Assessment of health-related quality of life and treatment satisfaction and their associated factors among older adults with heart failure: a prospective observational study in selected hospitals in Northwest Ethiopia

Abstract

Objectives

To assess health-related quality of life (HRQoL), treatment satisfaction and associated factors among older adults with acute heart failure in Northwest Ethiopia.

Design

Prospective, multicentre observational study.

Setting

Three tertiary hospitals in Northwest Ethiopia provide secondary and tertiary care services.

Participants

A total of 422 patients aged ≥60 years with a confirmed diagnosis of acute heart failure were consecutively enrolled between December 2024 and April 2025. Patients with unstable psychiatric conditions or advanced kidney disease were excluded.

Outcome measures

HRQoL was assessed using the WHO Quality of Life – Brief Version questionnaire, and treatment satisfaction was measured using the Treatment Satisfaction Questionnaire for Medication (TSQM). Multiple linear regression identified factors associated with HRQoL and treatment satisfaction.

Results

95% of participants reported moderate HRQoL, and 3% reported poor HRQoL. Weight loss was positively associated with HRQoL (β=1.52; 95% CI 0.04 to 3.07; p=0.021), whereas asthma was negatively associated with HRQoL (β = –3.28; 95% CI 6.94 to 0.37; p=0.001). Regarding treatment satisfaction, 65% of patients were moderately satisfied, with notable concerns regarding medication safety and overall experience. Rural residents reported lower satisfaction than urban residents (β = –0.20; 95% CI 0.34 to 0.05; p=0.007). Patients with New York Heart Association (NYHA) class III had higher satisfaction (β=0.25; 95% CI 0.05 to 0.45; p=0.016). Effective hypertension management was linked to increased satisfaction (β=0.20; 95% CI 0.02 to 0.37; p=0.026), whereas coronary heart disease was associated with lower satisfaction (β = –0.40; 95% CI 0.64 to 0.88; p=0.012).

Conclusions

Among older adults with heart failure in Northwest Ethiopia, 98% reported moderate to low HRQoL. Asthma and polypharmacy negatively affected HRQoL, whereas weight loss was positively associated with HRQoL. An NYHA class III status and well-managed hypertension improved treatment satisfaction, whereas rural residency and coronary heart disease were associated with lower satisfaction. These findings underscore the need for targeted interventions to enhance outcomes and QoL in this vulnerable population.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• (1) The prospective multicentre design across three tertiary hospitals improved methodological rigour.

• The use of validated instruments (WHO Quality of Life – Brief Version and Treatment Satisfaction Questionnaire for Medication) allowed standardised assessment of health-related quality of life (HRQoL) and treatment satisfaction.

• Rigorous training and quality control minimised measurement bias.

• Lack of heart failure–specific HRQoL tools and validated multimorbidity assessment may have affected measurement precision.

• The observational design precludes the establishment of causal relationships between variables.

Introduction

Heart failure (HF) is a significant global health concern, affecting approximately 64 million individuals worldwide and ranking among the leading causes of morbidity and mortality, particularly in older adults.¹ In Africa, HF prevalence is rising, affecting 1%–2% of adults², and in sub-Saharan Africa, it accounts for about 10% of adult hospital admissions.³ HF affects nearly 6% of adults in Ethiopia, imposing substantial strain on an already resource-limited healthcare system.⁴

HF not only compromises physical health but also significantly diminishes health-related quality of life (HRQoL) and treatment satisfaction. Older adults with HF frequently report lower HRQoL scores than younger populations, reflecting substantial limitations in physical, emotional and social well-being.⁵,⁷ Treatment satisfaction is a key component of effective HF management, as higher satisfaction is associated with better medication adherence and improved clinical outcomes.⁸,¹⁰ Nevertheless, a considerable proportion of elderly patients with HF report dissatisfaction with their treatment experience.¹¹

Despite the recognised importance of HRQoL and treatment satisfaction, there is a paucity of data specifically examining older adults with acute HF (AHF) in Ethiopia. Existing studies tend to focus on clinical parameters while overlooking patients’ subjective experiences, which are critical for designing effective, patient-centred interventions. This gap limits healthcare providers’ ability to deliver tailored care to this vulnerable population. To address this gap, this study assessed HRQoL, treatment satisfaction and associated factors among older patients with AHF in selected hospitals in Northwest Ethiopia. Insights from this research aim to inform the development of policies and interventions that enhance patient-centred care, improve treatment outcomes and increase the QoL for older patients living with HF.

