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. 2023 Aug 23;18(8):e0288824. doi: 10.1371/journal.pone.0288824

Adherence to self-care practices and associated factors among heart failure patients in Ethiopia: A systematic review and meta-analysis

Firomsa Bekele 1,*, Lalise Tafese 2, Addisalem Workie Demsash 2, Hana Tesfaye 3, Busha Gamachu Labata 4, Ginenus Fekadu 4,5
Editor: Mohammed Feyisso Shaka6
PMCID: PMC10446213  PMID: 37611019

Abstract

Background

Heart failure is the leading cause of hospital stays, medical expenses, and fatalities, and it is a severe problem for worldwide public health. Successful heart failure therapy requires a high level of self-care as well as devotion to different elements of the treatment plan. Despite the positive effects of heart failure self-care on health outcomes, many heart failure patients engage in insufficient self-care behaviors. Additionally, conflicting information has been found regarding the prevalence and predictors of self-care behaviors in Ethiopia. As a result, this review’s objective is to provide an overview of the most recent studies on Ethiopian heart failure patients’ self-care practices.

Methods

We have used four databases such as PubMed, Science Direct, Scopus and Google Scholar. Eventually, the final systematic review and meta-analysis contained eleven papers that matched the eligibility requirements. A systematic data extraction check list was used to extract the data, and STATA version 14 was used for the analysis. Heterogeneity was evaluated using the I2 tests and the Cochrane Q test statistic. To examine publication bias, a funnel plot, Egger’s weighted regression, and Begg’s test were utilized.

Result

The pooled magnitude of adherence to self-care was 35.25% (95%CI: 27.36–43.14). The predictors of good adherence to self-care behavior includes heart failure knowledge (odds ratio = 5.26; 95% CI, 3.20–8.65), absence of depressive symptoms (odds ratio = 3.20;95% CI,1.18–8.70), higher level of education (AOR = 3.09;95%CI,1.45–6.61), advanced New York Heart Association (NYHA) class (odds ratio = 2.66; 95% CI, 1.39–5.07), absence of comorbidity(odds ratio = 2.92; 95% CI,1.69–5.06) and duration of heart failure symptoms(odds ratio = 0.37; 95% CI, 0.24–0.58).

Conclusion

The extent of self-care behavior adherence is shown to be low among heart failure patients. This study showed a positive relationship between self-care behavior and factors such as proper understanding of heart failure, the absence of co-morbidity, depression, higher levels of education, a longer duration of heart failure symptoms, and advanced classes of heart failure disease. Therefore, a continuous health education should be given for patients to enhance their understanding of heart failure. Besides, special attention should be given for patients having co-morbidity and depressive symptom.

Background

Heart failure (HF) is a clinical condition that is indicated by signs and symptoms of fluid overload or inadequate tissue perfusion as a result of the heart’s decreased cardiac output, which is required to meet metabolic needs and accommodate venous return [1, 2]. It is a serious public health problem that is to blame for most global hospital stays, medical costs, and fatalities [1–3]. The fatality rate for heart failure patients in Africa is three to four times greater than in Western countries, especially in Sub-Saharan Africa [2].

Despite improvements in pharmaceutical therapy, heart failure morbidity and mortality remain high. Therefore, non-pharmacological management of heart failure, which primarily focuses on self-care management, deserves more attention [1, 4–7]. Doctors and other healthcare professionals devote a significant amount of time in each clinical encounter to educate patients and their families about the requirements of self-care in order to reduce heart failure exacerbations and re-hospitalizations [8].

Self-care behaviors become essential to halt the development of cardiac remodeling and avoid rapid decompensation, which can produce subpar clinical outcomes [9]. Self-care is viewed as the cornerstone of HF therapy and entails essential practices that have been shown to improve HF clinical outcomes. These include adjusting one’s lifestyle by taking prescribed medications as directed, sodium diet restriction, exercising, reducing liquid intake, and routinely weighing oneself [2, 10].

A significant amount of self-care and adherence to various components of the treatment plan are necessary for HF therapy to be successful [10]. Inadequate self-care practices lead to higher rates of morbidity and mortality, lower quality of life, and higher health care costs because of more outpatient treatment and higher hospital readmission rates [10–12].

Despite the impact of HF self-care on positive health outcomes, many HF patients don’t practice enough self-care [13]. People with HF who must adhere to a multi-pronged treatment plan are starting to understand how challenging it is to maintain self-care behavior [10, 11, 14]. Self-care practices were poor, according to several studies conducted in Ethiopia [1, 11, 15–18]. Few studies reportedly found that good self-care behaviors are generally practiced [2, 19, 20].

