Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Open Access

Peer-reviewed

Research Article

Bridging the gap between recommendation and reality: Improving dietary adherence of heart failure populations a cross-sectional study in Ethiopia

  • Takla Tamir ,

    Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft

    taklat12@gmail.com, taklat@du.edu.et

    Affiliation Department of Nursing, Dilla University College of Health Science and Medicine, Addis Ababa, Dilla, Ethiopia

    ⨯
  • Jemberu Nigussie,

    Roles Investigation, Methodology, Validation, Writing – review & editing

    Affiliation Department of Nursing, Dilla University College of Health Science and Medicine, Addis Ababa, Dilla, Ethiopia

    ⨯
  • Migbaru Endawoke

    Roles Investigation, Methodology, Validation, Writing – review & editing

    Affiliation Department of Nursing, Dilla University College of Health Science and Medicine, Addis Ababa, Dilla, Ethiopia

    ⨯

Abstract

Background

Heart failure (HF), a complex condition arising from impaired ventricular function, necessitates strict adherence to dietary recommendations for optimal patient management. However, information regarding adherence and its influencing factors remains limited.

Aim

This study aimed to assess dietary recommendation adherence and its associated factors among HF patients at Southern Ethiopia public hospitals.

Methods and results

A cross-sectional study involving 521 participants employed systematic random sampling. Data collection utilized pre-tested, interviewer-administered questionnaires and medical chart reviews. Data were entered and analyzed using Epi Data 3.1 and SPSS 20.0 software. Descriptive statistics were performed. Variables with p-values < 0.25 in binary logistic regression were included in multivariable logistic regression analyses. Statistical significance was set at p < 0.05 with a 95% confidence interval. Results are presented in text, tables, and figures.

With a 97.4% response rate, adherence ranged from 20.3% (vegetables and fruits) to 60.3% (fat-free diet). Only 8.1% achieved good adherence across all parameters, with overall adherence at 33.4% (95% CI: 29–37). Multivariable analysis revealed that patients aged 41–60 years (AOR: 1.7), with a history of admission (AOR: 2.5), free from comorbidities (AOR: 0.58), and possessing a favorable attitude (AOR: 0.45) had statistically significant associations with good adherence.

Conclusion

Dietary adherence among HF patients remains a challenge. Healthcare providers, particularly those in chronic follow-up settings, should prioritize improving patient attitudes towards proper dietary practices. Tailored education programs targeting younger patients and those free from comorbidities should be implemented. Continuous monitoring, evaluation, and staff recognition for effective client counseling are crucial.

Citation: Tamir T, Nigussie J, Endawoke M (2024) Bridging the gap between recommendation and reality: Improving dietary adherence of heart failure populations a cross-sectional study in Ethiopia. PLoS ONE 19(10): e0311663. https://doi.org/10.1371/journal.pone.0311663

Editor: Sepiso K. Masenga, Mulungushi University, ZAMBIA

Received: May 31, 2024; Accepted: September 23, 2024; Published: October 10, 2024

Copyright: © 2024 Tamir et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The datasets used for this study are available from the corresponding author.

Funding: This research was supported financially from Dilla University academic staff annual grant call budget. T-DU-4-8269 Dilla University, https://r.search.yahoo.com/_ylt=AwrkgJlW8YdmYc8cuxsM34lQ;_ylu=Y29sbwNpcjIEcG9zAzUEdnRpZAMEc2VjA3Ny/RV=2/RE=1720213975/RO=10/RU=https%3a%2f%2fwww.alluniversity.info%2fethiopia%2fdilla-university%2f/RK=2/RS=cqLPzZHH4GksbPoZrrQ_6ytke.4 The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: AHA, American Heart Association; AOR, Adjusted Odds Ratio; HF, Heart Failure; Na, Sodium; NYHA, New York Heart Association; SPSS, Statistical Package for Social Science; SSBs, Sugar-Sweetened Beverages; US, United States

Introduction

Heart failure is a chronic condition that weakens the heart’s ability to pump blood [1–5]. It can affect either the left, right, or both ventricles of the heart, and can be acute or chronic [6]. Symptoms include shortness of breath, difficulty breathing when lying down, and fatigue [2,6]. Despite advances in treatment, heart failure remains a burden on healthcare systems [7,8] due to frequent hospitalizations and reduced quality of life for patients [9,10]. While medication can slow the progression of heart failure, self-care measures like following a recommended diet are also important for managing the condition [7,11]. Although adherence to self-care can be inconsistent [3,12], studies have shown that participating in long-term self-care activities can improve outcomes for heart failure patients [9,10,13,14] and reduce the burden of the disease on individuals, families, and society [15,16].