Methods

Study setting, period and design

A multicentre prospective observational study was conducted from January to July 2024 at three tertiary hospitals in Northwest Ethiopia: Debre Tabor, Tibebe Ghion and Felege Hiwot Comprehensive Specialised Hospitals. Participants were enrolled based on predefined inclusion criteria, with a response rate of 92.1%. These hospitals serve populations of approximately 3, 7 and 7 million, respectively, in the Amhara region.

Population and inclusion and exclusion criteria

The source population comprised all patients diagnosed with AHF at the study sites. The study population included patients who met the following inclusion criteria: aged ≥60 years, confirmed diagnosis of HF and currently treated for the condition.

Sample size and sampling technique

The sample size was calculated using the single proportion formula:

n=Z² × P (1 − P) / W²,

where:

• n is the sample size.

• Z is the standard normal value of 95% CI (1.96)

• P is the estimated proportion (assumed to be 50% due to the absence of prior data)

• W is the margin of error (0.05).

Substituting the value:

n = (1.96) ² × 0.5 (1–0.5) / (0.05) ² = 384

To account for a 10% non-response rate, the final sample size was adjusted to 422.

Participants were proportionally allocated to each hospital patient load over the past 5 months using the following formula:

Ni = (Ni / N) × n,

where ni is the sample from each hospital, Ni is the number of eligible patients in each hospital and N is the total number of patients, as depicted in figure 1. A consecutive sampling method was used to select patients, with unique identification numbers ensuring no duplicates.

Figure 1. Schematic of the proportional allocation of the sample population across study sites in selected comprehensive hospitals in the Amhara region from June to November (n=422). CSH, Comprehensive Specialised Hospital.

Study variables

This study examined factors associated with HRQoL and treatment satisfaction among elderly patients with HF. The dependent outcome measures consisted of HRQoL and patients’ satisfaction with treatment. The independent variables, however, ranged from sociodemographic characteristics such as age, sex, marital status, place of residence, religion, education level, occupation status and insurance coverage. Clinic variables such as the HF type (acute decompensated HF or chronic HF), chronic diseases (hypertension and diabetes), substance use (alcohol, smoking and khat), duration of diagnosis, depression and anxiety levels, thyroid function test result, history of thyroid surgery, family history of HF and dietary habit (salt intake) were assessed. Weight loss was defined as unintentional loss exceeding 5% of the patient’s body weight over the previous 6 months.

Additionally, clinical indicators include the length of hospital stay, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class and various clinical signs such as pulmonary rales, shortness of breath during exertion, ankle swelling, weight loss, liver enlargement and night-time coughing. The study also looked at treatment-related variables, such as the current treatment regimen and medication history. Furthermore, khat, a psychoactive plant chewed for its stimulant effects in Ethiopia and nearby areas, may have cardiovascular implications and affect medication adherence. Its consumption was examined as a variable for potential health outcomes in patients with HF.

Classification of heart failure phenotypes

Participants’ HF phenotypes were classified according to the LVEF from echocardiographic evaluations. HF with reduced ejection fraction (HFrEF) was defined as LVEF <40%, whereas HF with preserved ejection fraction (HFpEF) was defined as LVEF ≥50%. Patients with LVEF between 40% and 49% were categorised as having HF with mildly reduced ejection fraction (HFmrEF). The study revealed a mean LVEF of 43%, indicating a significant prevalence of patients in the HFpEF and HFmrEF categories. This classification was essential for analysing the treatment differences, symptom profiles and HRQoL outcomes, impacting the clinical management and patient-reported results in the study design and analysis.

Operational definitions and definitions of terms

Health-related quality measures

• HRQoL: based on the 26-item WHO Quality of Life – Brief Version (WHOQOL-BREF) questionnaire, an individual with a score approaching 100 indicates the best possible QoL, and individuals with a score approaching 0 indicate the poorest QoL.¹²

• Treatment satisfaction: a comprehensive evaluation of a patient’s contentment with the overall healthcare experience, including the effectiveness of treatment, quality of communication with healthcare providers and perceived adequacy of care received, assessed through standardised satisfaction surveys.

Behavioural and sociodemographic factors

• Substance use: using at least one specific substance (alcohol, khat and cigarette) for non-medical purposes within the last 3 months according to alcohol, smoking and substance involvement screening tools.

• Sociodemographic characteristics: key attributes such as age, sex, marital status, residence (urban/rural), religion, educational status, occupation and health insurance status can influence health outcomes and access to care.

Clinical and chronic disease measures

• Chronic diseases: long-term health conditions such as hypertension and diabetes that persist over time and affect a patient’s QoL and treatment efficacy.¹³

• LVEF: a measurement of the percentage of blood ejected from the heart during contraction, which indicates cardiac function.^{14 15}

• NYHA class: a system categorising HF severity based on physical activity limitations, from class I (no limitations) to class IV (severe limitations).¹⁶

• Weight loss: unintentional loss exceeding 5% of the patient’s body weight over the previous 6 months.

