimorbidity Females more openly acknowledged psychological distress compared to males. While participants did not explicitly label their experiences as depression, they expressed feelings of distress related to pain, reduced functionality, and the difficulties of managing multiple conditions. Women more particularly associated the accumulation of health issues with feelings of frustration, especially regarding their ability to manage personal relationships and caregiver responsibilities. Females verbalized their experiences more and displayed higher tolerance for distress than males. Males were less likely to openly disclose emotional distress, but their struggles often manifested through financial concerns and physical symptoms. Cultural norms of emotional restraint and strength pressured males to internalize their struggles as primary providers. “I know him, his blood pressure is usually high when he overthinks or borrows and owes people money. When he faints in these situations, I know the BP has caused that. But generally, I think diabetes is the major threat,” FGD 001 Carer Female. Acknowledging the toll of multimorbidity on their health, women continued to provide physical and emotional support to others, expressing concern about how their male counterparts might feel burdened or ashamed by their condition. Females displayed more resilience towards managing the impacts of multimorbidity, balancing their own health needs with the emotional burden of caregiving. “I accepted the responsibilities otherwise it would be tough. For example, I am a business lady, sometimes he is worse, sometimes I am sick. During the early days, I was discouraged and thought, ‘’Should I be going to the hospital again?’’ but later, I accepted it. When he is not well, I leave business, only God knows,” FGD 002 Carer Female. “I feel bad when he feels sorry for himself because he cannot perform as a man. Look at him, they amputated one leg, why does he bother himself like that? Please talk to him,” FGD 003 Carer Female. Social support played a crucial role in managing multimorbidity for PLWMM and their carers. While both genders relied on family support, females were more likely to seek external support to reduce perceptions of isolation and employed proactive coping strategies through peer and community networks than males. “We have a BP and sugar support group…. we test sugar by ourselves, then we document in the health passport books,” IDI 004 PLWMM Female. “… at the society level no, mostly it is us at home, but to find people coming around to visit us (men) is very rare and I was shocked when I met this guy that came around at home,” FGD 004 PLWMM Male. Gendered roles in care giving and care seeking Gender norms shaped caregiving roles and care-seeking behaviours, placing a disproportionate burden on females and impacting their self-management of multimorbidity. Females often cared for others while unwell, while males faced fewer caregiving expectations, leading to an unequal distribution of responsibilities. When men did not take on these duties, the burden frequently fell on other female family members “A woman looks after a man until he is well but when the woman is sick, not every man nurses a woman, they look for someone else to care for the female patient,” FGD 004 Carer Female. Informal caregiving was frequently cited as a barrier to health-seeking by female participants. Internalized expectations not only delayed healthcare seeking but also contributed to heightened stress to fulfil the traditional caregiving role. “When I was admitted, I was told my blood pressure was very high. I asked if I could go and take care of a child I had left in the care of a workmate whom I didn’t know very well. I was in so much pain so I couldn’t leave. They gave me painkillers and I felt better. I still wanted to go and take the child home first, but they insisted that I cannot go until I receive treatment. However, that was taking too long, so when I felt better, I just packed and left with the files. I picked her, went home…, the next day, I came back to the hospital with a guardian,” IDI 005 PLWMM Female. Decision making regarding health seeking behaviour Decision-making regarding health-seeking behaviours for multimorbidity among males and females reflected broader societal gender norms. For males, hesitation to seek care was often influenced by societal expectations of masculinity, which discouraged vulnerability and framed help-seeking as a sign of weakness. Some cultural norms around strength and self-reliance hindered timely access to care, leading men to delay treatment until their health issues became more severe. “I believe some men have knowledge, but others are stubborn or misinformed. So, they start looking for alternatives rather than going directly to a doctor to learn that it (diabetes) is manageable,” FGD 005 Carer Male. In contrast, females were more likely to seek validation from male family members before pursuing treatment seeking. This reliance on males for decision-making not only contributed to delayed access to care but also highlighted gendered dynamics within households and communities that affected female’s health-seeking behaviours. “The husband sat me down that if I won’t take my younger sister to the hospital, it won’t be good showing that the medicine that granny found in her body is not what working so that’s when we went to the hospital,” FGD 006 Carer female. “My father didn’t even mention that she was sick and just sleeping in the bedroom for days…, Later he allowed her to tell me. I picked her to go to the hospital,” FGD 007 Carer Female. Discussion This study examined gendered experiences to living with multimorbidity in Malawi, highlighting how gender roles, stigma, and power dynamics shape treatment-seeking and decision-making affect perceptions of multimorbidity. We found that gendered factors, alongside the emotional burden of stigma, vulnerability, and societal expectations, deeply influence health-related choices. We recommend interventions that seek to reshape gender norms while addressing perceptions of vulnerability, stigma, and societal expectations to drive meaningful change. Further work is required to understand how gender intersects with social determinants such as age, socio-economic status, and education to understand how these factors shape experiences for PLWMM, and their carers in SSA. Gendered power shifts had differential effects between males and females living with multimorbidity. Females bore the dual burden of caregiving and self-management, often prioritising others at the expense of their own well-being, leading to self-neglect and heightened emotional stress. Males, in contrast, faced financial insecurity and emotional distress due to declining physical functionality, which limited their ability to work, provide for their families, and maintain intimacy. Among females, strengthening female agency, financial independence, and social support may reduce caregiving burdens and promoting shared health responsibility ( 8 , 34 ). These findings highlight the need for targeted interventions that address the distinct psychosocial and economic challenges faced by both men and women living with multimorbidity ( 13 , 35 ). Challenging masculinity norms that discourage care-seeking improves the well-being of both males and females ( 36 ). Building on this, a systematic review of male health interventions in SSA found that many programs overlooked masculinity norms, limiting male engagement with healthcare ( 37 ). A study in Malawi found that reshaping masculinity norms to promote early care-seeking improved male access to TB treatment ( 38 ). Similarly, female financial independence strengthened their role in healthcare decision-making within household in