Dietary changes are crucial for managing heart failure, especially reducing sodium and fat intake, and managing fluids [17,18]. A low-sodium diet (around 2–3 grams per day) is proven to improve symptoms and overall health for heart failure patients [19,20]. Dieticians can recommend specific sodium and fluid intake goals based on individual needs [16,20–24] Sodium intakes above and below the recommended range is associated with increased cardiovascular risk [25,26]. While some fat is necessary, a relatively low intake, particularly omega-3s from fish, may help prevent or slow heart failure progression failure [7]. On the other hand, refined carbohydrates and sugary drinks increase the risk of heart failure, while whole grains offer some protection [27].

In addition to dietary changes, guidelines recommend lifestyle modifications to manage heart failure [28]. The American Heart Association (AHA) emphasizes a healthcare system approach that encourages healthy behaviors like a balanced diet rich in fruits, vegetables, and whole grains. This aligns with recommendations for moderate alcohol intake, limited red meat and processed foods, and avoiding sugary drinks grains [17,29]. International guidelines also advise restricting salt and fluids for heart failure patients [30,31].

Heart failure is a global pandemic affecting at least 26 million people worldwide [32] and is increasing in prevalence with an impact on healthcare costs [15,16,33] due to its greatest reason of hospitalization [34]. Morbidity and mortality rates due to heart failure are increasing globally [18]. The incidence of HF increases with age, approximately from 20 per 1000 individuals with age 65 to 69 years to more than 80 per 1000 individuals aged 85 years [35].

Heart failure (HF) is a major public health problem in Ethiopia, affecting a significant number of people, primarily middle-aged adults [36] (Tenaadam & Demissei, 2018). Rheumatic heart disease is the most common cause of HF in the country [36,37]. A study of 496 HF patients revealed an in-hospital mortality rate of 24.4% [37]. Another study reported a 90-day all-cause mortality rate of 52.3% among 283 HF patients [38]. Health-related quality of life (HRQoL) is poor among Ethiopian HF patients, with 54% reporting low scores on the Minnesota Living with Heart Failure Questionnaire[39].

Heart disease accounted for 32.2% of the burden of cardiovascular disease [40]. Being non-compliant with at least one of the non-pharmacological recommendations had a higher risk of mortality or HF readmission [41]. The role of nutrition in the prevention and improvement of HF prognosis is recognized and noncompliance to sodium and fluid-restricted diet accounts for 30%–44% of readmission on HF patients [42,43].

The 2015 United States (US) Dietary Guidelines Advisory Committee recently concluded that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low-fat or nonfat dairy, seafood, legumes, and nuts; moderate in alcohol; lower in red and processed meat; and low in sugar-sweetened foods and drinks and refined grains [17,29]. Several factors, Age, co-morbidity, and knowledge, influence adherence of heart failure patients to their recommended diets [44]. Understanding these factors is crucial for effective management plan and intervention implementation.

Previous research on adherence to self-care practices among heart failure (HF) patients in Ethiopia has been limited [45,46], Existing studies have focused on general self-care behaviours in a single institution with small sample sizes, making them less specific and hindering the development of targeted interventions. To address this gap, this study aimed to assess adherence to dietary recommendations and its associated factors among HF patients in Southern Ethiopia. The findings from this study can inform policymakers and healthcare providers in designing interventions to improve dietary adherence and ultimately, patient outcomes.

Materials and methods

Study design, area and period

An institutional-based cross-sectional study was carried out in Gedeo zone and Sidama Region, Southern Ethiopia public hospitals. The study was conducted at 7 selected public hospitals from April to June 2022.

Population

All adult HF patients attending all public hospitals in Gedeo Zone and Sidama Region were the source population and those source populations attending selected public hospitals of Gedeo Zone and Sidama Region during the study period were the study population.

Eligibility criteria.

Participants must meet criteria: (1. Be an adult aged 18 years or older, 2. Have a confirmed diagnosis of heart failure by a healthcare professional and 3. Have had at least one documented follow-up visit at least a week prior to study enrolment) were included in the study where as participants were excluded from the study if they have had a recent follow-up visit within the data collection period at other included hospitals or if they have severe or uncontrolled comorbidities that would significantly impact their ability to participate in the study or accurately provide data.

Sample size determination and sampling procedure

The sample size for each objective was calculated by using the StatCalc function of Epi-Info version 7 software. The maximum sample size was 486 from the second objective and after adding a 10% non-response rate, the total sample size became 486+49 = 535.