Data collection, tools, instruments and procedures

A structured questionnaire adapted from previous studies and translated into Amharic was used.^{6 9 17 18} It was prepared in English and translated into the local Amharic language. Data were collected by interviewing patients using a tool consisting of four parts. The first part covered sociodemographic variables such as age, sex, marital status, residence, educational status, occupation, substance use and health insurance status. The second part included variables such as the presence of chronic disease, diagnostic types, illness and treatment duration and treatment modality. The third part assessed HRQoL using the WHOQOL–BREF with a 26-item questionnaire measuring four domains, namely, physical, psychological, social and environmental health, along with two items on overall QoL and health perception. Domain scores were calculated by the average item response for the domain. The fourth section assessed treatment satisfaction using the Treatment Satisfaction with Medicines Questionnaire (TSQM), a validated instrument consisting of 17 items across six dimensions: treatment effectiveness, convenience, side effects, medical care, impact on daily activities and global satisfaction.¹⁹ Responses were recorded on a 5-point Likert scale, and total raw scores (ranging from 0 to 68) were transformed to a 0–100 scale using the formula: Y’ = [(Yobs-Ymin) / (Ymax-Ymin)] ×100= Yobs × 1.471, where Ymax=68 (maximum total score), Ymin=0 (minimum total score), Yobs=total score obtained by the patient and Y’ = transformed score.

The WHOQOL-BREF, a generic QoL instrument, was used to assess the HRQoL in this study. It evaluates multiple domains but may not fully address HF-specific symptoms, such as fatigue and dyspnoea, which are better captured by instruments such as the Kansas City Cardiomyopathy Questionnaire²⁰ and Minnesota Living with Heart Failure Questionnaire.²¹ The lack of validated multi-morbidity assessment tools, especially those tailored to local contexts, further affects HRQoL measurement sensitivity and specificity. Nevertheless, the WHOQOL-BREF was preferred for its feasibility and low resource needs. Treatment satisfaction was assessed using the TSQM questionnaire, a validated instrument that provides a standardised evaluation of patients’ perceptions of their treatment.²² These tools facilitated a broad assessment of HRQoL and treatment satisfaction while recognising the potential underestimations of HF challenges.

The HRQoL and TSQM cut-off values were classified as poor (<60%), moderate (60%–80%) and good (>80%). The percentage obtained from the mean score and SD was used to categorise treatment satisfaction. Because the interviewer-administered questionnaire was structured, inter-rater reliability was not applicable. Nevertheless, uniform interviewer training and data-gathering practices preserved the quality of the data. Cronbach’s alpha was used to evaluate the measurement tool’s internal consistency; the result was α=0.82, which indicates good reliability.

Outcome measures and validation

Primary outcomes were HRQoL and treatment satisfaction. WHOQOL-BREF assessed HRQoL across physical, psychological, social and environmental domains. Treatment satisfaction was evaluated using the TSQM, a structured and validated instrument assessing provider communication, perceived effectiveness, accessibility and responsiveness of services. Both instruments were culturally adapted and pretested for content validity.

Missing data handling

The study employed a rigorous data handling technique, including structured questionnaires and thorough quality control procedures. This involved interviewer training, methodical completeness checks and instrument pretesting. Statistical analysis was performed using tools such as STATA, and data entry and cleaning were handled using specialised software. Missing data were filled using maximum likelihood estimation or multiple imputations. Missing data were handled using multiple imputation techniques, which reduce bias and improve statistical efficiency under the assumption of missing at random.²³

Data entry, analysis and quality control

The study used Epi-Data version 4.6.0 software to code and clean the data, which were then analysed using STATA version 17. Summary statistics were used to report patient characteristics. The study used P-Plot, scatter plot, Shapiro–Wilk test and variance inflation factor test to assess linearity, heteroscedasticity, normality and multicollinearity. Simple and multiple linear regression analyses were performed to identify the independent variables associated with HRQoL and treatment satisfaction. Variables with a p value<0.25 in the simple linear regression analysis were included in the multiple linear regression model to control for potential confounding.²⁴ Variables with a p value<0.05 in this analysis were deemed statistically significant, with associations quantified by beta coefficients (β) at a 95% CI. Additionally, data collectors underwent rigorous training on the questionnaire content, methods and ethical concerns. The questionnaires were regularly checked for completeness by the supervisors and principal investigators. Pre-test results were used to modify the tool, and the principal investigator provided feedback and corrections.