Malawi ( 34 ), South Africa ( 8 ) and Kenya ( 35 ), leading to improved treatment utilization and health outcomes. These findings underscore the importance of integrating cultural perspectives and power dynamics into health interventions in SSA, ensuring that efforts to improve care-seeking behaviours are responsive to the structural and social determinants shaping gendered health decisions ( 39 ). Our study aligns with existing data that females continue to provide the bulk of informal care giving in SSA ( 40 ). Addressing female health-seeking behaviours among women living with multimorbidity requires recognising the cultural perspectives and power dynamics that shape their roles. Given female reliance on peer interactions for information and social support, innovative approaches such as structured peer groups ( 41 ) and mobile clinics ( 42 ) could bring healthcare and supportive networks closer to women, minimising their need to balance conflicting priorities. A community-based HIV testing campaign for NCDs in Uganda reached 74% of adult population in the area, 95% of the female population as compared with males (52%) ( 43 ). In Malawi, a study reported challenges related to care seeking for NCDs were minimised using community-based integrated service intervention ( 44 ). Evidence from Nigeria ( 45 ), South Africa ( 46 ) and Cameroon ( 47 ) indicate that depression is more prevalent among females than males. However, among males, depression is often linked to poor healthcare-seeking behaviours influenced by internalized masculine norms that discourage emotional vulnerability and help-seeking ( 48 , 49 ). Males, however, were reluctant to label their feelings as stress or depression, often reframing them as emotional distress due to internalised masculine norms that discourage emotional vulnerability. Male reluctance to express distress stemmed from fear of being perceived as weak, reinforcing gendered vulnerability in alignment with a recent systematic review ( 44 ). Studies report following traditional masculine norms increases males' risk of emotional distress while reducing help-seeking behaviour ( 50 ). Male reluctance to acknowledge depression may contribute to underdiagnosis and untreated cases, causing unnecessary suffering ( 51 ). Strengths and limitations One strength of the study is that we successfully recruited equal numbers of male and female patients in IDIs, allowing us to engage with both sexes and ensuring a balanced perspective. Again, the triangulation of methods for data collection allowed for cross-validation of findings and mitigation of limitations inherent in any single approach while an iterative approach enabled refinement of data collection, improving depth and accuracy of findings ( 52 ). Some limitations to this study: we could not recruit equal numbers of males in FGDs. Again, we only included patients admitted to hospital at tertiary and district facilities. This group may have unique habits and experiences related to living with multimorbidity, which may not be representative of the broader population, including patients and carers at the community level. Critical gender theory was not used in tool development but was applied during analysis to interpret gendered experiences, allowing themes to emerge naturally. This improved validity, though earlier integration could have provided more structure. However, the insights and opportunities derived from this study can still be applied to other settings in Malawi and SSA where similar cultural and health system contexts exist. Conclusion We have demonstrated that gender plays a significant role in how individuals in Malawi experience living with multimorbidity. Care-seeking and decision-making are rooted in complex gendered roles, with women often prioritising care giving responsibilities over their own health, which affects their access to timely and care. Masculinity norms impact men, who are less likely to acknowledge the emotional toll of multimorbidity, even though they too are affected by depression. To improve the management of multimorbidity among PLWMM, interventions must address perceptions of vulnerability, stigma, and societal expectations to drive meaningful change. Declarations All participants provided informed consent to participate in the study, including consent for the publication of anonymized quotes as part of dissemination. Competing interests The authors have no competing interests. Acknowledgements The lead author would like to express our gratitude to patients and carers who shared with us information about their personal lives and experiences. Funding This research was funded by the NIHR (NIHR201708) using UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. Stephen A. Spencer was supported by a Wellcome Trust Clinical PhD Fellowship (Grant number 203919/Z/16/Z). Deborah Nyirenda is funded by the Global Health Bioethics Network, a Wellcome Strategic Award (228141/Z/23/Z). Author contributions Conceptualization: Sangwani Nkhana-Salimu, Ben Morton, Deborah Nyirenda, Nicola Desmond Data collection: Sangwani Nkhana-Salimu, Alice Rutta, Martha Oshoseny Formal analysis: Sangwani Salimu Funding acquisition: Ben Morton, Adamson Muula, Augustine Choko, Miriam Taegtmeyer, Matthew Rubach, Charity Salima, Mulinda Nyirenda, Sarah White, Paul Dark, Felix Limbani, Eve Worrall, Jamie Rylance Supervision: Ben Morton, Deborah Nyirenda, Nicola Desmond Writing : original draft: Sangwani Salimu Review & editing: Stephen A Spencer, Treighcy Gift Banda, Gimbo Hyuha, Alice Rutta, Martha Oshoseny, Augustine Choko, Julian T. Hertz, Blandina T. Mmbaga, Juma Mfinanga, Rhona Mijumbi, Laura Rosu, Francis Sakita, Charity Salima, Hendry Sawe, Ibrahim Simiyu, Miriam Taegtmeyer, Sarah Urasa, Nateiya M. Yongolo, Adamson Muula, Augustine Choko, Matthew Rubach, Charity Salima, Mulinda Nyirenda, Sarah White, Paul Dark Jamie Rylance, Eve Worrall, Felix Limbani, Nicola Desmond, Deborah Nyirenda, Ben Morton. Data availability statement The data set used and analysed during this study is available from the corresponding author on reasonable request. Please contact Sangwani Salimu, [email protected] . References Asogwa OA, Boateng D, Marzà-Florensa A, Peters S, Levitt N, van Olmen J, et al. Multimorbidity of non-communicable diseases in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open. 2022;12(1):e049133. World Health Organization. Multimorbidity: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Report No.: Licence: CC BY-NC-SA 3.0 IGO. Basto-Abreu A, Barrientos-Gutierrez T, Wade AN, Oliveira de Melo D, Semeão de Souza AS, Nunes BP, et al. Multimorbidity matters in low and middle-income countries. 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Chikovore J, Hart G, Kumwenda M, Chipungu GA, Desmond N, Corbett L. Control, struggle, and emergent masculinities: a qualitative study of men’s care-seeking determinants for chronic cough and tuberculosis symptoms in Blantyre, Malawi. BMC Public Health. 2014;14(1):1053. Desmond N. Engaging with risk in non-Western settings: an editorial. Health, Risk & Society. 2015;17:1-9. van Pinxteren M, Slome C, Mair FS, May CR, Levitt NS. Exploring the workload of informal caregiving in the context of HIV/NCD multimorbidity in South Africa. PLOS Global Public Health. 2024;4(10):e0003782. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: A systematic review of the literature. Ageing Research Reviews. 2011;10(4):430-9. García-Morales C, Heredia-Pi I, Guerrero-López CM, Orozco E, Ojeda-Arroyo E, Nigenda G, et al. Social and economic impacts of non-communicable diseases by gender and its correlates: a literature review. International Journal for Equity in Health. 