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What is known about heart failure in sub-Saharan Africa: a scoping review of the English literature
  1. Kellen Kimani1,2,
  2. Elizabeth Namukwaya2,3,
  3. Liz Grant4 and
  4. Scott A Murray5
  1. 1School of Public Health, University of Nairobi, Nairobi, Kenya
  2. 2Centre for Population Health Sciences, the Usher Institute, University of Edinburgh, Edinburgh, UK
  3. 3Makerere Palliative Care Unit, Department of Medicine, Makerere University, Kampala, Uganda
  4. 4Global Health Academy, University of Edinburgh, Edinburgh, UK
  5. 5Primary Palliative Care Research Group, The Usher Institute, University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Kellen Kimani, School of Public Health, University of Nairobi, P.O. Box 19676-00200, Nairobi, Kenya; K.N.Kimani{at}sms.ed.ac.uk

Abstract

We systematically reviewed and summarised existing knowledge on heart failure in sub-Saharan Africa (SSA). We searched the following databases Web of Science, EMBASE, Ovid MEDLINE, PsychINFO, Global Health, CINAHL and African Journals Online using a combination of key words: heart failure or congestive heart failure or cardiac failure. We limited our search to studies conducted in SSA and articles published 2000–2014. Twenty-seven articles met our inclusion criteria and all were quantitative studies. Existing knowledge is focused on 3 key areas: (1) epidemiology of heart failure, (2) psychological burden of heart failure, and (3) patient knowledge and compliance to treatment. SSA would benefit from longitudinal qualitative research on the experience of living with heart failure.

  • Heart failure
  • Psychological care
  • Spiritual care
  • Supportive care
  • Social care

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Introduction

In the past few years, the myth that chronic diseases are exclusive to wealthier western nations1 has been overturned. Sub-Saharan Africa (SSA) is currently facing an unprecedented double burden of infectious and non-communicable diseases.2 Better survival into adulthood especially with antiretroviral therapy alongside urbanisation and shifts in nutrition and lifestyles associated with economic development are contributing to an epidemiological transition across traditional infectious diseases to chronic conditions such as cancer, diabetes and cardiovascular diseases (CVDs).1 ,3 The burden of infectious diseases still remains heavy; these pose a threat to public health despite the efforts to improve infectious disease control in this region. However, CVDs are increasingly being recognised as an additional major threat to public health.1 ,4

Heart failure can be defined as a clinical syndrome in which a structural or functional cardiac abnormality limits the ability of the heart to deliver sufficient oxygen to meet metabolic demand. Often patients present with signs and symptoms of fluid and salt retention, especially during acute phases of the illness. Traditionally, heart failure has been described with reference to a normal or reduced left ventricular ejection fraction.5 However, differences in aetiologies of heart failure and diagnostic tools, such as ultrasound in SSA and western countries, may broaden this description. Although significant progress has been made in the treatment of heart failure, the prognosis remains poor and worse when compared with common cancers.6 Sudden death may also occur at any point along the illness trajectory making it difficult to determine when a patient has entered into the terminal phase of their illness.7

Globally, heart failure affects more than 26 million people, with the majority of patients living in Europe or North America. Although western nations bear a larger heart failure burden, low resource settings face higher mortality rates.8 Weaker health systems, inequitable access to effective healthcare, and catastrophic out-of-pocket spending on health contribute to poorer outcomes. Specifically, countries in SSA have the lowest total global expenditure on heart failure (0.16–0.25%). Inadequately funded health systems are unable to comprehensively care for patients’ needs and may drive households to sell assets or exhaust savings to access healthcare.9 Additionally, the reduction in income from work days lost may plunge households into vicious cycles of poverty. This poses significant challenges not only for achieving health goals, but also for social and economic development.

Despite the fact that lower income countries carry a disproportionate heart failure mortality burden, much of the existing research evidence originates from western nations.10 As SSA tackles an emerging epidemic from chronic diseases, including heart failure, there is a need to map the nature and extent of existing literature and identify research gaps whose evidence may inform much needed policy and practice.