Results

Participant flow diagram

Of 500 patients assessed for eligibility between December 2024 and April 2025, 78 were excluded: 50 did not meet the inclusion criteria, and 28 declined participation. A total of 422 participants provided informed consent, including 277 (65.6%) admitted to the cardiac unit and 139 (32.9%) admitted to the internal medicine unit (figure 2.

Figure 2. : Participant flow diagram showing recruitment, exclusion and final inclusion in the study.

Characteristics and treatment of patients with acute heart failure

Patients with AHF admitted to selected hospitals in Northwest Ethiopia were included. The mean age was 71.9±9.5 years, with 55.2% males and 77.5% residing in rural areas. Acute decompensated HF (ADHF) was the most common presentation (72.5%), and the majority had NYHA class III (85.8%), with a mean LVEF of 43%. Comorbidities included ischaemic heart disease (33.4%) and chronic rheumatic valvular heart disease (30%). Treatment predominantly involved diuretics (50%) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (41.5%), reflecting partial guideline adherence (table 1).

Table 1. Sociodemographic, clinical, comorbidities and medication use among admitted patients with AHF in selected hospitals in Northwest Ethiopia, December 2024–April 2025 (n=422).

Domain	Variable	Frequency/mean±SD	Key notes/implications
Sociodemographics	Age (years)	71.9±9.5	Older adult predominance
	Male sex	233 (55.2%)	Slight male predominance
	Rural residence	327 (77.5%)	Majority from rural areas
Clinical	ADHF	306 (72.5%)	Most cases are acutely decompensated
	NYHA III	362 (85.8%)	Severe functional limitation
	LVEF (%)	43±15	Moderate to reduced EF
Comorbidities	IHD	138 (33.4%)	Common comorbidity
	CRVDH	124 (30%)	Chronic structural heart disease
Medication	Diuretics	211 (50%)	Most commonly prescribed medications
	ACEI/ARB	175 (41.5%)	Guideline-directed therapy

A full detailed breakdown of all variables is available in online supplemental tables S1–S4.

ACEI/ARB, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker; ADHF, acute decompensated heart failure; CRVDH, chronic rheumatic valvular heart disease; EF, ejection fraction; IHD, ischemic heart disease; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association.

Domain and classification of health-related quality of life

HRQoL scores varied across domains. Mean scores were the lowest for physical health (51.62±11.27) and psychological health (56.11±10.65), indicating greater challenges. Social health (73.33±14.02) and environmental health (67.93±7.97) scores were higher, reflecting relatively better patient experiences. The overall HRQoL score averaged 78.68±21.30, with a wide range highlighting substantial variability among participants (figure 3).

Figure 3. Distribution of health-related quality of life across WHO Quality of Life-Brief Version mean, among admitted patients with chronic conditions in comprehensive hospitals in Northwest Ethiopia, from June to November (n=422).

Most respondents (401; 95%) were classified as having moderate HRQoL, whereas only 13 (3%) were categorised as having poor HRQoL. These findings highlight that although the majority maintained a moderate level of well-being, a small subset experienced significant challenges, underscoring the need for targeted interventions, particularly to improve physical and psychological health domains (figure 4).

Figure 4. Quality of life classification of acute heart failure in selected hospitals in Northwest Ethiopia, from December 2024 to April 2025 (n=422).

Treatment satisfaction domain and level

Most patients (274; 65%) reported moderate satisfaction with their treatment. Although many found medication regimens easy to follow, unmet needs remained, particularly regarding medication safety and overall treatment experience (table 2, figure 5).

Table 2. Summary of treatment satisfaction questionnaire for medication domain scores and patient satisfaction levels among older patients with chronic heart failure from June to November 2024 (n=170).

Domain	Mean±SD	Minimum	Maximum	Low satisfaction (%)	Moderate satisfaction (%)	High satisfaction (%)
Effectiveness	61.3±13.4	30	90	18	70	12
Convenience	70.2±11.7	40	94	10	65	25
Safety	55.1±14.8	20	85	33	55	12
Medical care/support	65.3±12.3	35	95	15	72	13
Impact on daily activities	61.4±13.9	25	88	19	68	11
Global satisfaction	59.8±15.0	15	92	25	60	15

Figure 5. Average patient satisfaction scores across six domains of the treatment satisfaction questionnaire for medication among older adult patients with heart failure: effectiveness, convenience, safety, medical care/support, impact on daily activities and global satisfaction.