To determine sample size allocation, we conducted a pre-recruitment survey at each participating hospital. This survey, along with a review of the past 3 months’ chronic follow-up data, allowed us to assess patient flow (daily, weekly, and monthly). Based on this data, a proportional sample size was allocated to each hospital.

For participant selection, we employed systematic random sampling. We calculated the sampling interval (k) as N/n (population size divided by desired sample size), which in this case was k = 2. Using a random lottery method, we selected the first participant. Subsequently, every other patient following the selected participant was included in the study.

Data collection tool, operational definitions, and procedures

Data were collected using a structured, interviewer-administered questionnaire developed by adapting and combining validated instruments from previous research [18,35,47–49]. The questionnaire addressed five key areas: sociodemographic information, clinical profile, dietary adherence, knowledge about HF, and attitude towards recommended diets.

Dietary adherence was assessed using the validated "Revised Heart Failure Compliance Scale" which focuses on adherence to low sodium, fat-free, fluid restriction, legumes, and fruits/vegetables diets [18,35,47,49] This instrument demonstrated good reliability and validity [18,35,41,47,49–51].

Adherence to dietary recommendations was assessed using a five-item (a low sodium diet, fat free diet, fluid restriction, legumes, and fruits and vegetables) questionnaire with a five-point Likert scale (always = 4, mostly = 3, half of the time = 2, seldom = 1, never = 0). For each item participants were categorized as "adherent” if they reported following a recommendation "always or mostly and for the overall as "adherent" if they adhered at least three of the five recommendations [18,35,47].

Knowledge of heart failure was assessed using the "Japanese Heart Failure Knowledge Scale" [18,48]. Cronbach’s alpha for internal consistency is 0.79. Knowledge about HF was assessed using a questionnaire with 11 yes/no/"don’t know" options. Scores above 75% were categorized as "good knowledge," [45,46].

Attitude towards recommended diets was assessed using six -item questionnaire with a five-point Likert scale (ranging from "very pleasant" to "very unpleasant"). Attitude towards recommended diets was assessed using six -item questionnaire with a five-point Likert scale (ranging from "very pleasant" to "very unpleasant"). Participants scoring above the mean score were classified as having a "favorable attitude." [45].

Interviews were conducted privately following participants’ healthcare appointments, adhering to COVID-19 prevention measures. Medical charts were reviewed to gather additional clinical data. Data collectors were nurses with BSc or higher degrees and supervisors were MSc nurses. All underwent training by the principal investigator on the study aims, questionnaire content, participant selection, data collection procedures, and ethical considerations. Data collection was performed by the trained nurses with close supervision by the principal investigator and supervisors throughout the process.

Ethics statement

Letter of ethical clearance was obtained from institutional review board of Dilla University; college of medicine and health sciences (duirb004/21-11). Approval was obtained from the participating hospitals. Informed, voluntary, written and signed consent was obtained from each respondent. Confidentiality of the information was kept throughout the study that data were analyzed anonymously. This study was done in accordance with declaration of Helsinki.

Data quality control

To ensure data accuracy and reliability, we implemented rigorous quality control measures throughout the research process. The questionnaire, originally developed in English, was translated to Amharic and back-translated to verify consistency. Experts in nutrition and internal medicine reviewed it for clarity and content validity. A pilot test on 5% of the sample size ensured the instrument’s effectiveness. Data collectors and supervisors received comprehensive training to minimize errors during collection. The principal investigator reviewed a portion of the collected data daily to identify and address any immediate issues. Finally, data entry staff verified the completeness, accuracy, clarity, and consistency of questionnaires before entering them into EpiData software. Double data entry was performed for verification, and data cleaning procedures addressed outliers, missing values, and inconsistencies before analysis.

Method of data processing and analysis

After checked, coded, entered into Epi data, validated, and compared to the original, data were exported to the Statistical Package for Social Science [SPSS] Version-20 software for analysis. Descriptive analysis was done to compute proportions and summary measures. Texts, tables, and figures were used to present the processed information.

In bivariate analysis, crude odds ratio with 95% CI, was estimated to see the crude association between each independent variable with the dependent variable. All variables with P < 0.25 at a 95% confidence level during the bivariate analysis were selected as a candidate for the multivariable analysis to control all possible confounders. The multi-co-linearity test was carried out to see the linear correlation among independent variables by using standard error. Standard error >2 was considered suggestive of the existence of multi-co-linearity and no multi-co-linearity was detected. Hosmer -Lemeshow goodness- of- fit was done to check model fitness. The Omnibus test was significant (p-value = 0.000) and Hosmer- Lemeshow’s test was insignificant (p-value > 0.35) which shows the model has fitted.