2024;23(1):274. Njuguna B, Vorkoper S, Patel P, Reid MJA, Vedanthan R, Pfaff C, et al. Models of integration of HIV and noncommunicable disease care in sub-Saharan Africa: lessons learned and evidence gaps. Aids. 2018;32 Suppl 1(Suppl 1):S33-s42. Wroe EB, Kalanga N, Mailosi B, Mwalwanda S, Kachimanga C, Nyangulu K, et al. Leveraging HIV platforms to work toward comprehensive primary care in rural Malawi: the Integrated Chronic Care Clinic. Healthc (Amst). 2015;3(4):270-6. Amoran O, Lawoyin T, Lasebikan V. Prevalence of depression among adults in Oyo State, Nigeria: A comparative study of rural and urban communities. Australian Journal of Rural Health. 2007;15(3):211-5. Tomlinson M, Grimsrud AT, Stein DJ, Williams DR, Myer L. The epidemiology of major depression in South Africa: results from the South African stress and health study. S Afr Med J. 2009;99(5 Pt 2):367-73. Gaynes BN, Pence BW, Atashili J, O'Donnell J, Kats D, Ndumbe PM. Prevalence and predictors of major depression in HIV-infected patients on antiretroviral therapy in Bamenda, a semi-urban center in Cameroon. PLoS One. 2012;7(7):e41699. Herreen D, Rice S, Currier D, Schlichthorst M, Zajac I. Associations between conformity to masculine norms and depression: age effects from a population study of Australian men. BMC Psychology. 2021;9(1):32. Oliffe JL, Kelly MT, Bottorff JL, Johnson JL, Wong ST. "He’s more typically female because he’s not afraid to cry": Connecting heterosexual gender relations and men’s depression. Social Science & Medicine. 2011;73(5):775-82. Good GE, Wood PK. Male gender role conflict, depression, and help seeking: Do college men face double jeopardy? Journal of Counseling & Development. 1995;74(1):70-5. Seidler ZE, Dawes AJ, Rice SM, Oliffe JL, Dhillon HM. The role of masculinity in men's help-seeking for depression: A systematic review. Clinical Psychology Review. 2016;49:106-18. Shenton A. Strategies for Ensuring Trustworthiness in Qualitative Research Projects. Education for Information. 2004;22:63-75. Additional Declarations The authors declare no competing interests. Supplementary Files TableS1COREQChecklistGenderandmultimorbidity.docx FigureS1Summaryofrecruitment.pptx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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16:33:44","extension":"pptx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":54141,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS1Summaryofrecruitment.pptx","url":"https://assets-eu.researchsquare.com/files/rs-7231827/v1/e7c108b42a5ec0cbcc43bb7e.pptx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eGender differences in response to living with multimorbidity in Malawi\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMultimorbidity is the presence of two or more long term conditions in a person at the same time (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The prevalence of multimorbidity is increasing in low- and middle- income countries (LMIC) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and is associated with increased healthcare utilization; increased costs; lower health-related quality of life; and increased mortality (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Existing evidence suggests that women suffer from a higher burden of multimorbidity than men (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), possibly due to accumulation of conditions through increased life expectancy (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, there remains a paucity of data on the interaction between gender and multimorbidity in sub Saharan Africa (SSA) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Understanding the specific challenges faced by people living with multimorbidity (PLWMM), especially in SSA, is crucial to inform targeted healthcare policies and interventions. This study aims to understand gendered responses to experiences of living with multimorbidity in Malawi.\u003c/p\u003e\u003cp\u003eGender plays a critical role in shaping the experiences of individuals living with illness and accessing care (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Critical gender theory examines how gender influences individual experiences and social roles, especially in relation to power dynamics and systems of inequality (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Using this approach, gender is not seen as binary or static; but rather as fluid as it intersects with other identities (e.g. race, class, power) to form unique experiences of care, suffering, and survival for different individuals (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The approach also seeks to understand how power structures (e.g. patriarchy, societal expectations of gender roles etc.) influence health; access to care; and emotional responses to illness (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Some studies from SSA report that structural factors predominantly favour men, especially when it comes to economic power (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e–\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Women, more often involved in informal unpaid work, experience increased vulnerability limiting their access to essential services and economic resources. Evidence suggests that greater autonomy among women enhances their ability to access healthcare, leading to higher utilization of services, particularly in general health care, reproductive health, and child health (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Women of reproductive age frequently visit healthcare facilities for reproductive and child health services but often must navigate non-integrated systems, with associated inefficiencies and increased time burdens (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Although the lack of integrated care may not reflect a gender bias in the conventional sense, it imposes an additional strain on women, exerting undue pressure on the already limited time and finances (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Delayed care seeking is reported to relate to societal expectations for women who must attend to household and care responsibilities (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGiven these gendered disparities in healthcare access and disease burden, it is crucial to explore how male and females experience and navigate multimorbidity within this context. This study employs a qualitative approach, using in-depth interviews (IDIs) and focus group discussions (FGDs) with PLWMM and carers in Malawi. Through a critical gender lens, it examines how gender shapes lived experiences to provide critical insights to inform development of services that could enhance health-related quality of life for both men and women.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a cross-sectional qualitative study using IDIs and FGDs, applying an iterative approach to data collection and analysis. Insights from early interviews and discussions were used to guide and refine subsequent sessions to enable a deeper understanding of issues. We collected demographic information including age, sex, marital status, education and self-reported conditions: diabetes (DM), hypertension (HTN), chronic kidney disease (CKD) and/or HIV. We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) to compile and present our findings. The completed checklist is available as supplementary material (Table S1).