Heart Failure (HF) is a clinical syndrome characterized by cardinal signs and symptoms (breathlessness, ankle swelling, fatigue, elevated jugular venous pressure, pulmonary crackles, and peripheral edema). In 2021, the incidence of HF in Europe was approximately 3/1000 person-years (all age groups) or 5/1000 person-years in adults [1]. Approximately 6 million American adults aged ≥ 20 years had HF according to data from 2015 to 2018 [2]. With aging population, the prevalence of HF has risen dramatically in recent decades [3]. However, in Sub-Saharan Africa (SSA), unlike high-income countries, HF is a disease of young and middle-aged adults with attendant high disability-adjusted life years. In SSA, HF accounted for 9.4–42.5% of all medical admissions and 25.6–30.0% of admissions into cardiac units [4].

Patient education and support for HF patients are needed to improve their self-care behaviors and are the goal of many HF management programs [5]. Self-care is essential for the long-term management of chronic heart failure. It can be defined as the process of maintaining health through health-promoting and preventive practices [6]. HF-related self-care behavior reflects the actions that HF patient undertakes to maintain life, healthy functioning, and wellbeing. Self-care includes behaviors such as adherence to medication, diet, and exercise, as well as self-management of symptoms; however, it also refers to behaviors such as daily weighing to assess fluid retention and seeking assistance when symptoms occur [5]. Literature indicates that patients with HF who have more effective self-care have better quality of life, and lower mortality and readmission rates than those with lower levels of self-care [6].

Worldwide, self-care behaviors are suboptimal in HF patients [7]. In a study by Sedlar et al. from Slovenia, more than half (51%) of the HF patients were reported to be inadequate in their self-care [8]. A systematic review revealed a diverse range of personal and environmental factors associated with self-care behaviors in heart failure patients. Age, health-related quality of life, sex, education, New York Heart Association class, depressive symptoms, and left ventricular ejection fraction were most often correlated with the European Heart Failure Self-care Behaviour Scale (EHFScBs) score [9], which was an internally consistent and valid instrument to measure HF-related self-care behaviour [5]. Regarding specific HF self-care behaviors, a study from Taiwan reported at least half of the HF patients never or rarely weighed themselves (50%) or checked their ankle swelling (62.8%). Moreover, 77.3% of the patients did not ask for low-salt items when eating out or visiting others [10].

There is a gap in the literature from Sub-Saharan Africa (SSA) because there is a scarcity of data regarding self-care behaviors among HF patients. A study from South Africa reported that among adult HF patients, adherence to self-care behaviors ranged from 2.5% to 98%. Daily weight monitoring and keeping a moderate alcohol intake (one beer, one to two glasses of wine per day) were the lowest and the highest rates of adherence, respectively [11]. In Ethiopia, few studies were published [12-15] regarding self-care behaviors among HF patients. The rate of good adherence to self-care behaviors was 22.3% in a study by Seid et al. [12] and 51.2% in a study by Fetensa et al. [15]. A higher level of good adherence was noted for taking prescribed medication (93.2%) and had follow-up appointments (90.2%). However, a higher level of poor adherence was noted for weight monitoring (87.6%), regular exercise (85.6%), and fluid restriction (70.5%) [14]. Gebru et al. [13] identified that age, educational level, comorbidity, knowledge about HF, and social support were significantly associated with self-care behavior. There was a scarcity of published studies related to self-care behaviors among HF patients in our setting, Jimma University Medical center (JUMC).

Self-care education, including the control of non-pharmacological measures, should be part of the daily management of HF patients both hospital and ambulatory settings. Nurses at HF follow-up clinics together with other professionals integrating the multidisciplinary team have played a fundamental role in the follow-up and management of patients [16]. Optimal outcomes for patients with HF depend on their engagement in effective self-care activities. Effective HF self-care is associated with several positive outcomes such as improved quality of life and reduced mortality, morbidity, and healthcare costs. Therefore, this study aimed to determine the level of adherence to self-care behaviors and assess the factors associated with self-care among adult HF patients attending follow-up care at JUMC.

Self-care is a naturalistic decision-making process that patients use in the choice of behaviors that maintain physiological stability (symptom monitoring and treatment adherence) and response to symptoms when they occur [23]. Patients with HF who report more effective self-care behaviors have a better quality of life, lower mortality and readmission rates than those with lower levels of self-care [6]. Thus, this study was designed to determine the level of adherence to self-care behaviors among adult HF patients attending chronic follow-up care at JUMC. The results of the study indicated that half of the HF patients on follow-up care in our setting had good adherence to HF self-care behavior recommendations. Participants’ education level, illness duration, and HF NYHA class were factors associated with adherence to self-care.

Regarding the background of the participants included in this study, 70.0% had NYHA classes II and III. Similarly, in several studies, the included participants mainly had HF NYHA functional classes II and III [11, 21, 24]. One-third of the patients in our study had a history of hospitalization in the past 6 months. In the same way, in a study by Vellone et al., 54.5% of the patients were hospitalized at least once [24].