This lack of compliance may be due to the complexity of such changes, the difficulty of self-care, the lack of perceived need for self-care, the necessity for long-term behavioral adjustments, a lack of motivation, or any of these factors [21]. In addition, a wide range of factors may affect how well HF patients follow self-care recommendations. Patients’ characteristics like age, sex, marital status, religion, place of residence, level of education, occupation, and family income are among them, as are clinical characteristics like length of diagnosis, stage of HF, co-morbidity, prior hospitalization, awareness of HF, presence of depressive symptoms, and family support [15, 17, 18, 20, 22, 23].

Despite a variable reports of magnitude and predictors of self-care practices in Ethiopia, there was no systematic review and meta-analysis conducted and the purpose of this paper is to summarize the recent findings on factors related to self-care behavior in order to provide an appropriate intervention.

Methods

Searching strategy

The objective of the review was to conclude the magnitude and risk factors of adherence to self-care practice among heart failure patients in Ethiopia. The Review protocol was registered on PROSPERO CRD42023423492.

The protocol of PRISMA 2020 was used to undertake this systematic review and meta-analysis [24]. Three data bases like PubMed, Science direct, Scopus and Google scholar were used. The time period used to conduct this review was from the February 9 to March 9, 2023. The last date to search was March 4, 2023. The MESH term for the database is ((Self-care Practice) OR (heart failure)) AND (associated factors)) AND (prevalence)) AND (Ethiopia).

Data collection process, items and extraction

Three authors namely FB, LT, and AWD were involved in collecting different literatures. Reference management software (endnote version X7.2) used to combine search results from databases and to remove duplicate articles. Data were extracted by two data extractors (FB and LT) using a standardized data extraction checklist on Microsoft excel. For the first outcome (magnitude), the data extraction checklist included author name, year of publication, region, study design, sample size and number of participants with the outcome. For the second outcome (associated factors), data were extracted in a format of two by two tables, and then the log OR for each factor was calculated based on the findings of the original studies. Discrepancies between two independent reviewers were resolved by involving a third and fourth reviewers (ADW and HT) after discussion for possible consensus. BGL and GF have overseen the overall process of data extraction and synthesis. The participant recruitment dates and/or date on which medical records were not accessed since our study was systematic review and meta-analysis.

Eligibility criteria

The findings published related to magnitude and predictors of adherence to self-care practice among heart failure patients in Ethiopia having all primary outcome and full texts available were included. The articles with unknown primary outcomes, systematic reviews and meta-analysis studies, not peer reviewed and commentary to editors were not eligible. The review used the CoCoPop (condition, Context, and Population) framework to assess the eligibility of the studies.

The study Population (POP) was heart failure patients, the Condition (CO) was adherence to self-care practice, and the context (CO) studies conducted in Ethiopia.

Outcome measurement

There were two main outcomes. The primary outcome of interest was the prevalence of adherence to self-care practices among heart failure patients, which was estimated as the total number of patients adhered to self-care practices divided by the total number of heart failure patients multiplied by 100. The second outcome was identifying factors associated with an adherence to self-care practice, which were determined using the odds ratio (OR) and calculated based on binary outcomes from the included primary studies.

The extent of self-care practice practices is low if less than the midpoint (50%) of the revised nine-item European Heart Failure Self-care Behavior Scale (EHFScBS-9) [25, 26].

Quality assessment

The Joanna Briggs institute meta-analysis of statistics assessment and review instrument (JBI- MAStARI) was used for quality assessment [27].

Data analysis and synthesis

Data exported to STATA V. 14 to calculate the pooled effect size with 95% CIs. To check heterogeneity among the included studies, the Cochran Q test (chi-squared statistic) and I2 statistic on forest plots were computed. Cochran’s Q statistical heterogeneity test is considered statistically significant at P ≤ 0.05. I2 statistics range from 0 to 100% and I2 statistic values of 0, 25, 50, and 75% were considered as no, low, moderate, and high degrees of heterogeneity, respectively. A funnel plot was used to assess publication bias. Asymmetry of the funnel plot is an indicator of publication bias. Besides, Egger’s weighted regression and Begg’s test were used to check publication bias. Statistical significance of publication bias was declared at a P-value of less than 0.05.

Risk of bias

The study population was known in all articles. We have obtained complete outcome variables in all articles. In all articles involved, selective reporting and publication bias were not obtained.

Results

Search results

A total of 8,950 articles were obtained up on initial searching from PubMed, Science direct, Scopus and Google scholar. A total of 8,006 articles were removed due to duplications. Finally a total of 913 articles were excluded by observing their title and abstracts. Consequently, only 31 articles were subject to a full-text review. Finally, 11 articles were selected to be included in our review [Fig 1].

