https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-025-02916-9
Multimorbid patients with hypertension experienced treatment burden from managing multiple chronic conditions. Although treatment burden can adversely affect self-care, several qualitative studies have suggested a complex relationship between the two factors. This study aimed to identify patient groups based on the level of multimorbidity treatment burden and self-care adherence and explore factors associated with these patient groups. We also examined if patients transitioned to a different group over six months and which factors were associated with either transitioning into or remaining in the ideal group (Lower burden with higher self-care) at six months.
This longitudinal study included hypertensive patients with at least two comorbidities (n = 484); 302 participants completed the 6-month follow-up. Patients were categorized into four groups based on multimorbidity treatment burden and self-care adherence levels: All-low (13.8%); Lower burden with higher self-care (26.0%); Higher burden with lower self-care (35.3%); and All-high (24.8%) groups. Multinomial logistic regression was used to explore factors associated with group membership, with the Lower burden with higher self-care group as the reference group. Binary logistic regression was used to explore factors associated with transitioning into or remaining in the ideal group at six months.
Older age, higher levels of health literacy, better subjective cognitive function, and greater shared decision-making decreased the likelihood of being in the All-low group. Lower depressive symptoms and higher subjective cognitive function decreased the likelihood of being in both Higher burden with lower self-care and All-high groups, while older age and greater shared decision-making were only associated with the Higher burden with lower self-care group. Patients in the All-low and All-high groups frequently transitioned to another group over six months, while the other two groups remained stable. At six months, participants who were male and had higher health literacy, better subjective cognitive function, and greater involvement in shared decision-making were more likely to belong to the ideal group.
Our study observed the complex relationship between multimorbidity treatment burden and self-care adherence in multimorbid patients with hypertension. Interventions aimed at improving shared decision-making considering patients’ circumstances (e.g., emotional status) may alleviate treatment burden and enhance self-care adherence.
Hypertension is a highly prevalent chronic condition globally [1], with significant rates also observed in South Korea [2]. Poorly controlled hypertension including non-adherence to self-care activities can lead to the development of other chronic conditions such as kidney disease and stroke [1]. Numerous studies have shown that patients with hypertension often have at least one additional comorbidity [3, 4], and that hypertension is one of the most common conditions in patients with multimorbidity [5]. Patients with hypertension who have additional chronic conditions experience unique challenges of performing recommended self-care activities compared to patients with only hypertension because of the complex nature of simultaneously managing multiple health conditions [6, 7]. For example, patients with hypertension and comorbidity reported difficulty scheduling multiple medications, concerns about potential interactions between medications, and challenges due to incompatible self-care regimens [6]. Thus, patients with multiple chronic conditions, including multimorbid patients with hypertension, experience the burden of managing multiple self-care regimens and the impacts of the self-care activities imposed on their lives [8]. This is referred to as treatment burden of multimorbidity [9, 10].
Treatment burden of multimorbidity, one of the core patient-reported outcome for patients with multimorbidity [11], is closely related to adherence to self-care [12]. The negative relationship between multimorbidity treatment burden and self-care adherence has been reported in several studies examining patients with multiple chronic conditions [6, 9, 13,14,15,16,17]. While most evidence of this treatment burden for patients with multimorbidity comes from qualitative studies [6, 13,14,15,16], several quantitative studies have also shown that greater treatment burden is associated with poorer self-care adherence in patients with chronic conditions including patients with HIV and stroke [18,19,20].
Several qualitative studies have identified a nuanced relationship in patients with multimorbidity [13,14,15,16]. For example, studies have found that some patients intentionally do not adhere to the recommended healthcare tasks to alleviate their treatment burden [13,14,15], whereas some patients faithfully perform the recommended self-care activities despite the significant treatment burden [15, 16]. The results of these qualitative studies highlight the intricate relationship between treatment burden and self-care, underscoring the importance of considering both factors simultaneously to fully understand the relationship.
The purpose of this study was to explore factors associated with patient groups categorized by the levels of multimorbidity treatment burden and self-care adherence among multimorbid patients with hypertension. Specific aims were (1) to identify distinct patient groups based on the levels of multimorbidity treatment burden and self-care adherence and to describe the characteristics of each group and (2) to explore factors associated with these patient groups. Treatment burden and self-care adherence change over time, and there is often a cyclical pattern between the two factors [12, 21]. For example, an increase in treatment burden can lead to non-adherence to self-care, which, in turn, may further elevate treatment burden [12, 21]. Therefore, we conducted a 6-month follow-up to examine if patients transitioned to another group from baseline to follow-up and which factors were associated with either transitioning into or remaining in the ideal group (i.e., Lower burden with higher self-care) at six months.
This longitudinal observational study recruited patients with hypertension and comorbidities from a large online platform. Participants were followed up at six months after the baseline assessment. Eligible patients in this study were individuals who were older than 19 years, had been diagnosed or currently being treated with hypertension at least three months before enrollment, and had at least two additional chronic conditions. Exclusion criteria included having a diagnosis of dementia or unable to read Korean. Participants’ comorbidities were assessed using a list of self-reported chronic diseases developed by Fortin and colleagues [22] (Supplementary Table 1). Participants were asked whether they had been diagnosed by a clinician and/or were currently being treated for any of the listed conditions.