Correlation between treatment satisfaction and health-related quality of life

Pearson correlation analysis showed significant positive relationships among treatment satisfaction domains and HRQoL. Treatment effectiveness correlated positively with convenience (r=0.063, p<0.001) and safety (r=0.167, p<0.001). Convenience also correlated positively with safety (r=0.222, p<0.001). Safety was positively associated with global satisfaction (r=0.227, p<0.001), indicating that higher perceived treatment safety corresponded to greater overall satisfaction (table 3).

Table 3. Pearson correlation coefficient between overall treatment satisfaction and HRQoL among hospitalised patients with acute heart failure (n=422).

		HRQoL	Effectiveness	Convenience	Safety	Global satisfaction
HRQoL	Coefficient		−0.059	−0.015	0.60	0.063
	p-value		0.228	0.764	0.218	0.200
Effectiveness	Coefficient			0.063	0.167	0.188
	p-value			<0.001	<0.001	0.198
Convenience	Coefficient				0.222	0.027
	p-value				<0.001	0.582
Safety	Coefficient					0.227
	p-value					<0.001
Global satisfaction	Coefficient
	p-value

HRQoL, health-related quality of life.

Factors influencing treatment satisfaction

Several factors significantly influenced treatment satisfaction. Rural residents reported lower satisfaction than urban participants (β= –0.20, p=0.007), reflecting possible disparities in healthcare access. Patients with NYHA class III reported higher satisfaction (β=0.25, p=0.016), possibly indicating better coping with effective treatments. Coronary heart disease was associated with lower satisfaction (β=–0.40, p=0.012), whereas effective hypertension management increased satisfaction (β=0.20, p=0.026), suggesting that symptom control enhances perceived treatment quality (table 4).

Table 4. Multivariate linear regression for overall treatment satisfaction and associated factors among hospitalised patients with heart failure (n=422).

Variable	Category	SLR: β (95% CI)	MLR: β (95% CI)	P value
Address	Rural	−0.07 (−0.14 to 0.003)	−0.20 (−0.34 to −0.05)	0.007*
	Urban	1	1
NYHA class	II	1	1
	III	0.10 (0.01 to 0.19)	0.25 (0.05 to 0.45)	0.016*
	IV	−0.05 (−0.25 to 0.16)	0.13 (−0.20 to 0.44)	0.436
Ventricular tachycardia	Yes	0.10 (−0.06 to 0.25)	0.08 (−0.20 to 0.36)	0.556
	No	1
IHD	Yes	0.04 (−0.02 to 0.10)	0.07 (−0.10 to 0.23)	0.431
	No	1	1
DCMP	Yes	−0.14 (−0.25 to −0.02)	0.18 (−0.05 to 0.41)	0.130
	No	1	1
Cause of heart failure	Yes	−0.07 (−0.01 to 0.003)	0.01 (−0.02.03)	0.538
	No	1	1
Comorbidity	Yes	−0.14 (−0.31 to 0.04)	0.17 (−0.08 to 0.41)	0.188
	No	1	1
Coronary heart disease	Yes	−0.15 (−0.31 to 0.04)	−0.40 (−0.64 to −0.08)	0.012*
	No	1	1
COPD	Yes	0.08 (−0.03 to 0.19)	0.17 (−0.10 to 0.44)	0.225
	No	1	1
Myocardial infarction	Yes	0.16 (−0.06 to 0.38)	0.31 (−0.08 to 0.71)	0.120
	No	1	1
Cardiomyopathy	Yes	−0.10 (−0.20 to 0.0)	−0.11 (−0.32 to 0.09)	0.278
	No	1	1
Hypertension	Yes	0.11 (0.03 to 0.20)	0.20 (0.02 to 0.37)	0.026*
	No	1	1
Asthma	Yes	−0.16 (−0.33 to 0.02)	−0.24 (−0.60 to 0.12)	0.190
	No	1	1
Degenerative valve	Yes	−0.06 (−0.15 to 0.03)	−0.03 (−0.33 to 0.26)	0.812
	No	1
CRVDH	Yes	−0.05 (−0.13 to 0.04)	−0.14 (−0.48 to 0.20)	0.417
	No	1	1
Previous admission to the hospital	Yes	0.04 (−0.002 to 0.09)	−0.08 (−0.34 to 0.17)	0.518
	No	1	1
Since the last admission in months	0–12	1	1
	13–24	0.02 (−0.05 to 0.10)	−0.02 (−0.12 to 0.07)	0.622
	>24	0.07 (−0.03 to 0.17)	−0.10 (−0.30 to 0.08)	0.255

^*Significant

.COPD, chronic obstructive pulmonary disease; CRVDH, chronic respiratory and vascular disease of the heart; DCMP, dilated cardiomyopathy; IHD, ischaemic heart disease; MLR, multiple linear regression, β - beta coefficient; SLR, simple linear regression.

