Lynch Rebecca, Hanckel Benjamin, Green Judith
Department of Women & Children's Health, King's College London, London, UK.
Western Sydney University Institute for Culture and Society, Penrith South, Australia.
Crit Public Health. 2021 Dec 30;32(4):450-461. doi: 10.1080/09581596.2021.2017854. eCollection 2022.
Multimorbidity has become an increasingly prominent lens through which public health focuses on the 'burden' of ill health in ageing populations, with the promise of a more upstream and holistic approach. We use a situational analysis (drawing on documentary analysis and interviews with service providers, policy actors and people living with multiple conditions) in south London, UK, to explore what this lens brings into focus, and what it obscures. Local initiatives mobilised the concept of multimorbidity in initiatives for integrating health care systems and for commissioning for prevention as well as care. However, as the latest of a series of historical attempts to address system fragmentation, these initiatives generated more complexity, and a system orientated to constant transformation, rather than repair or restoration. Service providers and patients continued to struggle to navigate the system. Dominant policy and practice narratives framed patient self-management as the primary route for addressing individualised risk factors on a trajectory to multimorbidity, whereas the narratives of those living with multiple conditions were more oriented to a relational model of health. The findings suggest possibilities and limitations for leveraging the concept of multimorbidity for public health. In this field, the promise arose from its potential to make spaces for a focus on populations, not patients with discrete diseases. Realising this promise, however, was limited by the inherent tensions of biomedical nosologies, which separate discrete diseases within individual bodies, and from epidemiological approaches that reify the socio-material contexts of failing health as risks for individuals.
多重疾病已成为公共卫生关注老年人群健康“负担”的一个日益突出的视角，有望带来一种更具上游性和整体性的方法。我们在英国伦敦南部进行了一项情境分析（借鉴文献分析以及对服务提供者、政策制定者和患有多种疾病的人群的访谈），以探究这个视角聚焦了什么，又掩盖了什么。地方倡议在整合医疗保健系统以及预防与护理委托的倡议中调动了多重疾病的概念。然而，作为解决系统碎片化问题的一系列历史性尝试中的最新举措，这些倡议产生了更多复杂性，以及一个倾向于持续变革而非修复或恢复的系统。服务提供者和患者继续在努力应对这个系统。占主导地位的政策和实践叙述将患者自我管理作为应对多重疾病发展轨迹上个体化风险因素的主要途径，而患有多种疾病的人群的叙述则更倾向于健康的关系模型。研究结果表明了利用多重疾病概念促进公共卫生的可能性和局限性。在这个领域，其前景源于它有潜力为关注人群而非患有特定疾病的患者创造空间。然而，实现这一前景受到生物医学疾病分类学固有张力的限制，这种分类学将个体身体内的特定疾病区分开来，也受到流行病学方法的限制，这些方法将健康状况不佳的社会物质背景具体化为个体风险。