Fig 1. Flow chart of the systematic research and study selection process.

Fig 1

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Characteristics of included studies

In our systematic review and meta-analysis the filtered articles were cross-sectional studies. The majority of the participant were female in eight of the articles [2, 15–20, 23], whereas male was predominant in the three articles [1, 11, 22]. The total sample was 3,657 heart failure patients, ranging from 235 to 424. Regarding to the study settings, five articles were from Oromia [2, 11, 19, 22, 20] and two were from Amhara [1, 18],two were from Addis Ababa [15, 16],each one article was from SNNP [17] and Tigray [23] [Table 1]. The variations seen in Oromia might be due to a difference in publication years and large variations in sample size.

Table 1. Summary of included studies on self-care practices among heart failure patients in Ethiopia, 2023.

Authors Years of publication Region Study design Sample size Gender (Male) Good adherence (95%CI)
Belayneh et al [1] 2022 Amhara Cross-sectional 312 58.6% 32.9(27.61,38.18)
Almaz et al [2] 2022 Oromia Cross-sectional 420 47.1% 53.6(48.80,58.34)
Negese et al [11] 2015 Oromia Cross-sectional 328 55.5% 17.4%(13.28, 21.48)
Getahun et al [19] 2021 Oromia Cross-sectional 424 42.9% 51.2%(46.42,55.94)
Aemiro et al [15] 2022 Finfinne Cross-sectional 294 41.84% 32.7%(27.29,38.01)
Bethlehem et al [16] 2021 Finfinne Cross-sectional 396 48.5% 28%(23.61,32.45)
Enu et al [17] 2022 SNNP Cross-sectional 235 45.4% 34.1%(27.92,40.2)
Jemal et al [22] 2014 Oromia Cross-sectional 264 51% 40.8%(34.75,46.82)
Temesgen et al [20] 2022 Oromia Cross-sectional 266 45.9% 50.0%(43.99,56.01)
Tsegu et al [23] 2020 Tigray Cross-sectional 408 45.1% 45.8%(41.0,50.67)
Mohammed et al [18] 2019 Amhara Cross-sectional 310 35.8% 22.3%(17.63,26.89)
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Adherence to self-care practices

The pooled magnitude of adherence to self-care was 35.25% (95%CI: 27.36–43.14). Heterogeneity was not observed across the included studies (I2 = 0.0, p = 0.552). Both the highest (53.6%) [2] and lowest (17.4%) [11] adherence level of self-care practices was reported in Oromia [Fig 2].

Fig 2. Forest plot of the pooled magnitude of adherence to self -care practices among heart failure patients in Ethiopia, 2023.

Fig 2

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Publication bias

To assess the presence of publication bias, funnel plot, Egger test and Begg’s test at 5% significant level were computed. The funnel plot looks asymmetry, but the Egger test and Begg’s test showed there is no statistically significant for the presence of publication bias with p-value = 0.363 and 0.175, respectively [Fig 3].

Fig 3. Funnel plot of the included studies to test publication bias in Ethiopia, 2023.

Fig 3

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Factors associated with adherence to self‑care practices

To identify the pooled predictors of self-care practices, eleven studies were included in the meta-analysis. The pooled effects of odds ratio was assessed by using the command of “metan logor selogor, xlab(0.1,1,10) label(namevar = authors) by (factors)random texts(180) eform.” Patients with HF that had a good knowledge on heart failure were 5.26 times more likely to practice good self-care than their counterparts (AOR = 5.26; 95% CI, 3.20–8.65). Similarly, patients hadn’t a depressive symptoms were 3.20 times more likely to practice good self-care (AOR = 3.20;95% CI,1.18–8.70). Patient that had a higher level of education were 3.09 times more likely to had a good adherence to self-care behaviors (AOR = 3.09;95%CI,1.45–6.61).

Regarding NYHA classification, those patients with NYHA class III and IV were 2.66 times more likely had good adherence to self-care recommendations compared to NYHA class I and II.(AOR = 2.66; 95% CI, 1.39–5.07). Heart failure patients that had not co-morbid disease were 2.92 times more likely adhered to self-care practices than patients having co-morbidity.(AOR = 2.92; 95% CI,1.69–5.06). However, patients having less than one year duration of heart failure were 63% less likely to adhere to self-care practices. (AOR = 0.37; 95% CI, 0.24–0.58) [Fig 4].

Fig 4. Forest plot of association factors of self-care practice among heart failure practice in Ethiopia, 2023.

Fig 4

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Discussion

To the best of our knowledge, this meta-analysis and systematic review are the first of its kind that conducted at the national level to estimates magnitude and identifies factors associated with a adherence to self-care practices among heart failure patients in Ethiopia.