Factors associated with the health-related quality of life

Unintentional weight loss was positively associated with overall HRQoL (β=1.52, p=0.021) but corresponded with poorer physical and psychological scores, highlighting nutritional cqooncerns. Asthma was associated with lower HRQoL (β=–3.28, p=0.01), with affected patients scoring approximately 3.3 points lower. Chronic HF was modestly associated with improved HRQoL (β=0.02, p=0.042), indicating adaptation over time. These findings underscore the importance of monitoring nutrition, managing asthma and considering disease duration when evaluating HRQoL in this population (table 5).

Table 5. Multivariate linear regression for overall quality of life and associated factors among admitted patients with AHF in selected hospitals in Northwest Ethiopia, from December 2024 to April 2025 (n=422).

Variable	Category	SLR: β (95% CI)	MLR: β (95% CI)	P value
Primary payer	Insurance	−1.36 (−3.17 to 0.44)	−1.25 (−3.51 to 1.01)	0.280
	Out of pocket	−0.48 (−2.43 to 1.48)	−0.67 (−3.16 to 1.83)	0.599
	Others*	1	1
Weight loss	Yes	1.12 (−0.09 to 2.35)	1.52 (0.04 to 3.07)	0.021*
	No	1	1
Pleural effusion	Yes	0.77 (−0.19 to 1.74)	0.40 (−0.69 to 1.49)	0.470
	No	1	1
Ventricular fibrillation	Yes	−1.78 (−4.75 to 1.20)	−1.65 (−4.70 to 1.41)	0.290
	No	1	1
Asthma	Yes	1.85 (−1.00 to 4.69)	−3.28 (−0.37 to 6.94)	0.01*
	No		1
CRVDH	Yes	0.68 (−0.46 to 1.81)	0.75 (−0.52 to 2.02)	0.247
	No	1	1
Pulmonary hypertension	Yes	−1.51 (−3.78 to 0.77)	−0.82 (−2.40 to 0.78)	0.315
	No
Duration of heart failure in months		0.13 (−0.002 to 0.03)	0.02 (0.008 to 0.04)	0.042*
Drug history	Yes	−0.90 (−2.00 to 0.18)	−1.29 (−2.65 to 0.07)	0.064
	No	1	1
Use of spironolactone	Yes	−0.77 (−1.80 to 0.23)	−0.30 (−1.52 to 0.98)	0.666
	No	1	1
Use of metoprolol succinate	Yes	−0.58 (−1.53 to 0.36)	−0.56 (−1.69 to 0.58)	0.338
	No	1	1
Use of warfarin	Yes	0.93 (−0.31 to 2.17)	0.38 (−1.20 to 1.96)	0.638
	No	1	1
Losartan	Yes	2.70 (0.24 to 5.16)	2.65 (−0.76 to 6.06)	0.127
	No	1	1
Aspirin	Yes	−0.61 (−1.620.41)	0.44 (−1.62 to 0.73)	0.456
	No	1	1
SGLTI	Yes	1.06 (−0.25 to 2.38)	1.15 (−0.33 to 2.63)	0.128
	No	1	1

β=regression coefficient.

P values<0.05 are considered statistically significant and are indicated with an asterisk (*).

Reference categories for categorical variables are indicated as ‘1’.

Weight loss refers to clinically significant unintentional weight loss in patients, which may indicate frailty or poor health status; coded as yes (weight loss present) and no (no weight loss).

Primary payer ‘Others’ includes government or charity coverage not classified as insurance or out-of-pocket.

Drug use variables (spironolactone, metoprolol succinate, warfarin, losartan, aspirin and SGLTI) are coded as yes (use of the drug) and no (no use of the drug).

Duration of heart failure is measured in months.

MLR, multiple linear regression; SGLTI, sodium-glucose linked transporter inhibitor; SLR, simple linear regression.

Discussion

This study examined older adults admitted with AHF in Northwest Ethiopia, revealing a predominantly older, rural population with low educational attainment and frequent reliance on governmental insurance, factors that likely influence healthcare access and outcomes. Clinically, patients commonly presented with acute decompensation, dyspnoea, pulmonary rales and reduced LV function. HRQoL was moderately impaired, with unintentional weight loss associated with higher overall HRQoL and asthma linked to lower HRQoL. Rural patients reported lower treatment satisfaction, reflecting barriers to care. These findings highlight the need for individualised, comprehensive care that addresses both clinical and sociodemographic determinants.

