Integrative review of the social determinants of health in older adults with multimorbidity

AIM: To examine how the social determinants of health have been considered in conceptualizations of multimorbidity in older adults in the literature and to identify implications for nursing practice, research and healthcare planning and policy. BACKGROUND: The common conceptualization of multimorbidity is the presence of multiple chronic conditions where one is not more central than others. DESIGN: The integrative review methodology of Whittemore and Knafl was employed. The World Health Organization Social Determinants of Health framework was used to determine how the social determinants of health have been considered in conceptualizations of multimorbidity. DATA SOURCES: A search of electronic databases (2000-2015) generated 22 relevant articles, including quantitative and qualitative studies and grey literature reports. REVIEW METHODS: A systematic process was used to appraise the quality of the documents, conduct qualitative data analysis procedures of data extraction, coding and theme development, and synthesize conclusions. RESULTS: Current conceptualizations of multimorbidity provide limited consideration of the complex interplay of multimorbidity with the broader social determinants of health. Gender, education, behaviours and the health system were the most commonly cited determinants. Ethnicity, socioeconomic status/social class and material circumstances received little attention. Most of the dimensions of socioeconomic political context were not discussed. CONCLUSION: The predominant conceptualization of multimorbidity focuses on the biomedical dimensions of multimorbidity. Consequently, nursing practice, research and policy informed by this literature could inadvertently sustain the mismatch between the needs of older adults with multimorbidity and the services they receive. Future research to inform a new conceptualization is necessary.