In this study, only half of the study participants had good adherence to self-care behavior recommendations. Our result is almost comparable to studies done in Slovenia by Sedlar et al. [8], in Ethiopia by Fetensa et al. [15], and Seid et al. (20), where 49.0%, 51.2%, and 52.0% of heart failure patients had good adherence to self-care behavior recommendations, respectively. However, our result is higher compared to studies by Gebru et al. (45.8%) [13], Tegegn et al. (28%) [14], and Seid et al. (22.3%) [12]. The difference in the findings might be related to the use of a different number of items to measure self-care behaviors. It might also be related to the differences in the level of education of the participants. For example, in studies by Seid et al. [12] and Gebreu et al. [13], about half of the participants had an educational level of illiterate compared to the 37.2% in our study. In support of this, studies have shown that HF patients with higher education were associated with higher self-care maintenance [25, 26].

Regarding the individual self-care recommendations, the most followed self-care behavior recommendation was “I take medication as prescribed” by 75.5% of the participants. Similar findings were reported by Lee et al. from the USA [27], Zamanzadeh et al. from Iran [28], Tegegn et al. and Seid et al. from Ethiopia [12, 14], Sedlar et al. from Slovenia [8], and Alber et al. from USA [29]. The reason for a higher proportion of patients following the recommendation to take medicines as prescribed could be that HF is a chronic condition associated with syndromes of symptoms that limit the patients’ daily physical and social activities; and HF patients who take their medications as prescribed might find they have fewer symptoms. In addition, taking medications does not require active effort, whereas other self-care behaviors do. Thus, all self-care behavior recommendations should be reinforced by nurses during follow-up visits to facilitate better treatment outcomes for patients with chronic HF.

This study revealed that the least followed self-care behavior recommendation was contacting doctors when one had shortness of breath (SoB) or swollen feet or legs. Similarly, in a study by Santesmases-Masana R et al., contacting doctors/nurses when experiencing SOB and swollen leg/feet was lower compared to other recommendations [30]. However, our study contrasts with a study by Seid et al., in which, patients were more frequently contacted by doctors or nurses when they experienced shortness of breath and a sign of legs/feet edema [20]. A similar finding was also reported by Zamanzadeh et al. from Iran, where the item “regular visits to the doctor or nurse” was the second following recommendation only after the item “Taking medication in the prescribed time” [28]^. The difference in the patients contacting doctors/nurses when symptoms occur might be related to socioeconomic differences between patients, or lack of knowledge related to its importance.

Studies have confirmed that patient socio-demographic characteristics and disease state affected HF self-care adherence [9]. Our analysis revealed that the participants who could not read and write were 70.0% less likely to adhere to HF self-care behaviors compared to patients with a college education. Similarly, in a study by Gebru et al., patients who had an educational level of diploma and above were 2.55 times more likely to have good self-care behavior compared to those who could not read and write [13]. Sedlar et al. also reported having an education level below high school was negatively (OR: 0.314) associated with adequate self-care among HF patients [8]. However, in a study by Asadi et al., self-care behavior scores did not have a significant relationship with the level of participants’ education [31]. Regarding the HF duration with HF self-care recommendations, patients with an HF duration of ≥ 10 years were less likely to have good adherence to self-care behavior recommendations. However, this finding contrasts with a study by Fetensa et al., where patients with a duration of HF greater than 1 year were positively associated with good self-care recommendations [15]. Gebru et al. also reported that patients with an HF duration of less than one year were 62% less likely to have good self-care behaviors [13].

In this study, the last variable associated with self-care behavior recommendations was HF NYHA functional class. Patients with NYHA class II HF were 77.0% less likely to be well adherent to self-care behavior recommendations. Similarly, Gebru et al. reported that respondents with NYHA functional class I were 83% less likely to have good self-care [13]. A study conducted in the USA also revealed better HF symptom status was negatively associated with self-care [27]. This may be because patients with HF in the non-advanced NYHA class have lower symptom burdens; so they may not adhere to self-care recommendations. A study reported that when HF symptoms were severe, and self-care was high, health-related quality of life was better than when symptoms were high and self-care was low [32].

This study was single-center and included patients on follow-up care who had at least three follow-up visits. Therefore, the findings may not be generalizable to HF patients who were recently diagnosed with HF or those who were recently discharged from the hospital.

Many HF patients had low levels of knowledge and understanding of heart failure and self-care. The HF guidelines stress the importance of patient education on treatment adherence, lifestyle changes, symptom monitoring and adequate response to possible deterioration [6]. Educational interventions should be used to empower patients to recognize and manage their symptoms. In a study by Son et al., nurse-led HF self-care education significantly reduced the risk of all-cause readmission to the hospital, HF-specific readmission, and all-cause mortality or readmission [33]. Nurses have a crucial role teaching HF patients' self-care abilities, which include weight monitoring, sodium and fluid restrictions, physical activities, regular medication use, monitoring signs and symptoms of disease worsening and early search for medical care. Knowing the level of self-care behaviors in HF patients will help nurses to recognize behaviors that need to be modified or added for better disease control and consequently, better quality of life. Ongoing assessment of HF patients’ self-care behaviors should be an essential part of nursing practice. Based on our findings, we recommend that clinicians, in particular nursing professionals, should counsel or educate patients with HF on self-care practice recommendations, particularly patients with a lower education level and who live longer with HF. Local policymakers should also develop strategies to strengthen nursing education on self-care behaviors at follow-care for HF patients.

The results of this study indicated that half of the HF patients have poorly adhered to self-care behaviors. Participants’ lower education level, longer illness duration, and HF NYHA class II were predictors of poor adherence to self-care.