Sociodemographic and lifestyle factors

Participants had a mean age of 72 years, consistent with the high prevalence of HF in older adults. Age-related cardiovascular changes, such as reduced cardiac reserve and increased vascular stiffness, along with higher rates of comorbidities such as hypertension and diabetes, increase susceptibility to severe manifestations of HF.^{1 15 16}

Approximately 75% of participants resided in rural areas, where limited access to specialised care, transportation barriers and resource shortages likely contributed to poorer health outcomes, delayed diagnoses and reduced emergency care use. Systematic reviews indicate that rural patients with HF experience worse prognoses due to these structural and socioeconomic challenges.²⁵,²⁹

Khat use and cardiovascular implications

Khat (Catha edulis) use is common in Ethiopia and has cardiovascular implications relevant to HF. Its active compounds, cathinone and cathine, increase heart rate and blood pressure, potentially worsening HF and arrhythmia risk.^{30 31} Chronic use may reduce HRQoL, impair exercise tolerance and disrupt adherence to medications,^{32 33} along with a decline in HRQoL, fatigue and reduced exercise capacity.³⁴ Additionally, frequent use may lead to poorer medication adherence by disrupting sleep and daily routines.^{35 36} These findings underscore the importance of assessing khat use and providing culturally appropriate counselling in clinical practice.

Most participants (67%) relied on governmental insurance, whereas 25% paid out-of-pocket, highlighting financial vulnerabilities among older adults with fixed incomes. The burden of chronic disease management may delay care-seeking and worsen outcomes. Policies to improve access to affordable healthcare could mitigate these disparities.^{32 37 38}

Additionally, 36% of participants had no formal education, reflecting limited health literacy, which can hinder understanding of disease and adherence to treatment. Educational interventions and community-based programmes for older adults may enhance knowledge, self-care and overall QoL.^{39 40} This text discusses the importance of educational initiatives to improve health literacy among older patients, particularly in managing conditions such as HF. It highlights that community health programmes aimed at educating seniors can enhance their health outcomes and overall QoL.⁴¹

Clinical picture

ADHF was present in 73% of patients, with 87% experiencing dyspnoea and 85% demonstrating pulmonary rales. The mean LVEF was 43%, indicating moderate-to-severe LV dysfunction, which is associated with higher mortality in older adults.⁴² Comorbidities, such as pneumonia (16%), atrial fibrillation (16%) and chronic respiratory diseases, complicate HF management in older adults. This can intensify symptoms and decrease the treatment efficacy. A holistic management approach is essential, highlighting the need for screening and treatment of comorbid conditions in the elderly.

Comorbidities, including pneumonia (16%), atrial fibrillation (16%) and chronic respiratory diseases, complicate management, intensify symptoms and reduce treatment efficacy. Dyspnoea and ankle oedema were prevalent and significantly impaired physical function and HRQoL, contributing to frailty and dependence. Symptom management and tailored rehabilitation programmes may improve functional capacity, reduce readmissions and enhance outcomes.^{43 44}

Health-related quality of life

This study revealed that 95% of older participants perceived their QoL as moderate, emphasising the significant effect of AHF on daily activities and psychosocial health. Additionally, 92% reported moderate-to-poor HRQoL, reflecting a notable decline in health status. Conversely, some older adults in other studies reported good or excellent HRQoL, indicating that a minority adapt better to HF, leading to lower 1-year mortality and hospitalisation rates.⁶⁴⁵,⁴⁸ The HRQoL observed in this study aligns with findings from other low-income and middle-income settings for patients with HF.⁴⁹

Most participants (95%) reported moderate overall QoL, reflecting the substantial impact of AHF on daily functioning and psychosocial well-being. Unintentional weight loss was positively associated with overall HRQoL (β=1.52, p=0.021) but indicated frailty and nutritional concerns rather than fluid removal. Although diuretics relieve oedema and dyspnoea, they do not address functional capacity or overall well-being. Monitoring weight trajectories helps distinguish fluid changes from frailty, guiding nutritional interventions and patient-centred care.^{50 51} Frailty significantly affects HRQoL in older adults with HF, compromising both physical and emotional aspects. It mediates the relationship between higher NYHA functional class and reduced QoL. The prevalence of frailty complicates clinical management and decreases self-care, highlighting the importance of early geriatric assessments and personalised care. Meta-analyses indicate that frail older patients with HF have higher risks of mortality and hospitalisation, underscoring the necessity for routine frailty screening in HF management.⁵²,⁵⁴

Frailty itself adversely affects HRQoL, mediating the relationship between higher NYHA class and reduced QoL. Asthma also reduced HRQoL (β=–3.28, p=0.001), limiting physical activity and complicating HF management.^{55 56} These findings underscore the need for comprehensive assessments of comorbidities and frailty in older adults with HF.

