Determinants of multimorbidity in low- and middle-income countries: A systematic review of longitudinal studies and discovery of evidence gaps
Determinants of multimorbidity in low- and middle-income countries: A systematic review of longitudinal studies and discovery of evidence gaps
复制标题
低收入和中等收入国家多发病的决定因素：纵向研究的系统回顾和证据差距的发现
作者：
Tan M
多重发病——同一个人同时存在至少两种慢性健康状况——是一个重要的全球健康挑战。在高收入国家 (HIC)，多种疾病以非传染性疾病 (NCD) 为主；然而，低收入和中等收入国家（LMIC）的情况可能有所不同，那里的慢性传染病仍然很突出。本系统评价的目的是从已发表的针对中低收入国家不同人群或社区居住人群的纵向研究中确定多发病的决定因素（包括风险和保护因素）和潜在机制。我们使用预定义的搜索术语和选择标准，并辅以手动搜索，系统地搜索了三个电子数据库（Medline、Embase 和 Global Health）。所有标题、摘要和全文均由四名研究人员中的两名审稿人独立筛选。数据提取和报告是根据系统评价和荟萃分析的首选报告项目 (PRISMA) 指南进行的。使用纽卡斯尔-渥太华量表进行队列研究，进行方法学质量和偏倚风险评估。使用叙述综合来总结数据。搜索产生了 1782 条记录。在纳入审查的 52 篇全文文章中，8 篇基于人群的纵向研究被纳入最终数据合成。几乎所有研究都是在亚洲进行的，只有一项来自南美洲，没有一项来自非洲。所有研究均发表于过去十年，其中一半于 2021 年发表。用于多重发病的定义各不相同，其中每项研究涉及 3-16 种慢性病。主要的慢性疾病是心脏病、中风和糖尿病，并且缺乏对心理健康状况（MHC）、传染病和营养不良的考虑。前瞻性评估的决定因素包括社会经济地位、社会不平等的标志、童年逆境、生活方式、肥胖、血脂异常和残疾。该综述揭示了中低收入国家证据的缺乏以及多发病研究分布的地理偏差。有必要对多种疾病的流行病学方面进行纵向研究，以在亚洲以外的地区建立科学证据。这些证据可以提供疾病发展的详细情况，对中低收入国家的社区、临床和干预措施具有重要意义。本综述中观察到的研究设计、暴露、结果和统计方法的异质性要求在对多发病进行流行病学研究时加强方法学标准化。证据有限，表明 MHC、传染病和营养不良是多种疾病的组成部分，因此需要对全球多种疾病进行更全面的定义。
Multimorbidity—the coexistence of at least two chronic health conditions within the same individual—is an important global health challenge. In high‐income countries (HICs), multimorbidity is dominated by non‐communicable diseases (NCDs); whereas, the situation may be different in low‐ and middle‐income countries (LMICs), where chronic communicable diseases remain prominent. The aim of this systematic review was to identify determinants (including risk and protective factors) and potential mechanisms underlying multimorbidity from published longitudinal studies across diverse population‐based or community‐dwelling populations in LMICs. We systematically searched three electronic databases (Medline, Embase, and Global Health) using pre‐defined search terms and selection criteria, complemented by hand‐searching. All titles, abstracts, and full texts were independently screened by two reviewers from a pool of four researchers. Data extraction and reporting were according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Methodological quality and risk of bias assessment was performed using the Newcastle‐Ottawa Scale for cohort studies. Data were summarized using narrative synthesis. The search yielded 1782 records. Of the 52 full‐text articles included for review, 8 longitudinal population‐based studies were included for final data synthesis. Almost all studies were conducted in Asia, with only one from South America and none from Africa. All studies were published in the last decade, with half published in the year 2021. The definitions used for multimorbidity were heterogeneous, including 3–16 chronic conditions per study. The leading chronic conditions were heart disease, stroke, and diabetes, and there was a lack of consideration of mental health conditions (MHCs), infectious diseases, and undernutrition. Prospectively evaluated determinants included socio‐economic status, markers of social inequities, childhood adversity, lifestyle behaviors, obesity, dyslipidemia, and disability. This review revealed a paucity of evidence from LMICs and a geographical bias in the distribution of multimorbidity research. Longitudinal research into epidemiological aspects of multimorbidity is warranted to build up scientific evidence in regions beyond Asia. Such evidence can provide a detailed picture of disease development, with important implications for community, clinical, and interventions in LMICs. The heterogeneity in study designs, exposures, outcomes, and statistical methods observed in the present review calls for greater methodological standardisation while conducting epidemiological studies on multimorbidity. The limited evidence for MHCs, infectious diseases, and undernutrition as components of multimorbidity calls for a more comprehensive definition of multimorbidity globally.