In view of this need, this scoping review aims to (1) systematically review and summarise existing knowledge on heart failure in SSA, and (2) identify research gaps and priorities for future research.

Methods

Scoping reviews or studies are gaining popularity as a method of examining research evidence.11 These aim to map existing medical literature to: determine the breadth and depth of a research activity, summarise key research findings, identify gaps in literature for future studies and inform systematic reviews. Unlike systematic reviews, scoping studies may not aim to evaluate the quality of studies to be reviewed.12

Although there is no precise method for conducting a scoping review, Arksey and O’Malley12 offer a substantive staged methodological approach to guide the process of undertaking a scoping study which includes (1) identifying a research question of interest, (2) identifying relevant studies, (3) selecting studies, (4) charting data, and (5) collating, summarising and reporting results. As demonstrated below, this review borrows on the Arksey and O’Malley12 approach to review and explore the breadth and width of existing literature in this field.

Stage 1: identifying research question

The research question to be addressed in this review is: ‘What is known from existing literature about heart failure in SSA’.

Stage 2: identifying relevant studies

We took the following step to identify relevant studies.

Developed a search strategy for electronic databases

We aimed to identify journal articles that addressed our research question. We searched the following electronic databases: Web of Science, EMBASE, Ovid MEDLINE, PsychINFO, Global Health, CINAHL and African Journals Online.

We used the combination of disease and study location-specific terms. Study location terms were informed by the World Bank classification of countries in SSA.13 Search strategies were modified to suit each electronic database (table 1).

Table 1

Electronic database search strategy

In addition, we broadened our search to include key journals, websites of relevant organisations, and reference lists from the articles we identified.

Stage 3: study selection

Our inclusion criteria which guided study selection were: original research or review papers focused on heart failure in SSA (or any of its constituent countries), articles published in English, and studies recruiting people 18 years and above. We excluded commentaries, editorials, case studies and papers focused on drug development or physiological processes. Abstracts with unavailable full-text versions were also excluded. Owing to limited resources, we restricted our search to articles published in 2000–2014.

Stage 4: charting data

All data were charted on an Excel spread sheet according to the author, year of publication study location, aim(s) of the study, study methods, population and key findings. We summarised data in line with the central aim of each paper, for example, heart failure epidemiology, psychological burden, and patient knowledge and treatment compliance. We reserved the search to original articles only.

Results

Our search strategy resulted in 1709 citations. We identified 118 abstracts which we examined for relevance. Forty-eight articles met our inclusion criteria and were reviewed. Twenty-seven articles were original articles while the remainder (n=21) were review articles. We reviewed 27 full-text original articles (figure 1).

Figure 1

Literature identification and selection process.

Of the 27 original articles identified, African countries were represented as follows: Nigeria (n=16), South Africa (n=3), Cameroon (n=2), Tanzania (n=1), Ghana (n=1), Kenya (n=1), Rwanda (n=1). Two articles reported the results of the nine-country survey.

All original full-text articles identified were quantitative studies seeking to determine the epidemiology of heart failure, psychological burden or level of knowledge and treatment compliance in specific African countries. Most articles reported the results of observational hospital studies examining the aetiology, characteristics, associated factors, and outcomes or knowledge level of patients diagnosed with heart failure.

Online supplementary table S2 summarises the articles retrieved.

In the following section, we outline three key topics we identified from our review of heart failure literature from SSA: epidemiology, psychological burden, patients’ knowledge and compliance to treatment.