The pooled prevalence of adherence to self-care practices among heart failure patients in Ethiopia is 35.25%. In Ethiopia, the prevalence of adherence to self-care practices is relatively increasing from previous studies (17.4% in 2015) to recent ones (53.6% in 2022). The lack of an interventional strategy and ongoing monitoring of heart failure patients may be to blame for the relative increase between earlier trials and more recent ones. The rate of adherence is equivalent to that of the study done in Brazil(35.17%) [9], lower than that of the studies done in the Netherlands(41%) [6] and Taiwan(53.37%) [28], and higher than that of Korea(31.98%) [14]. This discrepancy could be due to the difference in the sample size and sampling techniques and different data collection used.

This systematic review and meta-analysis also identified factors associated with adherence to self-care practices. Heart failure patients who had a good knowledge on heart failure had more likely to have a good adherence. This finding is supported by a study conducted in a California [8] and Korea [14]. This could be explained by the fact that a patient’s understanding of their illness is a requirement for improving self-care behaviors, and that individuals with good knowledge exhibited good health-seeking behaviors to avoid needless readmissions to the hospital.

Heart failure patients who were on advanced stage were more likely to be adhered to self-care practices than their counterparts. This is similar with the systematic review of European Heart Failure Self-Care Behavior Scale studies [13] and inconsistent with Korea [14]. This might be as a result of their frequent interactions with medical personnel and worry of a bad treatment outcome. Additionally, patients with NYHA functional classes I and II think their HF symptoms may have completely subsided more frequently, and this belief may hold true in the future.

Heart failure patients who were having higher level of education were more likely to be adhered to self-care practices than their counterparts. Similar finding was reported according to systematic review of European Heart Failure Self-Care Behavior Scale studies [13] and Nepal [3]. This can be explained by the fact that people with higher educational levels have higher levels of reasoning and decision-making for performing self-care behaviors and they can easily understand the information required for self-care that leads them to good adherence.

Patients were more likely to follow their self-care routines if they did not exhibit depressed symptoms. According to results from Nezerland [12] and a systematic evaluation of research using the European Heart Failure Self-Care Behavior Scale [13], similar findings have been observed. Patients with better mental health are more likely to adhere to self-care recommendations because they have unaltered thinking abilities and a positive attitude toward maintaining their health. Depression may increase the burden of patients’ overall clinical condition, making the patients less likely to follow the recommended self-care practice.

Patients were more likely to follow their self-care routines if they did not have a co-morbid ailment. This is consistent with a Japanese study’s result that diabetes mellitus is a predictor of poor self-care behaviors [7]. Patients with diabetes mellitus need to engage in self-care activities linked to the disease, such as a special diet and exercise to control blood sugar. Patients with HF who also have diabetes mellitus require a different or more intensive treatment regimen, as well as more complex self-care behavior components. Such patients are likely to have difficulty with self-care behavior, and they may therefore need individually tailored support to help them combine the needed self-care behavior.

Co-morbid participants were more likely to be non-adherent than non-co-morbid participants, which may be because patients with multiple chronic illnesses must overcome additional functional, cognitive, and physical barriers in order to carry out multicomponent self-care recommendations. These patients are more likely to see many doctors, and they may get advice that is unclear or contradictory, which could lower their degree of adherence.

Patients were less likely to adhere to self-care practices if their heart failure symptoms had not been present for a longer period of time. This result was consistent with research conducted in Southern California Ohio [29] and Brazil [30], This is because individuals who were recently diagnosed with HF had a harder time identifying their own HF symptoms. Therefore, compared to newly diagnosed patients, experienced patients were more likely to use appropriate self-care strategies.

Limitation of the study

As the limitation, the sample size of the included studies was small. In addition, all of the studies included in this review were cross-sectional study design; as a result, the causal effect relationship was could not be identified.

Conclusion

In current systematic review and meta-analysis, the magnitude of adherence to self-care behavior is among heart failure patients is found to be low. This study showed that adequate knowledge of heart failure, absence of co-morbidity, depression, higher level of education, longer duration of heart failure symptoms, and advanced class of heart failure disease were positively associated with the adherence to self-care behavior. Therefore, a proper health education towards improving the patient’s knowledge is vital to improve self-care behavior. Besides, special attention should be given for patients having co-morbidity, advanced stage of heart failure, and shorter duration of heart failure symptom. Finally, it is important for health care providers to learn to recognize depressive symptoms in heart failure patients and treat depressed patients according to existing psychiatric guidelines.

Supporting information

S1 Checklist. PRISMA-2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analysis-2020) checklist.