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe recruited PLWMM and their carers at Queen Elizabeth Central Hospital, Blantyre, and Chiradzulu District Hospital, Chiradzulu, Malawi. According to the World Bank’s Fiscal Year 2024 classification, Malawi is categorized as a lower-middle-income country (LMIC) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The country is experiencing rapid shifts in demographic and disease patterns, characterized by ageing populations and increasing prevalence of non-communicable diseases (NCDs) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Malawi suffers a critical shortage of health care workers and a strained health care system (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) similar to other countries in the SSA region. The number of physicians in the country was reported at 0.05 per 1,000 people in 2022 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), highlighting the critical shortage in medical personnel. Further details of the facilities where recruitment took place can be found in our a priori published protocol (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and report (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eSampling and recruitment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe purposively recruited PLWMM living with at least two of DM, HTN, HIV and/or CKD (and their carers). All patient participants had been enrolled into an overarching prospective cohort study designed to evaluate prevalence of multimorbidity in people admitted acutely to hospital in Malawi (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Whilst there was also recruitment in Tanzania in this overarching study, this report focuses solely on Malawi. Research nurses approached cohort study participants at the point of hospital discharge for additional recruitment to our qualitative study as trusted intermediaries (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Researchers for this sub-study had no prior relationships with participants. Patient inclusion criteria: aged ≥ 18; recently discharged alive from one of the two facilities; aware of their multimorbidity diagnosis (DM, HTN, HIV or CKD); capacity to participate in interviews or discussions (were not too acutely ill or debilitated); capable of providing informed consent; and resident within defined facility catchment areas of the two facilities. Carer inclusion criteria: aged ≥ 18 and provides regular care to a PLWMM recruited to the overarching multimorbidity cohort study. To enhance the diversity of insights, we intentionally chose not to pair patients with their carers in this study. Additionally, we categorized the data by participant age, gender, and disease combinations to enrich findings (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of PLWMM involved in IDIs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant ID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDisease combinations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHypertension, Diabetes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension, Diabetes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension, Diabetes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, CKD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHypertension, Diabetes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHypertension, Diabetes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV, Hypertension, Diabetes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHypertension, Diabetes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHypertension, Diabetes, CKD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSS, a female PhD student and social scientist with expertise in qualitative methods, facilitated and recorded the IDIs and FGDs. Data collection took place from January 2023 to October 2023, with interviews conducted at hospital discharge and repeated 90 days later. The 90-day interviews primarily occurred during planned visits to the admitting facility, except in 6 cases where patients or carers requested rescheduling, and follow-ups were therefore arranged at alternative times. We scheduled FGDs after hospital discharge and met within the hospital premises for the district facility and at a public school close to the tertiary facility. FGDs at the school took place after school hours or during school holidays. For FGDs, we recruited participants who were willing to participate in a group discussion; had not participated in IDIs; and lived within predefined facility catchment areas for both facilities (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). An organizational vehicle was made available to transport participants from (and to) predefined pick-up points if they preferred. We recruited 94 participants, included in 16 IDIs and 8 FGDs. We used data triangulation to leverage both individual and group-level insights to enhance our understanding (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). IDIs with patients and carers provided detailed insights into lived experiences, including those of patients too ill to participate in FGDs. FGDs facilitated dynamic discussions, to enable participants to share experiences and enhance their collective understanding of living with multimorbidity (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Sessions were conducted until theoretical saturation was achieved. These themes included the experiences with gender norms and expectations, and how these dynamics influenced care-seeking behaviour, power distribution, decision-making, and treatment adherence. At the end of each session, the facilitator summarized the key issues and engaged participants to validate and refine interpretations of emerging themes, to ensure that findings accurately captured the gendered dimensions of living with multimorbidity. Only qualitative research facilitators were present during IDIs while research nurses also attended FGDs to support study logistics. Research nurse involvement helped establish familiarity and trust, crucial when recruiting vulnerable populations with complex health needs (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This collaboration between researchers and nurses promoted transparency and empowered participants to make informed decisions about their involvement in the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData management and analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll sessions were conducted in Chichewa, the most spoken local language in Malawi, recorded, transcribed verbatim, and anonymized before translation into English. Data analysis followed an interpretive thematic approach using NVivo 12 Pro, (QSR International, Melbourne, Australia, released 2023) underpinned by critical gender theory (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This theoretical framework informed the exploration of how gendered power dynamics, social roles, and inequalities shape the experiences of living with multimorbidity. SS read 10 initial transcripts, recording impressions and generated initial codes focused on the experiences of living with multimorbidity. These were discussed with the team of supervisors, with the amended codes subsequently applied to the full dataset. First-order descriptive coding identified surface-level elements such as direct quotes and behaviours. Second-order pattern coding grouped related codes into themes such as impact of multimorbidity on functionality or gender-specific health concerns. Third-order thematic interpretation explored how these themes interacted with broader socio-cultural factors, such as perceptions of multimorbidity (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). SS coded all data.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositionality\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs an insider within the research team, SS was able to recognize the unique ways in which gender power relations manifested in that setting. However, insider status also posed a risk of bias due to potential acclimatisation to these issues and unintentional perception as routine, overlooking their significance. To counterbalance this, critical reviews of the raw data and feedback from study supervisors were essential to ensure the analysis remained objective and holistic.