Epidemiology of heart failure

In SSA, the most common causes of heart failure are: hypertension (8–78%), cardiomyopathy (7.5–54%) and rheumatic heart disease (2.4–25%). Other causes include heart failure secondary to chronic obstructive pulmonary disease (4.4–27%), ischaemic heart disease (0.2–9%) and congenital heart disease (3%).14–23

In most facilities, heart failure accounts for 9.4–15% of all hospital admissions,15 ,20 ,24 with length of stay ranging from 5 to 21 days.15 ,19 Changes in lifestyle, metabolic abnormalities, exposure to environmental contaminants and viruses have been identified as risk factors for heart failure. Laabes et al25 identified alcohol consumption, obesity and metabolic dysfunction as additional risk factors. Environmental factors, including poor kitchen ventilation and exposure to occupational dust, have been linked to cases of right-sided heart failure in Kenya.26 Enteroviruses and HIV have been identified as risk factors for cardiomyopathy and right-sided heart failure, respectively.26 ,27

Comorbidity has been documented in people living with heart failure in SSA. In a Cameroon study, Dzudie et al28 found renal impairment, chronic obstructive pulmonary disease, and gout as common comorbid conditions diagnosed in people living with heart failure. Comorbid psychiatric disorders, such as major depression, generalised anxiety and schizophrenia, have also been identified and linked to poorer quality of life especially in people of younger age.29–31 Coexisting conditions, such as cancer, HIV, chronic lung disease and poor kidney function, have been identified as prognosticators of mortality.32

Psychological distress

Using the hospital depression and anxiety scale, Ansa et al33 evaluated the presence of depression and anxiety in 100 people living with heart failure in Nigeria. More than a third (39%) of patients had both depression and anxiety, while 16% and 13% reported having depression or anxiety, respectively. Similarly, Mbakwem and Aina34 identified depression in nearly two-thirds of 122 admissions, and one-third of 82 outpatients with heart failure in Nigeria. Young people are more likely to experience psychological distress due to the challenges of adjusting and coping with illness.

Heart failure knowledge and compliance with treatment

Ruf et al's35 study on the adherence, self-care and knowledge of 200 people with heart failure in South Africa found that people had poor knowledge of their medication and its side effects, with more than half unable to mention any side effect of their medication. Patients who reported having received health education regarding their condition had twice as high knowledge scores than those who did not receive education. Poorest compliance was reported for diuretics due to their side effects. Similar results were reported by Bhagat and Mazayi-Mupanemunda36 study of 22 Zimbabwean patients living with heart failure. Half of the patients were unable to correctly recall their prescribed medication and one-third were non-compliant.

Discussion

Summary of findings

Since 2000, research on heart failure in SSA has focused on determining disease epidemiology by exploring patients’ psychological distress, level of knowledge and compliance to treatment. All the studies we identified employed quantitative research methods and therefore may point to an urgent need to quantify and characterise an emerging chronic disease epidemic previously considered to occur mainly in wealthier countries.

From the results of our scoping review, we noted limited research on the understanding of the lived experience of people with heart failure in SSA. While some attention has been given to patients’ level of psychological distress, to the best of our knowledge, the holistic lived experience of people with heart failure in SSA is yet to be described.

A first-hand account of patients’ experience of living with heart failure is necessary to explore their multidimensional needs and inform appropriate services. Previous studies have identified significant symptom burden, psychological and spiritual distress.37 Patients also report poor understanding of their illness and the need for more information and better communication from health workers. Presently, no cure exists for heart failure and a patient-centred approach to care focused on improving symptom control, quality of life and offering psychosocial support might be beneficial to patients and families.37 Additionally, primary and secondary prevention strategies aimed at early identification, treatment and control of common causes of heart failure, such as hypertension, should be encouraged.

In developed countries, research into understanding heart failure patients’ lived experience has gained interest.37 This research has the potential to identify patients’ needs, priorities and preferences with the aim of informing quality care. The results of our scoping review reveal the leading causes of heart failure in SSA as hypertension, cardiomyopathy and rheumatic heart disease, with the illness occurring two decades earlier compared with western countries, such as the UK,38 and with younger people experiencing significant distress. Additionally, patients are likely to present with advanced illness while those on treatment have poor knowledge of their medication which results in non-compliance. However, given significant contextual differences, it is uncertain whether results from research on the lived experiences of patients with heart failure in developed countries can be transferred to SSA. Cognisant of this emerging research gap, Namukwaya et al39 present initial findings of their research on the experience of living with heart failure in Uganda. In their conference abstract, the authors identify significant physical, psychological and spiritual distress, presentation in later stages of illness, recurrent admissions, poor awareness of symptoms and financial challenges. In a recent review of the palliative and supportive care needs for heart failure in SSA, Selman et al40 argue that similar research is urgently needed to inform services that account for differences in epidemiological, cultural, socioeconomic and health system contexts of SSA.