(DOCX)

Click here for additional data file. (35.3KB, docx)
S1 Data. The microsoft excel data of pooled magnitude of adherence to self-care practices.

(XLSX)

Click here for additional data file. (10.1KB, xlsx)
S2 Data. The microsoft excel data of the pooled associated factors of adherence to self-care practices.

(XLSX)

Click here for additional data file. (15.2KB, xlsx)

Acknowledgments

We would like to thank all authors of the studies included in this systematic review and meta-analysis.

Abbreviations

AOR

Adjusted Odds Ratio

CI

Confidence Interval

HF

Heart failure

NYHA

New York Heart Association

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-analyses

SNNP

Southern Nation Nationalities and People

Data Availability

The data are only available upon request. The data would be guarded carefully by our third party data for the only purpose of this scientific study. Participants were not signed consent for data publicly. For all these reasons and following the indications of the research review committee of College of Health Sciences, Mettu University, the authors must not upload the dataset to a stable, public repository. Interested, qualified researchers can access the data by requesting our third party, Mattu University (mattuniversity@meu.edu.et).

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Mohammed Feyisso Shaka

27 Apr 2023

PONE-D-23-06552Self-care practices and associated factors among heart failure patients in Ethiopia: A systematic review and Meta-AnalysisPLOS ONE

Dear Dr. Bekele,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Reviewer #1: Independent Review Report

Evaluation

The evaluation is for the review article titled “Self-care Practices and associated factors among heart failure patients in Ethiopia: A systematic review and Meta-Analysis”

With the present study, the following areas are observed, commented and recommended.

1. Throughout the main text, it was sequential and well organized.

2. It requires grammatical corrections throughout the document.

3. This manuscript has a sum up of novelty.

Comments to the author/s

Abstract:

1. Try to avoid abbreviation of words in the abstract part

2. “We have used three databases such as Pub Med, Science Direct and Google Scholar.

Why do you exclude other important databases that you might get potential primary studies from?

3. Heterogeneity was evaluated using the I2 tests and the Cochrane Q test statistic.

What is the advantage of performing the Q test in addition to the I2 test to assess heterogeneity?

4. To examine publication bias, a funnel plot, Egger's weighted regression, and Begg's test were utilized. What is the importance of using different tests?

5. “The extent of self-care behaviour adherence is shown to be low among heart failure patients”. What is the standard reference to say “low or high”?

Method

6. Please use the uniform reference citation system

7. Please try to strictly adhere to all the PRISMA 2020 guidelines to write up your paper, especially the method section.

8. Does this review registered on PROSPERO?

9. What is your last search date included in the method part?

10. What you have done if a study has low quality or higher risk?

11. “Finfinnee" is not a legal name, not yet known

12. What you have done if there is heterogeneity and publication bias between the primary studies?

13. How to perform the pooled effect of odds ratio to identify the factors associated with good selfie care? Please show on your paper as it is critical.

Result

14. Table 1 column 6 gender (male). What is this???

15. Why you have performed sub-group analysis and sensitivity test?

Reviewer #2: Dear authors, thank you for your contribution. In general the issue you raised is very good. However, I have some comments and questions which described below.

1. Language edition service is required throughout the document

2. Please rephrase this sentence found in your abstract’ ‘The patient's understanding must therefore be improved by effective health education if self-care behaviour is to be improved.’’

3. The databases scrutinized to search studies are too small. Why only three databases? I think some papers are missed. Therefore please search on at least familiar databases like HINARI, Scopus, and AJOL

4. The MESH terms are little, why?

5. Why you preferred CoCoPop?

6. With this visible heterogeneity among studies, it is difficult to accept. Therefore, I need further evidence /explanation for this because the authors even mentioned the presence the presence of heterogeneity between studies conducted in Oromia. Why?

7. In your discussion part you mentioned this’ ’The prevalence of adherence is comparable with the study conducted in Brazil (35.17%)(9) and lower than the study of Netherland(41%)(6) and Taiwan(53.37%)(26) and higher than the study of Korea(31.98%)(14). This discrepancy could be due to the difference in the study method.’’ What type of difference in study method?

8. On your limitation please rephrase this sentence’ ‘The small sample due to a limited number of included studies with a small sample size for all included studies was a limitation of this study. ‘’

9. The number of studies included in your study is 11 but in the funnel plot it is more than 20 (each dot on the figure represent one study), Why this variation

Thank you

==============================

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Academic Editor

PLOS ONE

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- https://doi.org/10.1016/j.hrtlng.2008.11.002

- https://www.slideshare.net/negesesewagegn/adherence-toselfcarebehavioursandknowledgeontreatmentamongheartfailurepatientsinethiopiathecaseofatertiaryteachinghospital23760419s4001

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We will update your Data Availability statement to reflect the information you provide in your cover letter.