\u003c/p\u003e\u003cp\u003eAs a woman raised in the same context as participants, SS may have been more sensitive to gender power dynamics. Personal experiences with gender roles likely aided empathy with participants, especially women facing similar challenges. However, this could also have introduced bias, as experiences of gender inequality might have shaped interpretations, particularly around power dynamics. Additionally, gender may have influenced participant interaction, either encouraging or hindering open discussions and shaping how topics were approached. To further minimize bias, SS remained vigilant about these potential influences; consistently reflected on her role; and sought feedback from supervisors to ensure balanced interpretations.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e Ethical approval was obtained from LSTM (21–086) and College of Medicine Research and Ethics Committee (COMREC), Malawi (P.11/21/3462). We obtained written informed consent from all participants.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eDemographic data\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOf the 94 participants recruited in this qualitative study, 32 were enrolled to IDIs and 62 to FGDs. Of the IDIs, 16 were PLWMM, 16 were carers. The median age for PLWMM was 50 (IQR: 41\u0026ndash;55). The youngest person living with multimorbidity was 26 while the oldest was 69. To ensure balanced representation of male and female participants, we conducted an equal number of initial IDIs among carers and PLWMM males (n\u0026thinsp;=\u0026thinsp;8) and females (n\u0026thinsp;=\u0026thinsp;8), and organized eight FGDs, divided equally by sex (four with males and four with females) (Figure S1). Of the eight FGDs, four included PLWMM and 4 included carers. We recruited 5\u0026ndash;6 male participants and 9\u0026ndash;10 female participants for each FGD as there were limited male participants available in from our cohort in both care-seeking and caregiving roles. The most common disease clusters were HIV and HTN (four males, three females), followed by DM and HTN (two males, two females). In total, four PLWMM had three conditions (two versus one male with HIV, HTN and DM) and one female with HTN, DM and CKD (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003eA for males and 2B for females).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFindings\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eEmerging themes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe present our findings under three themes: (i) perceptions of multimorbidity; (ii) gendered roles and care seeking; and (iii) decision-making regarding health seeking (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEmerging themes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub themes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceptions of multimorbidity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Impact of multimorbidity on functionality\u003c/p\u003e\u003cp\u003e\u0026bull; Gender-specific health concerns\u003c/p\u003e\u003cp\u003e\u0026bull; Gendered understanding and empathy\u003c/p\u003e\u003cp\u003e\u0026bull; Women more likely to use external support networks\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGendered roles and care seeking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Balancing caregiving and health-seeking roles for women\u003c/p\u003e\u003cp\u003e\u0026bull; Informal caregiving presents an opportunity cost to care seeking\u003c/p\u003e\u003cp\u003e\u0026bull; Emotional stress related to informal caregiving\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecision making regarding health seeking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Masculinity norms and health seeking behaviour dominate decision making\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eGendered perceptions of multimorbidity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe observed gendered perceptions of multimorbidity among PLWMM and their carers. Females more often associated hypertension comorbidity with feelings of depression. They also displayed a higher tolerance for the side effects of DM, prioritising their own health management while simultaneously shouldering the emotional burden of caregiving. In addition, they expressed concern over males feeling ashamed or burdened by their conditions, acknowledging both the physical and emotional toll alongside their role in providing support.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel bad when he feels sorry for himself because he cannot perform as a man. Look at him, they amputated one leg, why does he bother himself like that?\u0026rdquo;\u003c/em\u003e IDI 001 Carer Female.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe inability to work and provide for their families due to physical weakness was a major concern for males with diabetes comorbidity, contributing to feelings of inadequacy, distress, and financial instability. This was compounded by sexual dysfunction, which further strained their emotional well-being. The fear of being unable to fulfil both economic and intimate roles led to deep anxieties about abandonment and self-worth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The relationship between hypertension and diabetes is that sometimes you lose hope because you don\u0026rsquo;t do the work you used to do previously\u0026hellip;. I don\u0026rsquo;t have the strength to work, I can\u0026rsquo;t provide for my family,\u0026rdquo;\u003c/em\u003e FGD 001 PLWMM Male.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Diabetes is dangerous; you may feel well like any healthy human, but it also has a downside, an insult\u0026hellip;. You lose the intimate spark in bed. Imagine I just got married, she could divorce me, I wouldn\u0026rsquo;t even re-marry \u0026hellip; I would not embarrass myself,\u0026rdquo;\u003c/em\u003e IDI 001 PLWMM Male.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn the context of multimorbidity, gender played a significant role in self-management, especially with regards to complementary treatments and herbal remedies. Both males and females recognized the challenges of managing DM, including blood glucose monitoring, lifestyle changes, and insulin therapy. Both perceived DM as more potentially fatal than HTN due to its complexity, which influenced their management strategies. Both genders considered medical pluralism as helpful towards the control of blood sugar, blood pressure, or detoxing the body. However, female perceptions were shaped by their role as keepers of traditional knowledge; active participation in social networks; and limited financial and healthcare access while males were influenced by the impact of side effects of lived conditions. Limited physical ability was a more common driver among all males while and sexual health was more common among younger males in the early stages of multimorbidity. However, this tended to decline over time due to perceived reduced efficacy, changing health priorities, or the increasing reliance on medical treatments. Males were also driven by curiosity and openness to new technologies, associating these with progress and modernity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We use herbs because our parents used the same,\u0026rdquo;\u003c/em\u003e FGD 002 PLWMM Female.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I used \u0026lsquo;gondolosi\u0026rsquo;\u003c/em\u003e (an aphrodisiac plant) \u003cem\u003eto control my sugar and give me a boost, but my sugar was still high, now, I just use hospital medicine now,\u0026rdquo;\u003c/em\u003e FGD PLWMM 003 Male.