The growing burden of heart failure is likely to impose significant challenges on already weak health systems in SSA. Arguments have been posed whether current primary care services are prepared to support care for those living with chronic diseases, including heart failure.41 An integrated approach placing patients at the centre of their care may benefit people with heart failure. This model of care has been shown to improve patients’ health status as involved in their own care are likely to experience less anxiety, which has been linked to patients’ functional status. Patient-centred care has also been shown to reduce hospital visits and financial costs of care,42 which may further reduce the risk of catastrophic health expenditure.

Although patient-centred care offers significant benefit, several challenges exist in its delivery. Population-based research describing the burden of chronic diseases in SSA remains scarce and thus the need for services is poorly defined. Inadequate research expertise and funding limits the extent to which healthcare services can be appropriately informed in order to meet changing needs.43 Challenges in health financing, access to quality medicines and technology, and the availability of well-trained and well-compensated health work force also present significant barriers to the delivery of patient-centred approaches.40

Limitations of our review

In our review, we aimed to evaluate the depth and breadth of heart failure research in SSA in recent years. While we attempted to summarise the evidence in this field, we did not assess articles for methodological quality. Unlike systematic reviews, scoping reviews may not aim at assessing the quality of articles selected for review. Second, by limiting our search to articles published in English, we may have omitted several articles. Third, most of the studies included in our review were hospital-based surveys, which may not be representative of the general population in SSA or its constituent countries. Lastly, two-thirds of the articles included in our review originate from Nigeria and these studies were conducted in hospitals offering specialised services to a predominantly urban population. After South Africa, Nigeria records the second highest spending on heart failure in SSA.9 We advise caution when applying the results of this review to other settings in SSA serving a primarily rural population which might not be comparably resourced.

Implications for research

In order to inform services based on person-centred needs, the lived experience of patients with heart failure in SSA should be explored. To investigate this, qualitative research methods would be suitable as these allow for in-depth understanding of patients’ needs and preferences.44 Specifically, longitudinal qualitative research is appropriate for exploring individual experiences through time. Using this method, we can map patients’ needs from diagnosis to death.44 To respond to the WHO's recent resolution that all member states should integrate palliative care in the care of all conditions in all settings,45 and the urgent need for culturally appropriate research on CVDs,43 countries in SSA would greatly benefit from evidence on the lived experience of patients with heart failure in order to inform practice and policy that meets patients’ changing needs.

Conclusion

SSA is currently experiencing a rising burden of chronic diseases, including heart failure. People living with heart failure experience an unpredictable illness and require services that meet their changing needs. In order to develop appropriate care, it is imperative to generate evidence to inform policy and practice. So far, research into heart failure in SSA has focused mainly on describing the epidemiology, psychological burden or level of knowledge and treatment compliance in specific African countries. However, evidence on the lived experience of people with heart failure in SSA may offer deeper insights into their needs and preferences. Additionally, longitudinal qualitative research methods would allow for an in-depth understanding of patients’ illness experience along the heart failure trajectory. To the best of our knowledge, this research is yet to be conducted in SSA. Countries in SSA would benefit from longitudinal qualitative research on the experience of living with heart failure in order to develop social and culturally sensitive services that cater to patients’ needs.

References

Footnotes

  • Contributors KK, EN, LG and SAM formulated the research question and research strategy. KK conducted the search, extracted data and prepared the first draft of the manuscript. All authors contributed to the final version of the manuscript. KK is the guarantor.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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