Additional Editor Comments:

  • Needs extensive language revision

  • Use consistent font style

  • How do proper understanding of HF measured? Or you are speaking about the knowledge?

  • Under your conclusion you have said, “…. patients with co-morbidities and depressive symptoms require extra care. What findings imply for such conclusion? Please rephrase it based on your findings.

  • Write Pub Med as PubMed

  • Use consistent bracket for references. E.g. you used square bracket for reference #24

  • Please share us the data extraction checklist on Microsoft excel which you have used to extract data with the extracted data for both objectives

  • Please correct the I2  under the data analysis section on page 5

  • Did you measured adherence to selfcare or the practice of good selfcare. Your result and what you have described in the methodology is confusing. Please clearly describe what was measured and how it was measured

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Independent Review Report

Evaluation

The evaluation is for the review article titled “Self-care Practices and associated factors among heart failure patients in Ethiopia: A systematic review and Meta-Analysis”

With the present study, the following areas are observed, commented and recommended.

1. Throughout the main text, it was sequential and well organized.

2. It requires grammatical corrections throughout the document.

3. This manuscript has a sum up of novelty.

Comments to the author/s

Abstract:

1. Try to avoid abbreviation of words in the abstract part

2. “We have used three databases such as Pub Med, Science Direct and Google Scholar.

Why do you exclude other important databases that you might get potential primary studies from?

3. Heterogeneity was evaluated using the I2 tests and the Cochrane Q test statistic.

What is the advantage of performing the Q test in addition to the I2 test to assess heterogeneity?

4. To examine publication bias, a funnel plot, Egger's weighted regression, and Begg's test were utilized. What is the importance of using different tests?

5. “The extent of self-care behaviour adherence is shown to be low among heart failure patients”. What is the standard reference to say “low or high”?

Method

6. Please use the uniform reference citation system

7. Please try to strictly adhere to all the PRISMA 2020 guidelines to write up your paper, especially the method section.

8. Does this review registered on PROSPERO?

9. What is your last search date included in the method part?

10. What you have done if a study has low quality or higher risk?

11. “Finfinnee" is not a legal name, not yet known

12. What you have done if there is heterogeneity and publication bias between the primary studies?

13. How to perform the pooled effect of odds ratio to identify the factors associated with good selfie care? Please show on your paper as it is critical.

Result

14. Table 1 column 6 gender (male). What is this???

15. Why you have performed sub-group analysis and sensitivity test?

Reviewer #2: Dear authors, thank you for your contribution. In general the issue you raised is very good. However, I have some comments and questions which described below.

1. Language edition service is required throughout the document

2. Please rephrase this sentence found in your abstract’ ‘The patient's understanding must therefore be improved by effective health education if self-care behaviour is to be improved.’’

3. The databases scrutinized to search studies are too small. Why only three databases? I think some papers are missed. Therefore please search on at least familiar databases like HINARI, Scopus, and AJOL

4. The MESH terms are little, why?

5. Why you preferred CoCoPop?

6. With this visible heterogeneity among studies, it is difficult to accept. Therefore, I need further evidence /explanation for this because the authors even mentioned the presence the presence of heterogeneity between studies conducted in Oromia. Why?

7. In your discussion part you mentioned this’ ’The prevalence of adherence is comparable with the study conducted in Brazil (35.17%)(9) and lower than the study of Netherland(41%)(6) and Taiwan(53.37%)(26) and higher than the study of Korea(31.98%)(14). This discrepancy could be due to the difference in the study method.’’ What type of difference in study method?

8. On your limitation please rephrase this sentence’ ‘The small sample due to a limited number of included studies with a small sample size for all included studies was a limitation of this study. ‘’

9. The number of studies included in your study is 11 but in the funnel plot it is more than 20 (each dot on the figure represent one study), Why this variation

Thank you

**********

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Reviewer #1: Yes: Mulugeta W/Selassie (Assistant Professor)

Reviewer #2: Yes: Bekahegn Girma Negie

**********

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Attachment

Submitted filename: Reviewer comment.docx

Click here for additional data file. (14.6KB, docx)
PLoS One. 2023 Aug 23;18(8):e0288824. doi: 10.1371/journal.pone.0288824.r002

Author response to Decision Letter 0

12 May 2023

Mohammed Feyisso Shaka, MPH

Academic Editor of PLOS ONE

Dear Editor of the Manuscript PONE-D-23-06552 Self-care practices and associated factors among heart failure patients in Ethiopia: A systematic review and Meta-Analysis," submitted to PLOS ONE. Thanks for your time and consideration in editing and reviewing the manuscript. We have carefully read your comments and corrected inline of your comments and suggestions. All comments raised were edited and incorporated in the revised manuscript.