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOlder females often concealed their use of medical pluralism from healthcare providers for fear of reprisal, while older males viewed it as a private matter and chose not to disclose. Faced with information overload, younger males were more reluctant to use of complimentary treatments for multimorbidity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWe think they are going to ask us why we go there yet we use herbs, \u0026lsquo;you think herbs help you, then why did you come here?\u0026rsquo;\u0026rdquo;\u003c/em\u003e IDI 002 Carer Female.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t mention. We have many adverts these days\u0026hellip;, sometimes you want to test if what they are saying is helpful\u0026hellip;. this one cleanses the body, removes bad minerals etc.,\u0026rdquo;\u003c/em\u003e IDI 002 PLWMM Male.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAt the same time, males showed scepticism toward traditional remedies, questioning their effectiveness compared to biomedical treatments.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Let me not lie, I have gone through a lot, at the hospital, or traditional\u0026hellip;. I have given up about traditional healers,\u0026rdquo;\u003c/em\u003e IDI 003 PLWMM Male.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnspoken depression: how gender shapes emotional distress and resilience in the experience of multimorbidity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFemales more openly acknowledged psychological distress compared to males. While participants did not explicitly label their experiences as depression, they expressed feelings of distress related to pain, reduced functionality, and the difficulties of managing multiple conditions. Women more particularly associated the accumulation of health issues with feelings of frustration, especially regarding their ability to manage personal relationships and caregiver responsibilities. Females verbalized their experiences more and displayed higher tolerance for distress than males. Males were less likely to openly disclose emotional distress, but their struggles often manifested through financial concerns and physical symptoms. Cultural norms of emotional restraint and strength pressured males to internalize their struggles as primary providers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I know him, his blood pressure is usually high when he overthinks or borrows and owes people money. When he faints in these situations, I know the BP has caused that. But generally, I think diabetes is the major threat,\u0026rdquo;\u003c/em\u003e FGD 001 Carer Female.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAcknowledging the toll of multimorbidity on their health, women continued to provide physical and emotional support to others, expressing concern about how their male counterparts might feel burdened or ashamed by their condition. Females displayed more resilience towards managing the impacts of multimorbidity, balancing their own health needs with the emotional burden of caregiving.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I accepted the responsibilities otherwise it would be tough. For example, I am a business lady, sometimes he is worse, sometimes I am sick. During the early days, I was discouraged and thought, \u0026lsquo;\u0026rsquo;Should I be going to the hospital again?\u0026rsquo;\u0026rsquo; but later, I accepted it. When he is not well, I leave business, only God knows,\u0026rdquo;\u003c/em\u003e FGD 002 Carer Female.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel bad when he feels sorry for himself because he cannot perform as a man. Look at him, they amputated one leg, why does he bother himself like that? Please talk to him,\u0026rdquo;\u003c/em\u003e FGD 003 Carer Female.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSocial support played a crucial role in managing multimorbidity for PLWMM and their carers. While both genders relied on family support, females were more likely to seek external support to reduce perceptions of isolation and employed proactive coping strategies through peer and community networks than males.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We have a BP and sugar support group\u0026hellip;. we test sugar by ourselves, then we document in the health passport books,\u0026rdquo;\u003c/em\u003e IDI 004 PLWMM Female.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; at the society level no, mostly it is us at home, but to find people coming around to visit us (men) is very rare and I was shocked when I met this guy that came around at home,\u0026rdquo;\u003c/em\u003e FGD 004 PLWMM Male.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eGendered roles in care giving and care seeking\u003c/b\u003e\u003c/p\u003e\u003cp\u003eGender norms shaped caregiving roles and care-seeking behaviours, placing a disproportionate burden on females and impacting their self-management of multimorbidity. Females often cared for others while unwell, while males faced fewer caregiving expectations, leading to an unequal distribution of responsibilities. When men did not take on these duties, the burden frequently fell on other female family members\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A woman looks after a man until he is well but when the woman is sick, not every man nurses a woman, they look for someone else to care for the female patient,\u0026rdquo;\u003c/em\u003e FGD 004 Carer Female.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eInformal caregiving was frequently cited as a barrier to health-seeking by female participants. Internalized expectations not only delayed healthcare seeking but also contributed to heightened stress to fulfil the traditional caregiving role.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I was admitted, I was told my blood pressure was very high. I asked if I could go and take care of a child I had left in the care of a workmate whom I didn\u0026rsquo;t know very well. I was in so much pain so I couldn\u0026rsquo;t leave. They gave me painkillers and I felt better. I still wanted to go and take the child home first, but they insisted that I cannot go until I receive treatment. However, that was taking too long, so when I felt better, I just packed and left with the files. I picked her, went home\u0026hellip;, the next day, I came back to the hospital with a guardian,\u0026rdquo;\u003c/em\u003e IDI 005 PLWMM Female.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDecision making regarding health seeking behaviour\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDecision-making regarding health-seeking behaviours for multimorbidity among males and females reflected broader societal gender norms. For males, hesitation to seek care was often influenced by societal expectations of masculinity, which discouraged vulnerability and framed help-seeking as a sign of weakness. Some cultural norms around strength and self-reliance hindered timely access to care, leading men to delay treatment until their health issues became more severe.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe some men have knowledge, but others are stubborn or misinformed. So, they start looking for alternatives rather than going directly to a doctor to learn that it\u003c/em\u003e (diabetes) \u003cem\u003eis manageable,\u0026rdquo;\u003c/em\u003e FGD 005 Carer Male.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn contrast, females were more likely to seek validation from male family members before pursuing treatment seeking. This reliance on males for decision-making not only contributed to delayed access to care but also highlighted gendered dynamics within households and communities that affected female\u0026rsquo;s health-seeking behaviours.