Clinical characteristics and impact of heart failure phenotypes

Preserved or mildly reduced ejection fraction HF (HFpEF and HFmrEF) was common, consistent with global trends. Patients with HFpEF often have comorbidities such as hypertension, obesity and diabetes, which worsen HRQoL, particularly in physical and psychological domains. In contrast, patients with HFrEF may benefit more from pharmacological interventions. Understanding HF phenotypes is essential for tailoring treatment and improving HRQoL and treatment satisfaction, especially in resource-limited settings.^{57 58}

Treatment satisfaction

Approximately 65% of participants reported moderate treatment satisfaction, consistent with studies in low-resource settings where medication safety and communication issues are common.^{9 10} Rural patients reported lower satisfaction because of limited access to healthcare resources, long travel distances and lower health literacy.^{8 10 39 45 59} Interventions such as patient education, improved pharmaceutical safety and enhanced accessibility are essential to improve satisfaction and adherence.

This study highlights that rural older adult patients with AHF report significantly lower treatment satisfaction than their urban counterparts. The findings align with previous research indicating systemic barriers in rural areas, such as limited access to speciality care, fewer healthcare resources, long travel distances and medication shortages, alongside factors such as lower health literacy and adverse social determinants, including poverty and education.^{9 25 39 41 60 61} Multifaceted interventions are essential to address healthcare inequities, such as enhancing rural healthcare infrastructure, implementing mobile clinics, utilising telemedicine, strengthening the workforce and providing culturally sensitive, patient-centred care to improve treatment adherence and satisfaction.

Patients with NYHA class III reported higher satisfaction, possibly reflecting more intensive symptom management, frequent healthcare interactions and participation in multidisciplinary care programmes. Psychological adaptation may also contribute, as patients with more severe illness adjust expectations over time, improving perceived care quality.⁶¹,⁶⁸ Effective hypertension management was linked to higher satisfaction, emphasising the importance of symptom relief, patient education and communication between healthcare providers and older adults.⁶⁹

Implications for healthcare and future research directions

These findings underscore the need for personalised healthcare strategies for older adults with AHF in Northwest Ethiopia. Improved infrastructure, mobile clinics, telemedicine, culturally sensitive community education and integrated multidisciplinary care may enhance treatment satisfaction. Future research should explore social determinants, community resources and interventions targeting HRQoL and medication adherence.

Although primarily set in sub-Saharan Africa, the findings of this prospective study have significant global implications for managing older adults with HF.⁷⁰ Multi-morbidity is a crucial independent predictor of poor HRQoL, a finding consistent with studies from Europe and North America.^{61 71} This finding underscores the challenges in managing patients with complex HF and non-cardiac conditions such as chronic kidney disease and diabetes. It advocates for multidisciplinary heart teams to tackle these interconnected health issues, following recommendations from organisations such as the American College of Cardiology / American Heart Association (ACC/AHA) and European Society of Cardiology (ESC)¹⁷ . Additionally, lower physical HRQoL scores in older adults reflect widespread quality-of-care deficits, highlighting the need for improved patient-centred care. The study contributes data towards the formation of globally relevant clinical guidelines that factor in diverse socioeconomic and cultural aspects while promoting geriatric care.⁷²,⁷⁶

International context and relevance

Findings from Ethiopia provide insights into HRQoL and treatment satisfaction among older adults with HF, particularly HFpEF, and reflect global patterns of comorbidities such as hypertension, diabetes and obesity. Regional factors, such as khat use, may uniquely affect cardiovascular health and adherence. Although validated generic tools were used, disease-specific sensitivity and multimorbidity assessment were limited. As an observational study, causal inference is restricted.

Strengths and limitations of the study

Study strengths include its multicentre observational design, representative sample and use of validated instruments (WHOQOL-BREF and TSQM) with rigorous quality control. Limitations include the observational design, recruitment from tertiary centres limiting generalisability, use of generic rather than HF-specific instruments and lack of standardised multimorbidity assessment. Socio-economic and healthcare access factors were incompletely explored. Despite these limitations, this study provides valuable insights into patient-centred outcomes in resource-limited settings, informing future research and interventions.

Conclusion

In this multicentre study of older adults with HF, most participants reported moderate-to-low HRQoL and moderate treatment satisfaction. Asthma and polypharmacy were associated with poorer outcomes, whereas unintentional weight loss correlated with better perceived QoL. These findings underscore the need for patient-centred HF care that optimises the management of comorbid conditions and ensures access to guideline-directed medical therapy. Additionally, interventions tailored to context-specific factors, such as socioeconomic barriers, healthcare access limitations and lifestyle behaviours, may further enhance HRQoL and treatment satisfaction, particularly in resource-limited settings.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.