Here are the responses and elaborations for the comments from the editor and reviewer!

EDITOR COMMENTS

Editor comment: Needs extensive language revision

Author response: We have corrected the whole English grammar in the revised manuscript

Editor comment: Use consistent font style

Author response: We have used consistent font style in revised manuscript

Editor comment: How do proper understanding of HF measured? Or you are speaking about the knowledge?

Author response: We mean heart failure knowledge

Editor comment: Under your conclusion you have said, “…. patients with co-morbidities and depressive symptoms require extra care. What findings imply for such conclusion? Please rephrase it based on your findings.

Author response: Our result revealed the association between co-morbidities and depressive symptoms and we have rephrased it

Editor comment: Write Pub Med as PubMed

Author response: We have corrected it throughout the documents

Editor comment: Use consistent bracket for references. E.g. you used square bracket for reference #24

Author response: We have corrected it in the documents

Editor comment: Please share us the data extraction checklist on Microsoft excel which you have used to extract data with the extracted data for both objectives

Author response: We will send it as supplementary file during submission

Editor comment: Please correct the I2 under the data analysis section on page 5

Author response: We have corrected it in the documents

Editor comment: Did you measured adherence to selfcare or the practice of good selfcare. Your result and what you have described in the methodology is confusing. Please clearly describe what was measured and how it was measured

Author response: We have measured the adherence level to self-care practice. The extent of adherence to self-care practice practices is low if less than the midpoint (50%) of the revised nine-item European Heart Failure Self-care Behavior Scale (EHFScBS-9)(25,26)

Editor comment: We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

Author response: We have paraphrased sentences to remove overlapping texts

REVIEWER COMMENTS

Reviewer 1:

Reviewer comments:. It requires grammatical corrections throughout the document.

Author response: We have corrected the whole English grammar in the revised manuscript

Reviewer comments: Try to avoid abbreviation of words in the abstract part

Author response: We have omitted abbreviation under abstract

Reviewer comments: “We have used three databases such as Pub Med, Science Direct and Google Scholar.Why do you exclude other important databases that you might get potential primary studies from?

Author response: We have added the Scopus and other like HINARI are not freely accessed in our institution

Reviewer comments: Heterogeneity was evaluated using the I2 tests and the Cochrane Q test statistic. What is the advantage of performing the Q test in addition to the I2 test to assess heterogeneity?

Author response: The Q test identifies the Heterogeneity by using the Pvalue ≤ 0.05 and I2 statistics is used to assess the degrees of heterogeneity.

Reviewer comments: To examine publication bias, a funnel plot, Egger's weighted regression, and Begg's test were utilized. What is the importance of using different tests?

Author response: The funnel plot is the traditional diagrammatic representation used to assess the publication whereas, Egger's weighted regression, and Begg's test shows weather the publication bias was significant or not.

Reviewer comments: “The extent of self-care behaviour adherence is shown to be low among heart failure patients”. What is the standard reference to say “low or high”?

Author response: The extent of self-care practice practices is low if less than the midpoint (50%) of the revised nine-item European Heart Failure Self-care Behavior Scale (EHFScBS-9) as mentioned under outcome measurement

Reviewer comments: Please use the uniform reference citation system

Author response: We have used uniform reference citation system

Reviewer comments: Please try to strictly adhere to all the PRISMA 2020 guidelines to write up your paper, especially the method section.

Author response: We have modified the contents of method section as per PRISMA 2020 guidelines

Reviewer comments: Does this review registered on PROSPERO?

Yes, it is already registered

Reviewer comments: What is your last search date included in the method part?

Author response: The last date to search was March 4, 2023.

Reviewer comments: What you have done if a study has low quality or higher risk?

Author response: Normally, a low quality studies was not found in our review. If the studies with a low quality are present, studies perceived to be of lower quality are removed and the analysis is then repeated.

Reviewer comments: “Finfinnee" is not a legal name, not yet known

Author response: “Finfinnee" is replaced by Addis Ababa

Reviewer comments: What you have done if there is heterogeneity and publication bias between the primary studies?

Author response: We will do a subgroup analysis and sensitivity analysis if heterogeneity and publication bias occurred:

Reviewer comments: How to perform the pooled effect of odds ratio to identify the factors associated with good selfie care? Please show on your paper as it is critical.

Author response: We have done by using the commands of The pooled effects of odds ratio was assessed by using the command of “metan logor selogor, xlab(0.1,1,10) label(namevar= authors) by ( factors)random texts(180) eform.”on STATA

Reviewer comments: Table 1 column 6 gender (male). What is this???