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The husband sat me down that if I won\u0026rsquo;t take my younger sister to the hospital, it won\u0026rsquo;t be good showing that the medicine that granny found in her body is not what working so that\u0026rsquo;s when we went to the hospital,\u0026rdquo;\u003c/em\u003e FGD 006 Carer female.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My father didn\u0026rsquo;t even mention that she was sick and just sleeping in the bedroom for days\u0026hellip;, Later he allowed her to tell me. I picked her to go to the hospital,\u0026rdquo;\u003c/em\u003e FGD 007 Carer Female.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined gendered experiences to living with multimorbidity in Malawi, highlighting how gender roles, stigma, and power dynamics shape treatment-seeking and decision-making affect perceptions of multimorbidity. We found that gendered factors, alongside the emotional burden of stigma, vulnerability, and societal expectations, deeply influence health-related choices. We recommend interventions that seek to reshape gender norms while addressing perceptions of vulnerability, stigma, and societal expectations to drive meaningful change. Further work is required to understand how gender intersects with social determinants such as age, socio-economic status, and education to understand how these factors shape experiences for PLWMM, and their carers in SSA.\u003c/p\u003e\u003cp\u003eGendered power shifts had differential effects between males and females living with multimorbidity. Females bore the dual burden of caregiving and self-management, often prioritising others at the expense of their own well-being, leading to self-neglect and heightened emotional stress. Males, in contrast, faced financial insecurity and emotional distress due to declining physical functionality, which limited their ability to work, provide for their families, and maintain intimacy. Among females, strengthening female agency, financial independence, and social support may reduce caregiving burdens and promoting shared health responsibility (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). These findings highlight the need for targeted interventions that address the distinct psychosocial and economic challenges faced by both men and women living with multimorbidity (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eChallenging masculinity norms that discourage care-seeking improves the well-being of both males and females (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Building on this, a systematic review of male health interventions in SSA found that many programs overlooked masculinity norms, limiting male engagement with healthcare (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). A study in Malawi found that reshaping masculinity norms to promote early care-seeking improved male access to TB treatment (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Similarly, female financial independence strengthened their role in healthcare decision-making within household in Malawi (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), South Africa (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and Kenya (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), leading to improved treatment utilization and health outcomes. These findings underscore the importance of integrating cultural perspectives and power dynamics into health interventions in SSA, ensuring that efforts to improve care-seeking behaviours are responsive to the structural and social determinants shaping gendered health decisions (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur study aligns with existing data that females continue to provide the bulk of informal care giving in SSA (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Addressing female health-seeking behaviours among women living with multimorbidity requires recognising the cultural perspectives and power dynamics that shape their roles. Given female reliance on peer interactions for information and social support, innovative approaches such as structured peer groups (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) and mobile clinics (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) could bring healthcare and supportive networks closer to women, minimising their need to balance conflicting priorities. A community-based HIV testing campaign for NCDs in Uganda reached 74% of adult population in the area, 95% of the female population as compared with males (52%) (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). In Malawi, a study reported challenges related to care seeking for NCDs were minimised using community-based integrated service intervention (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEvidence from Nigeria (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), South Africa (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) and Cameroon (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) indicate that depression is more prevalent among females than males. However, among males, depression is often linked to poor healthcare-seeking behaviours influenced by internalized masculine norms that discourage emotional vulnerability and help-seeking (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Males, however, were reluctant to label their feelings as stress or depression, often reframing them as emotional distress due to internalised masculine norms that discourage emotional vulnerability. Male reluctance to express distress stemmed from fear of being perceived as weak, reinforcing gendered vulnerability in alignment with a recent systematic review (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Studies report following traditional masculine norms increases males' risk of emotional distress while reducing help-seeking behaviour (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Male reluctance to acknowledge depression may contribute to underdiagnosis and untreated cases, causing unnecessary suffering (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne strength of the study is that we successfully recruited equal numbers of male and female patients in IDIs, allowing us to engage with both sexes and ensuring a balanced perspective. Again, the triangulation of methods for data collection allowed for cross-validation of findings and mitigation of limitations inherent in any single approach while an iterative approach enabled refinement of data collection, improving depth and accuracy of findings (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Some limitations to this study: we could not recruit equal numbers of males in FGDs. Again, we only included patients admitted to hospital at tertiary and district facilities. This group may have unique habits and experiences related to living with multimorbidity, which may not be representative of the broader population, including patients and carers at the community level. Critical gender theory was not used in tool development but was applied during analysis to interpret gendered experiences, allowing themes to emerge naturally. This improved validity, though earlier integration could have provided more structure. However, the insights and opportunities derived from this study can still be applied to other settings in Malawi and SSA where similar cultural and health system contexts exist.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe have demonstrated that gender plays a significant role in how individuals in Malawi experience living with multimorbidity. Care-seeking and decision-making are rooted in complex gendered roles, with women often prioritising care giving responsibilities over their own health, which affects their access to timely and care. Masculinity norms impact men, who are less likely to acknowledge the emotional toll of multimorbidity, even though they too are affected by depression. To improve the management of multimorbidity among PLWMM, interventions must address perceptions of vulnerability, stigma, and societal expectations to drive meaningful change.