'Examining the characteristics of multimorbidity as a uniquely disparate population group in health care' : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Wellington, New Zealand

Abstract

Multimorbidity is a prevalent concern that burdens not only the individual but healthcare system delivery. This thesis identifies the characteristics of people with multimorbidity, through an exploration of vulnerability and disparity in relation to determinants of health in a population group with chronic kidney disease known to be multimorbid. The position of this thesis is known factors of disparity are equalised by the presence of multimorbidity where a discrete point of change is identified. This work is underpinned by critical discourse analysis through a lens in blending critical social theory methodologies. Key concepts include vulnerability, inequity, identity, power, and social networks where the work of Foucault, extended by Fairclough, provide the framework to examine these concepts further using games of truth, eventalisation, technologies of self and resistance. This study is embedded in the New Zealand healthcare context and takes a multimethod case study approach with a strong qualitative position through examination of a regional specialist service. Community, clinical care, and Indigenous Peoples needs are strong drivers. Findings describe a continuum of vulnerability, where determinants and healthcare are influencing disparate factors. Two or more comorbid conditions demonstrated statistical significance in identifying a discrete point in which known factors of disparity are outweighed by the presence of multimorbidity increasing the risk and need for elevation of care. People with Chronic Kidney Disease multimorbidity are exposed to multiple truths in their pursuit of care in a health system struggling to meet government aspirations for care and become voiceless and hidden in noise of the system. This thesis proposes a novel way in interpreting Foucault’s concepts of power and social capillary networks where discursive shifts, fissure points and a change in identity is explored in a new suggestion of a Reset and Translational Change process. Findings also suggest an extension in interpretation of person-centred care to person-centric care and the need to realign care models in the modern context of multimorbidity. It offers caution in the use of Quality-of-Life surveys, commonly used to understand care perspectives and effectiveness of treatment regimes. Importantly this thesis provides a ‘voice’ for people who walk a ‘trail of tears’ in their attempt to find a way through each day who deserve and need health care providers to walk with them differently.