Author response: It represents the percentage of male participants in each study

Reviewer comments: Why you have performed sub-group analysis and sensitivity test?

Author response: Dear reviewer we haven’t done sub-group analysis and sensitivity test because our study was not heterogeneous

Reviewer 2:

Reviewer comments: Language edition service is required throughout the document

Author response: We have corrected the whole English grammar in the revised manuscript

Reviewer comments: Please rephrase this sentence found in your abstract’ ‘The patient's understanding must therefore be improved by effective health education if self-care behaviour is to be improved.’’

Author response: We have rephrased it in revised manuscript

Reviewer comments: The databases scrutinized to search studies are too small. Why only three databases? I think some papers are missed. Therefore please search on at least familiar databases like HINARI, Scopus, and AJOL

Author response: We have added the Scopus and other like HINARI are not freely accessed in our institution

Reviewer comments: The MESH terms are little, why?

Author response: Dear reviewer, the MESH term is sufficient for obtain our outcome variables

Reviewer comments: Why you preferred CoCoPop?

Author response:

� The CoCoPop framework can be used for reviews addressing a question relevant to prevalence or incidence

� The CoCoPop framework is used for research questions focusing on associated factors. It is used most frequently to determine associations between certain risk factors or exposures and an outcome.

Reviewer comments: With this visible heterogeneity among studies, it is difficult to accept. Therefore, I need further evidence /explanation for this because the authors even mentioned the presence the presence of heterogeneity between studies conducted in Oromia. Why?

Author response: Generally, there was no heterogeneity in our study. The variations seen in Oromia might be due to a difference in publication years and large variations in sample size.

Reviewer comments: In your discussion part you mentioned this’ ’The prevalence of adherence is comparable with the study conducted in Brazil (35.17%)(9) and lower than the study of Netherland(41%)(6) and Taiwan(53.37%)(26) and higher than the study of Korea(31.98%)(14). This discrepancy could be due to the difference in the study method.’’ What type of difference in study method?

Author response: As mentioned in discussion, this discrepancy could be due to the difference in the sample size and sampling techniques and different data collection used.

Reviewer comments: On your limitation please rephrase this sentence’ ‘The small sample due to a limited number of included studies with a small sample size for all included studies was a limitation of this study. ‘’

Author response: We have rephrased it as per your recommendation

Reviewer comments: he number of studies included in your study is 11 but in the funnel plot it is more than 20 (each dot on the figure represent one study), Why this variation

Author response: To assess the publication bias we have used the commands for the Odds ratio/associated factors. Therefore, the number of the dots represents the number of associated factors.

Dear reviewer, the number of dots represents the number of studies if the publication bias was depicted by using the commands for the magnitude of the problem.

Thanks for your time and consideration,

Regards!

Attachment

Submitted filename: META RESPONSE.docx

Click here for additional data file. (33.7KB, docx)

Decision Letter 1

Mohammed Feyisso Shaka

5 Jul 2023

Adherence to self-care practices and associated factors among heart failure patients in Ethiopia: A systematic review and Meta-Analysis

PONE-D-23-06552R1

Dear Dr. Bekele,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Mohammed Feyisso Shaka, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Mohammed Feyisso Shaka

11 Aug 2023

PONE-D-23-06552R1

Adherence to self-care practices and associated factors among heart failure patients in Ethiopia: A systematic review and meta-analysis

Dear Dr. Bekele:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Mr. Mohammed Feyisso Shaka

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. PRISMA-2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analysis-2020) checklist.

    (DOCX)

    Click here for additional data file. (35.3KB, docx)
    S1 Data. The microsoft excel data of pooled magnitude of adherence to self-care practices.

    (XLSX)

    Click here for additional data file. (10.1KB, xlsx)
    S2 Data. The microsoft excel data of the pooled associated factors of adherence to self-care practices.

    (XLSX)

    Click here for additional data file. (15.2KB, xlsx)
    Attachment

    Submitted filename: Reviewer comment.docx

    Click here for additional data file. (14.6KB, docx)
    Attachment

    Submitted filename: META RESPONSE.docx

    Click here for additional data file. (33.7KB, docx)

    Data Availability Statement

    The data are only available upon request. The data would be guarded carefully by our third party data for the only purpose of this scientific study. Participants were not signed consent for data publicly. For all these reasons and following the indications of the research review committee of College of Health Sciences, Mettu University, the authors must not upload the dataset to a stable, public repository. Interested, qualified researchers can access the data by requesting our third party, Mattu University (mattuniversity@meu.edu.et).

    Articles from PLOS ONE are provided here courtesy of PLOS

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