An adjusted odds ratio with 95% CI was estimated during multivariate analysis to identify factors associated with adherence to the dietary recommendation. Independent variables at the level of statistical significance P < 0.05 were reported as factors having a statistically significant association with adherence to the dietary recommendation. We used the STROBE cross sectional reporting guidelines described in S1 Table [52]. Information about the dataset used for the analysis of this study is also described in S2 Table.

Result

Socio-demographic characteristics

A total of 521 participants were successfully interviewed, representing a 97.4% response rate. Participant ages ranged from 18 to 90 years old, with a median age of 45 (IQR = 25). Males comprised the majority of participants (52.6%), and approximately 28% reported being unable to read or write (Table 1).

thumbnail
Download:
Table 1. Socio-demographic characteristics of participants for adherence to dietary recommendation and associated factors among adult HF patients at public hospitals of, Southern Ethiopia 2022 (n = 521).

https://doi.org/10.1371/journal.pone.0311663.t001

Clinical characteristics

Over half (58.2%) of participants reported being diagnosed with heart failure for more than 4 years, indicating a long-standing health concern. Additionally, approximately 40.3% had a history of hospitalization, suggesting potential disease severity in some cases. Nearly 43% of participants lived with at least one additional chronic condition, with hypertension being the most prevalent, followed by diabetes mellitus (Table 2).

thumbnail
Download:
Table 2. Clinical characteristics of participants for adherence to dietary recommendation and associated factors among adult HF patients at public hospitals of Southern Ethiopia 2022 (n = 521).

https://doi.org/10.1371/journal.pone.0311663.t002

Knowledge and attitude

The study assessed participants’ understanding of heart failure and their attitudes towards recommended dietary guidelines. Using a cut-off score of 75% on the knowledge assessment, approximately 34% of participants demonstrated poor knowledge about their condition. In terms of attitudes, two-thirds (68.1%) of participants expressed unfavorable views towards the recommended diets based on the mean score of the attitude assessment.

Dietary adherence

Adherence to the recommended low-sodium, fat-free, fluid-restricted diet with inclusion of legumes, vegetables, and fruits was assessed. Participants were categorized as "adherent" if they reported following a recommendation "always or mostly and "non-adherent" otherwise. Adherence scores ranged from 20.3% (vegetables and fruits) to 60.3% (fat-free diet), indicating generally low adherence across most dietary components. Notably, only 8.1% of participants achieved good adherence to all dietary recommendations (Table 3).

thumbnail
Download:
Table 3. Adherence status of participants for dietary components designed for adherence to dietary recommendation and associated factors among HF patients at public hospitals of Southern Ethiopia 2022 (n = 521).

https://doi.org/10.1371/journal.pone.0311663.t003

Only 33.4% (95% CI: 29–37) of respondents met their recommended diet (Fig 1).

thumbnail
Download:
Fig 1. Adherence status of participants for adherence to dietary recommendation and associated factors among adult HF Patients at public hospitals of Southern Ethiopia 2022 (n = 521).

https://doi.org/10.1371/journal.pone.0311663.g001

Factors associated with dietary adherence

Bivariate analysis explored potential factors influencing dietary adherence, including age, education, residence, occupation, hospitalization history, comorbidity, knowledge, and attitude. Multivariate logistic regression then identified factors with statistically significant associations with adherence (p-value < 0.05). These factors were age, history of hospitalization, presence of comorbidity, and attitude towards the recommended diet. Participants aged 41–60 were 1.7 times more likely to adhere compared to those aged 18–40. Furthermore, a history of hospitalization was associated with a 2.5 times greater likelihood of adherence. Interestingly, individuals with no comorbid conditions were 42% less likely to adhere than those with at least one comorbidity. Finally, a favourable attitude towards the recommended diet was a significant factor, with participants having unfavourable attitudes being 55% less likely to adhere. The detailed results of this analysis, including odds ratios and confidence intervals for each significant factor, are likely presented in Table 4

thumbnail
Download:
Table 4. Bivariable and multivariable analysis for adherence to dietary recommendation and associated factors among HF patients at public hospitals of, Southern Ethiopia 2022.

https://doi.org/10.1371/journal.pone.0311663.t004

Discussion

This study investigated dietary adherence and its associated factors among heart failure (HF) patients in Southern Ethiopia. These findings highlight the presence of multiple health concerns among some participants and concerning gaps in knowledge, unfavorable attitudes towards dietary recommendations, and overall low adherence to specific dietary components. Additionally, the study identified factors influencing adherence, including age, hospitalization history, presence of comorbidities, and attitude towards the recommended diet.

