Patients’ lived experiences and coping mechanisms following mitral valve replacement at the National Cardiac Institute in Tanzania: a qualitative study

Abstract

Objective

To qualitatively explore patients’ lived experiences and coping mechanisms following mitral valve replacement (MVR) at the National Cardiac Institute in Tanzania.

Design

A descriptive qualitative study using in-depth interviews and thematic analysis.

Setting

The study was conducted at the National Cardiac Institute, located in Dar es Salaam, the sole tertiary cardiac centre in Tanzania offering open-heart surgery.

Participants

17 participants were purposively sampled. Inclusion criteria were as follows: patients aged ≥18 years, had at least 28 days post-MVR, without chronic conditions (eg, diabetes and HIV) and attending postoperative cardiac clinics.

Main outcome measures

Semi-structured interviews conducted in May 2024 using an interviewer guide explored post-MVR challenges, daily life adjustments, patient-provider interactions and coping strategies. Thematic analysis was employed to identify key themes.

Results

Three primary themes emerged: (1) Quality of life after MVR, encompassing physical, social, economic and psychological challenges; (2) Quality of care after MVR, highlighting patient-provider interactions and access to services; and (3) Adapting to post-MVR life, including psychological adaptation and lifestyle modification. Participants reported improved quality of life through shared experiences and support.

Conclusion

Patients experienced physical, socio-economic and psychological challenges post-MVR. However, quality of life improved through access to care, peer support and adaptive coping. Adaptation to life with an artificial valve is feasible with robust support systems, even in resource-limited settings.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• In-depth interviews conducted in private, comfortable settings fostered trust and openness, enhancing the credibility of the data.

• Recruitment from Tanzania’s national cardiac referral centre enabled inclusion of a socioeconomically and culturally diverse patient population, enriching the data.

• The study relied on participants’ recollection of their experiences following mitral valve replacement, which may have introduced recall bias.

• Interviews were conducted in Kiswahili and translated into English during the coding process; as such, there is a potential risk of loss of nuance or meaning during translation.

• Purposive sampling was used; however, gender imbalance within the available patient population may limit the generalisability of the findings.

Introduction

Cardiovascular diseases (CVDs) remain a major global public health challenge, responsible for 20.5 million deaths (30%) worldwide.¹ Low- and middle-income countries (LMICs) account for nearly 80% of these deaths.^{2 3} In Tanzania, CVDs contribute to 13% of all non-communicable disease-related deaths, which is higher than in most other African countries.4,6

Valvular heart disease (VHD), commonly resulting from damage to the heart valves following rheumatic fever, is a significant contributor to the CVD burden.⁷ Although the global prevalence of rheumatic heart disease declined by 8.67% between 1990 and 2017, the incidence of non-rheumatic VHD increased by 45.10% over the same period⁸. In Tanzania and similar LMIC settings, rheumatic heart disease remains the leading cause of VHD, unlike in high-income countries, where degenerative changes predominate.⁹

VHD often leads to symptoms such as fatigue, dyspnoea and chest discomfort. If untreated, it can impair cardiac function by disrupting normal blood flow.⁸ Treatment depends on severity: medications may relieve symptoms in moderate disease, whereas severe mitral valve stenosis, regurgitation or mixed disease often requires mitral valve replacement (MVR).¹⁰ Successful MVR depends on surgical expertise and vigilant postoperative care, which reduces early mortality.¹¹

Following MVR, patients require lifelong anticoagulation to prevent thromboembolism and endocarditis, conditions that carry a lifetime risk of up to 34% without treatment¹². Additional recommendations include physical activity, psychosocial support, a balanced diet and wound care to promote recovery and minimise complications.13,15

At the National Cardiac Institute in Dar es Salaam, approximately 20–40 patients undergo MVR each month. Reports indicate that 3.7% die within 30 days due to postoperative complications, and two to three patients are readmitted monthly for MVR-related issues.¹⁶ These readmissions suggest that routine clinical data may not fully capture the challenges patients face after surgery, including adherence difficulties and unmet support needs. To address this gap, this study explored the lived experiences and coping mechanisms of patients following MVR at the National Cardiac Institute in Tanzania.

Methods

Study design

This study employed a descriptive qualitative design to explore the lived experiences and coping mechanisms after mitral valve replacement.¹⁷ As outlined in the supporting information (online supplemental file 1), the Standards for Reporting Qualitative Research (SRQR) checklist was used to enhance the rigour and transparency of the study’s reporting.

Study area

The study was conducted at a National Cardiac Institute located in Dar es Salaam, Tanzania. This institute is the largest and only public hospital providing cardiac surgery services, including valve replacement. The institute has a 143-bed capacity with about 350 staff, including health professionals and supporting staff. Currently, the institute receives more than 200 patients with cardiac problems, whereby approximately 5–10 patients with valve replacement attend the clinic every weekday.

Study population and eligibility criteria

The study included patients who underwent MVR therapy at the National Cardiac Institute’s cardiac clinic, with a minimum follow-up period of 28 days post-procedure. Individuals with chronic conditions, including kidney disease, diabetes mellitus, HIV or cancer, were excluded. This exclusion aimed to minimise factors that might compromise data quality, as comorbid illnesses could influence post-MVR quality of life and perceptions.

Sample size and sampling procedure

To ensure comprehensive representation of diverse perspectives, 17 participants were recruited using a purposive sampling strategy aimed at maximum variation. Variation was sought across key dimensions, such as age, gender, time since MVR and geographical location. Recruitment continued until data saturation was achieved, which was determined when no new information emerged from iterative analysis, and subsequent participant responses became repetitive.¹⁸

Data collection tool

An in-depth interview guide (online supplemental file 2), comprising open-ended questions and follow-up probes, was used to collect data. The guide was developed collaboratively by the research team, informed by a review of relevant literature and the study’s focus. Audio recorders were used to gather information from the interviews.