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAll participants provided informed consent to participate in the study, including consent for the publication of anonymized quotes as part of dissemination.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe lead author would like to express our gratitude to patients and carers who shared with us information about their personal lives and experiences.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the NIHR (NIHR201708) using UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. Stephen A. Spencer was supported by a Wellcome Trust Clinical PhD Fellowship (Grant number 203919/Z/16/Z). Deborah Nyirenda is funded by the Global Health Bioethics Network, a Wellcome Strategic Award (228141/Z/23/Z).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization:\u003c/strong\u003e Sangwani Nkhana-Salimu, Ben Morton, Deborah Nyirenda, Nicola Desmond\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection:\u003c/strong\u003e Sangwani Nkhana-Salimu, Alice Rutta, Martha Oshoseny\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFormal analysis:\u003c/strong\u003e Sangwani Salimu\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding acquisition:\u003c/strong\u003e Ben Morton, Adamson Muula, Augustine Choko, Miriam Taegtmeyer, Matthew Rubach, Charity Salima, Mulinda Nyirenda, Sarah White, Paul Dark, Felix Limbani, Eve Worrall, Jamie Rylance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupervision:\u003c/strong\u003e Ben Morton, Deborah Nyirenda, Nicola Desmond\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWriting\u003c/strong\u003e: original draft: Sangwani Salimu\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReview \u0026amp; editing:\u003c/strong\u003e Stephen A Spencer, Treighcy Gift Banda, Gimbo Hyuha, Alice Rutta, Martha Oshoseny, Augustine Choko, Julian T. Hertz, Blandina T. Mmbaga, Juma Mfinanga, Rhona Mijumbi, Laura Rosu, Francis Sakita, Charity Salima, Hendry Sawe, Ibrahim Simiyu, Miriam Taegtmeyer, Sarah Urasa, Nateiya M. Yongolo, Adamson Muula, Augustine Choko, Matthew Rubach, Charity Salima, Mulinda Nyirenda, Sarah White, Paul Dark Jamie Rylance, Eve Worrall, Felix Limbani, Nicola Desmond, Deborah Nyirenda, Ben Morton.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data set used and analysed during this study is available from the corresponding author on reasonable request. Please contact Sangwani Salimu, [email protected]. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAsogwa OA, Boateng D, Marz\u0026agrave;-Florensa A, Peters S, Levitt N, van Olmen J, et al. Multimorbidity of non-communicable diseases in low-income and middle-income countries: a systematic review and meta-analysis. 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Associations between conformity to masculine norms and depression: age effects from a population study of Australian men. BMC Psychology. 2021;9(1):32.\u003c/li\u003e\n\u003cli\u003eOliffe JL, Kelly MT, Bottorff JL, Johnson JL, Wong ST. \u0026quot;He\u0026rsquo;s more typically female because he\u0026rsquo;s not afraid to cry\u0026quot;: Connecting heterosexual gender relations and men\u0026rsquo;s depression. Social Science \u0026amp; Medicine. 2011;73(5):775-82.\u003c/li\u003e\n\u003cli\u003eGood GE, Wood PK. Male gender role conflict, depression, and help seeking: Do college men face double jeopardy? Journal of Counseling \u0026amp; Development. 1995;74(1):70-5.\u003c/li\u003e\n\u003cli\u003eSeidler ZE, Dawes AJ, Rice SM, Oliffe JL, Dhillon HM. The role of masculinity in men\u0026apos;s help-seeking for depression: A systematic review. Clinical Psychology Review. 2016;49:106-18.\u003c/li\u003e\n\u003cli\u003eShenton A. 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Education for Information. 2004;22:63-75.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Liverpool School of Tropical Medicine","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multimorbidity, Gender, HIV, Hypertension, Chronic Kidney Disease, Diabetes, Sub-Saharan Africa, Decision making, Stigma, Power, Health seeking","lastPublishedDoi":"10.21203/rs.3.rs-7231827/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7231827/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMultimorbidity is an urgent public health challenge in sub-Saharan Africa (SSA). Gender, defined as the socially constructed roles, behaviours, activities, and attributes that societies deem appropriate for males and females, significantly influences healthcare access and health-seeking behaviours. The aim of this study was to examine gendered experiences of living with multimorbidity (PLWMM) in Malawi.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis qualitative study is nested within a broader program of multimorbidity research conducted within two hospitals in Malawi. We recruited patients with \u0026ge;\u0026thinsp;2 combinations of diabetes, HIV, hypertension and chronic kidney disease, the most common chronic conditions in the Malawi setting. We conducted 32 in-depth-interviews (IDI) and 8 focus group discussions (FGDs) with people living with multimorbidity (PLWMM) and their carers. Baseline data were supplemented with follow-up interviews at 90 days post-admission. Data were thematically analysed using the critical gender theory.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThree key themes emerged: gendered perceptions of chronic conditions; gendered roles and care-seeking; and decision-making behaviours. Wider structural gender norms informed experiences of living with multimorbidity. Men frequently expressed reluctance to seek care due to societal norms around masculinity and stigma associated with vulnerability, whilst women encountered barriers due to required caregiver roles and limited agency to make health decisions. Limited access to essential resources and reduced physical functionality were common features across both genders. We observed increased propensity toward medical pluralism among females, influenced by their roles as carers and economic factors while males predominantly sought to manage side-effects of treatment.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eGender shapes the experiences of multimorbidity, with male reluctance to seek care driven by masculinity norms, and females engagement with illness constrained by caregiving responsibilities and limited agency. We recommend health education and peer-to-peer initiatives to reframe gendered healthcare interactions and address perceptions of vulnerability and stigma. Among females, strengthened female agency; increased financial independence; and social support may reduce caregiver burdens and promote shared health responsibility\u003c/p\u003e","manuscriptTitle":"Gender differences in response to living with multimorbidity in Malawi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 16:17:39","doi":"10.21203/rs.3.rs-7231827/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f325461c-bc8d-4c94-b60a-723eb73c02f3","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":52219396,"name":"Preventive Medicine"},{"id":52219397,"name":"Gender Studies"},{"id":52219398,"name":"Health Policy"}],"tags":[],"updatedAt":"2025-07-31T16:17:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-31 16:17:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7231827","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7231827","identity":"rs-7231827","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}