The study revealed variations in adherence across dietary components, with the lowest adherence observed for vegetables and fruits. Furthermore, only a small percentage of participants achieved good adherence to all recommendations. About thirty three percent of respondents met adherence to their recommended diet. Our findings is consistent with previous research by Marti, Georgiopoulou et al. [53]. However, adherence is lower compared to studies by van der Wal, van Veldhuisen et al., Conceição, Santos et al., Sewagegn, Fekadu et al., Fetensa, Yadecha et al. [1,41,46,54]. This difference might be due to variations in sample size. Studies by Conceição, Santos et al., Sewagegn, Fekadu et al., Fetensa, Yadecha et al. [1,46,54] had smaller sample sizes compared to our study. Another potential explanation for the variation lies in the study design and coverage area. The study by van der Wal, van Veldhuisen et al. [41] was a multicenter trial involving 17 hospitals, encompassing a much larger geographical area compared to our study.

Conversely, our adherence rate was higher than the one reported in Seid, Abdela et al. [18]. This difference is likely due to the assessment parameters employed. The previous study assessed adherence to general self-care behaviours, with diet being just one component. In contrast, our study specifically focused on adherence to dietary recommendations. Overall, the findings suggest that adherence to dietary recommendations remains a challenge.

The analysis identified several factors influencing adherence. Participants aged 41–60 were more likely to adhere compared to younger participants. This finding was supported by van der Wal, van Veldhuisen et al., Sewagegn, Fekadu et al. [41,46]. This could be due to increased awareness of health risks and a greater focus on self-care with advancing age. More over as the prevalence of HF increases with aging population the issue of HF self-care adherence among the elderly will become even more important Sewagegn, Fekadu et al. [46]. On the other hand over ages, people have observed the profound link between emotions, mood, and food choices. This influence manifests in various ways, from strong cravings to subtle subconscious cues. It can be physiological, impacting appetite, or behavioral, affecting food availability Gibson [55].

Participant clients who had a history of admission were more likely to adhere to their recommended diet compared to participants who had no history of admission. This was supported by van der Wal, van Veldhuisen et al. [41]. This association could be explained by the potential for increased education and dietary counseling during hospitalization and it is clear that increasing patients’ level of knowledge about the disease is a prerequisite to improve self-care behavior Sewagegn, Fekadu et al. [46].

Interestingly, individuals with no comorbidities were less likely to adhere than those with comorbidities. This is supported by Sewagegn, Fekadu et al. [46]. This may suggest that experiencing health complications reinforces the importance of dietary changes for some patients. And this might be also due to those participants who had additional diseases may have repeated counseling and they may fear the severity. On the other hand, the finding was contradicted by Seid, Abdela et al. [45] it might be due to the previous study seeing association to adherence of general self-care behavior while the current study to adherence of only dietary recommendation.

Finally, as expected, a favorable attitude towards the recommended diet was a significant factor associated with adherence. This finding is supported by Aridi, Walker et al. [56]. The possible explanation might be a positive outlook on a recommended diet can significantly boost adherence, diet is viewed as enjoyable and tasty, it feels more like a lifestyle change than a restrictive burden. This makes it easier to resist unhealthy temptations and stay committed. People who believe the diet will improve their health or well-being are also more motivated to follow it Karimy, Koohestani et al. [57].

Conclusion and recommendations

The study employed rigorous methods, including validated instruments, a large sample size, and systematic sampling, to ensure generalizability. Bivariate and multivariate analyses identified factors influencing dietary adherence. Ethical standards were strictly followed to maintain research integrity. However, the cross-sectional design limits establishing causal relationships between factors and adherence. Additionally, self-reported dietary data may be influenced by recall bias, and the study’s generalizability might be limited due to the specific population and healthcare setting. Further research opportunities include longitudinal studies to track adherence changes, incorporating objective measures to strengthen assessment, and conducting multicenter studies to enhance more generalizability.

This study identified low adherence to dietary recommendations among heart failure patients in Southern Ethiopia. The analysis revealed that age, hospitalization history, presence of comorbidities, and attitude towards the recommended diet were all factors influencing adherence. These findings highlight the need for multifaceted interventions that target negative attitudes, provide support to overcome challenges associated with dietary changes, and consider the specific needs of different patient subgroups.

To improve dietary adherence in this population, strategies to address negative attitudes towards the diet, such as recipe modifications and culturally-appropriate meal planning, are crucial. Ongoing support through groups, technology, and healthcare visits can further enhance adherence. Finally, tailoring interventions for specific patient subgroups based on factors like age and comorbidities is important. This finding suggests that younger patients might require additional support or targeted interventions to overcome challenges in adhering to dietary recommendations. Additionally, while the number of participants from urban and rural areas was similar, further analysis could explore potential variations in adherence patterns between these demographics in future studies. Future research should focus on understanding the reasons behind low adherence through qualitative studies and evaluating the effectiveness of interventions on long-term outcomes. By implementing these recommendations, healthcare professionals can empower patients to better disease management, improved quality of life, and potentially reduced healthcare costs.

Supporting information

S1 Table. STROBE checklist report for the study of bridging the gap between recommendation and reality: Improving dietary adherence of heart failure populations a cross-sectional study in Ethiopia.

https://doi.org/10.1371/journal.pone.0311663.s001

(PDF)

S2 Table. The dataset used for the study of bridging the gap between recommendation and reality: Improving dietary adherence of heart failure populations a cross-sectional study in Ethiopia.

https://doi.org/10.1371/journal.pone.0311663.s002

(XLS)

Acknowledgments

We authors would like to express our gratitude to Dilla University and all the participants for their contribution.

References

  1. 1. Fetensa G, Yadecha B, Tolossa T, Bekuma TT. Medication adherence and associated factors among chronic heart failure clients on follow up Oromia region, west Ethiopia. Cardiovascular & Hematological Agents in Medicinal Chemistry (Formerly Current Medicinal Chemistry-Cardiovascular & Hematological Agents). 2019;17(2):104–14. pmid:31629399
  2. 2. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):1810–52. pmid:23741057
  3. 3. Dracup K, Moser D, Pelter MM, Nesbitt T, Southard J, Paul SM, et al. Rural patients’ knowledge about heart failure. The Journal of cardiovascular nursing. 2014;29(5):423. pmid:23839575
  4. 4. Sanches Machado d’Almeida K, Ronchi Spillere S, Zuchinali P, Corrêa Souza G. Mediterranean diet and other dietary patterns in primary prevention of heart failure and changes in cardiac function markers: a systematic review. Nutrients. 2018;10(1):58. pmid:29320401
  5. 5. Members ATF, McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European heart journal. 2012;33(14):1787–847. pmid:22611136
  6. 6. Inamdar AA, Inamdar AC. Heart failure: diagnosis, management and utilization. Journal of clinical medicine. 2016;5(7):62. pmid:27367736
  7. 7. Stanley WC, Dabkowski ER, Ribeiro RF Jr, O’Connell KA. Dietary fat and heart failure: moving from lipotoxicity to lipoprotection. Circulation research. 2012;110(5):764–76. pmid:22383711
  8. 8. Unverzagt S, Meyer G, Mittmann S, Samos F-A, Unverzagt M, Prondzinsky R. Improving treatment adherence in heart failure: a systematic review and meta-analysis of pharmacological and lifestyle interventions. Deutsches Ärzteblatt International. 2016;113(25):423.
  9. 9. Buck HG, Lee CS, Moser DK, Albert NM, Lennie T, Bentley B ea. Relationship Between Self-care and Health-Related Quality of Life in Older Adults With Moderate to Advanced Heart Failure. Cardiovasc Nurs. 2012;27(8):15.
  10. 10. Wu JR, Corley DJ, Lennie TA,. MD. Effect of a medication-taking behavior feedback theory-based intervention on outcomes in patients with heart failure. Card Fail 2012;18:9.
  11. 11. Dickson VV, Buck H, Riegel B. A qualitative meta-analysis of heart failure self-care practices among individuals with multiple comorbid conditions. Journal of cardiac failure. 2011;17(5):413–9. pmid:21549299
  12. 12. Vellone E, Fida R, Ghezzi V, D’agostino F, Biagioli V, Paturzo M, et al. Patterns of self-care in adults with heart failure and their associations with sociodemographic and clinical characteristics, quality of life, and hospitalizations: a cluster analysis. Journal of Cardiovascular Nursing. 2017;32(2):180–9. pmid:26938506
  13. 13. Lee KS, Moser DK, Pelter MM, Nesbitt T, Dracup K. Self-care in rural residents with heart failure: What we are missing. European Journal of Cardiovascular Nursing. 2017;16(4):326–33. pmid:27566598
  14. 14. Moser DK, Dickson V, Jaarsma T, Lee C, Stromberg A, Riegel B. Role of self-care in the patient with heart failure. Current cardiology reports. 2012;14(3):265–75. pmid:22437374
  15. 15. Corotto PS, McCarey MM, Adams S, Khazanie P, Whellan DJ. Heart failure patient adherence: epidemiology, cause, and treatment. Heart failure clinics. 2012;9(1):49–58. pmid:23168317
  16. 16. Scalvini S, Giordano A. Optimal postdischarge management of chronic HF. Nature Reviews Cardiology. 2013;10(1):9–10.
  17. 17. Amakali K. Clinical care for the patient with heart failure: a nursing care perspective. Cardiol Pharmacol. 2015;4:142.
  18. 18. Seid MA, Abdela OA, Zeleke EG. Adherence to self-care recommendations and associated factors among adult heart failure patients. From the patients’ point of view. PloS one. 2019;14(2).
  19. 19. Arcand J, Ivanov J, Sasson A, Floras V, Al-Hesayen A, Azevedo ER, et al. A high-sodium diet is associated with acute decompensated heart failure in ambulatory heart failure patients: a prospective follow-up study. The American journal of clinical nutrition. 2011;93(2):332–7. pmid:21084647
  20. 20. Fleg JL, Cooper LS, Borlaug BA, Haykowsky MJ, Kraus WE, Levine BD, et al. Exercise training as therapy for heart failure: current status and future directions. Circulation: Heart Failure. 2015;8(1):209–20.
  21. 21. Hirai DM, Musch TI, Poole DC. Exercise training in chronic heart failure: improving skeletal muscle O2 transport and utilization. American Journal of Physiology-Heart and Circulatory Physiology. 2015;309(9):H1419–H39. pmid:26320036
  22. 22. Feltner C, Jones CD, Cené CW, Zheng Z-J, Sueta CA, Coker-Schwimmer EJ, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Annals of internal medicine. 2014;160(11):774–84. pmid:24862840
  23. 23. Giamouzis G, Kalogeropoulos A, Georgiopoulou V, Laskar S, Smith AL, Dunbar S, et al. Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions. Journal of cardiac failure. 2011;17(1):54–75. pmid:21187265
  24. 24. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, et al. HFSA 2010 comprehensive heart failure practice guideline. Journal of cardiac failure. 2010;16(6):e1–194. pmid:20610207
  25. 25. Alderman MH, Cohen HW. Dietary sodium intake and cardiovascular mortality: controversy resolved? American journal of hypertension. 2012;25(7):727–34. pmid:22627176
  26. 26. Doukky R, Avery E, Mangla A, Collado FM, Ibrahim Z, Poulin M-F, et al. Impact of dietary sodium restriction on heart failure outcomes. JACC: Heart Failure. 2016;4(1):24–35.
  27. 27. Temple NJ. Fat, sugar, whole grains and heart disease: 50 years of confusion. Nutrients. 2018;10(1):39. pmid:29300309
  28. 28. Lainscak M, Blue L, Clark AL, Dahlström U, Dickstein K, Ekman I, et al. Self‐care management of heart failure: practical recommendations from the Patient Care Committee of the Heart Failure Association of the European Society of Cardiology. European journal of heart failure. 2011;13(2):115–26. pmid:21148593
  29. 29. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics—2017 update. 2017.
  30. 30. Philipson H, Ekman I, Swedberg K, Schaufelberger M. A pilot study of salt and water restriction in patients with chronic heart failure. Scandinavian cardiovascular journal. 2010;44(4):209–14. pmid:20636228
  31. 31. Philipson H, Ekman I, Forslund HB, Swedberg K, Schaufelberger M. Salt and fluid restriction is effective in patients with chronic heart failure. European journal of heart failure. 2013;15(11):1304–10. pmid:23787719
  32. 32. Savarese G, Lund LH. Global public health burden of heart failure. Cardiac failure review. 2017;3(1):7. pmid:28785469
  33. 33. Heidenreich PA, Albert NM, Allen LA, Bluemke DA, Butler J, Fonarow GC, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circulation: Heart Failure. 2013;6(3):606–19.
  34. 34. Hall MJ, Levant S, DeFrances CJ. Hospitalization for congestive heart failure: United States, 2000–2010: US Department of Health and Human Services, Centers for Disease Control and …; 2012.
  35. 35. AL-khadher MAA, Fadl-Elmula I, Ahmed WAM. Compliance to treatment and quality of life of Sudanese patients with heart failure. Int J Prev. 2015;1:40–4.
  36. 36. Tsega TA, Demissei BG. A systematic review of epidemiology, treatment and prognosis of heart failure in adults in Ethiopia. Journal of Cardiovascular Medicine. 2018;19(3):91–7.
  37. 37. woldeyes Asfaw E. Five years clinical characteristics and in hospital outcome of acute heart failure at tertiary care hospital in Ethiopia. Ethiopian Medical Journal. 2020;58(01).
  38. 38. Beri B, Fanta K, Bekele F, Bedada W. Management, clinical outcomes, and its predictors among heart failure patients admitted to tertiary care hospitals in Ethiopia: prospective observational study. BMC cardiovascular disorders. 2023;23(1):4. pmid:36609240
  39. 39. Mulugeta H, Sinclair PM, Wilson A. Health-related quality of life and its influencing factors among people with heart failure in Ethiopia: using the revised Wilson and Cleary model. Scientific Reports. 2023;13(1):20241. pmid:37981652
  40. 40. Abebe SM, Andargie G, Shimeka A, Alemu K, Kebede Y, Wubeshet M, et al. The prevalence of non-communicable diseases in northwest Ethiopia: survey of Dabat Health and Demographic Surveillance System. BMJ open. 2017;7(10):e015496. pmid:29061601
  41. 41. van der Wal MH, van Veldhuisen DJ, Veeger NJ, Rutten FH, Jaarsma T. Compliance with non-pharmacological recommendations and outcome in heart failure patients. European heart journal. 2010;31(12):1486–93. pmid:20436049
  42. 42. Desai AS. The three-phase terrain of heart failure readmissions. Am Heart Assoc; 2012. pmid:22811548
  43. 43. Paulus WJ, Tschöpe C. A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. Journal of the American College of Cardiology. 2013;62(4):263–71. pmid:23684677
  44. 44. Sewagegn N, Fekadu S, Chanie T. Adherence to self-care behaviours and knowledge on treatment among heart failure patients in Ethiopia: the case of a tertiary teaching hospital. Journal of Pharmaceutical Care & Health Systems. 2015;10:2376–419.
  45. 45. Seid MA, Abdela OA, Zeleke EG. Adherence to self-care recommendations and associated factors among adult heart failure patients. From the patients’ point of view. PloS one. 2019;14(2):e0211768. pmid:30730931
  46. 46. Sewagegn N, Fekadu S, Chanie T. Adherence to self-care behaviours and knowledge on treatment among heart failure patients in Ethiopia: the case of a tertiary teaching hospital. Journal of Pharmaceutical Care & Health Systems 2015;10(2):43.
  47. 47. Jankowska-Polańska B, Kuśnierz M, Dudek K, Jaroch J, Uchmanowicz I. Impact of cognitive function on compliance with treatment in heart failure. Journal of Education, Health and Sport. 2017;7(2):392–414.
  48. 48. Kato N, Kinugawa K, Nakayama E, Hatakeyama A, Tsuji T, Kumagai Y, et al. Development and psychometric properties of the Japanese heart failure knowledge scale. International heart journal. 2013;54(4):228–33. pmid:23924936
  49. 49. Nieuwenhuis MM, Jaarsma T, van Veldhuisen DJ, Postmus D, van der Wal MH. Long-term compliance with nonpharmacologic treatment of patients with heart failure. The American journal of cardiology. 2012;110(3):392–7. pmid:22516525
  50. 50. van Der Wal MH, Jaarsma T, Moser DK, Veeger NJ, van Gilst WH, van Veldhuisen DJ. Compliance in heart failure patients: the importance of knowledge and beliefs. European heart journal. 2006;27(4):434–40. pmid:16230302
  51. 51. Evangelista LS, Berg J, Dracup K. Relationship between psychosocial variables and compliance in patients with heart failure. Heart & Lung. 2001;30(4):294–301.
  52. 52. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. The lancet. 2007;370(9596):1453–7.
  53. 53. Marti CN, Georgiopoulou VV, Giamouzis G, Cole RT, Deka A, Tang WW, et al. Patient‐reported selective adherence to heart failure self‐care recommendations: a prospective cohort study: the Atlanta cardiomyopathy consortium. Congestive heart failure. 2013;19(1):16–24. pmid:22958604
  54. 54. Conceição APd Santos MAd, Bd Santos, Cruz DdALMd. Self-care in heart failure patients. Revista latino-americana de enfermagem. 2015;23:578–86.
  55. 55. Gibson EL. Emotional influences on food choice: sensory, physiological and psychological pathways. Physiology & behavior. 2006;89(1):53–61. pmid:16545403
  56. 56. Aridi YS, Walker JL, Roura E, Wright OR. Nutritional knowledge of the Mediterranean diet is associated with positive attitudes and adherence in a non-Mediterranean multi-ethnic society. Dietetics. 2022;1(2):124–36.
  57. 57. Karimy M, Koohestani HR, Araban M. The association between attitude, self-efficacy, and social support and adherence to diabetes self-care behavior. Diabetology & metabolic syndrome. 2018;10:1–6. pmid:30534204