To ensure methodological rigour, the guide underwent content validity assessment through an expert review process: two independent qualitative research experts evaluated its relevance, clarity and alignment with the study’s objectives.

The interview guide comprised three main questions with follow-up probes, along with a section for participants’ background information. The primary question was: “Tell me about your experience of living with a mechanical heart valve”.

Interviews were designed to elicit lived experiences by focusing on meaningful events and emotions that participants could recall clearly. Participants were also encouraged to describe current impacts and ongoing coping processes following MVR, thereby minimising potential recall bias.

Patient and public involvement

No patients were involved in the design, conduct or reporting of this study. Two nurses contributed to the development of the interview guide and were involved in planning and conducting the study at the hospital.

Data collection and management

Data collection took place from 28 March to 19 April 2024. Potential participants were identified through the cardiac surgery clinic’s daily roster and registration book. Eligible individuals were approached during clinic visits or contacted in advance to schedule interviews. Researchers established rapport through clear communication, informed eligible participants about the study and obtained written consent before data collection.

Interviews were conducted in a private, quiet clinic room to ensure comfort and confidentiality, with sessions lasting 40–60 min. All interviews were conducted in Kiswahili (Tanzania’s national and most widely spoken language). Early interviews informed iterative refinements to subsequent questions, enhancing data depth.

Audio recordings and field notes documenting verbal and non-verbal cues were securely stored, with access restricted to the authors to ensure confidentiality. Daily reviews of interviews and notes enabled procedural improvements. Data saturation was reached by the 17th interview.¹⁹ Recruitment continued until this point to confirm thematic redundancy, after which data collection was stopped. All interviews were audio-recorded and transcribed verbatim.

Data analysis

Inductive thematic analysis, following the six-phase approach developed by Braun and Clarke (2006), was employed for data analysis and presentation.²⁰ The primary researcher (JP) began by thoroughly familiarising with the data through repeated reading of interview transcripts and listening to audio recordings. Subsequently, JP conducted systematic coding, translating data segments from Kiswahili to English. To enhance the trustworthiness of the analysis and minimise potential translation bias, the coding framework and translations were reviewed and validated through regular discussions with the full research team (SB, MN). All authors are fluent in both Kiswahili and English and are well-versed in the cultural context.

After initial code generation, the research team also collaboratively searched for themes that captured meaningful patterns and insights aligned with the study’s objectives. The themes were reviewed, refined and compared with the coded extracts and the complete data set to ensure that key information was accurately represented. In collaboration with one qualitative research expert, the final themes and subthemes were defined and named.

Trustworthiness of the study

To enhance trustworthiness, the study adhered to the four established criteria for evaluating qualitative research: credibility, dependability, confirmability and transferability as proposed by Lincoln and Guba.²¹ Credibility was strengthened through regular discussions among the research team and with an external peer. This process helped to challenge assumptions, refine interpretations and enhance the validity of the findings.

Dependability was ensured through a transparent and methodical approach to data handling. All stages of the research process were carefully documented, including the use of audio recordings and coding frameworks. These materials facilitated consistent and collaborative analysis by the research team and a qualitative expert.

Confirmability was addressed by maintaining a comprehensive audit trail, comprising audio recordings, coded transcripts and detailed notes, which enabled the verification of findings and minimised researcher bias.

Transferability was supported by providing rich, contextual descriptions of the study setting, participant demographics, data collection methods and analytical procedures. The information may enable readers to determine the applicability of the findings to their respective contexts.

Researcher characteristics and reflexivity

The researchers (JP, SB and MN) were not previously known to any of the participants. The primary researcher, JP, is a male registered nurse with over 5 years of clinical experience in general nursing, currently pursuing a Master’s in Cardiovascular Nursing, and has experience conducting qualitative interviews. SB is a female assistant lecturer with a nursing background in cardiovascular care for over 5 years and has experience in qualitative research. MN is a male lecturer with a nursing background in Emergency and Critical Care for over ten years and is experienced in both qualitative and quantitative research. This clinical background was beneficial for establishing rapport and understanding participants’ medical narratives; however, it also created the potential for assumptions. To mitigate this, JP practised bracketing during interviews, consciously setting aside clinical expectations to listen openly to each patient’s lived experience. During data analysis, the research team regularly discussed JP’s initial interpretations to ensure they were grounded in the data itself rather than influenced by clinical preconceptions.

Ethical considerations

Ethical approval was granted by the Muhimbili University of Health and Allied Sciences Senate Research and Ethics Committee (MUHAS-SREC; Ref. No. DA.282/298/01 .C/2091), with additional permission for data collection obtained from the National Cardiac Institute management (Ref. No. AB.123/307/01K/25).

Participants were provided with oral and written study details, including the purpose, procedures and their right to withdraw without consequence. Written informed consent, including permission for audio recording, was obtained before interviews. Participants were explicitly informed that no monetary or material compensation would be provided. To ensure confidentiality, all data were anonymised using coded identifiers during analysis and reporting.

Results

The study included 17 participants who had undergone MVR. The sample was predominantly female, 13 (76.5%), with a majority aged ≤45 years, 9 (52.9%). Most participants were 1–5 years post-MVR 7 (41.2%). Education levels were distributed across categories: five participants (29.4%) each had primary, secondary or college/higher education. Occupationally, self-employment was most common 10 (10, 58.8%). For details, see table 1.

Table 1. Participants’ characteristics (n=17).

Characteristic	Category	Number
Gender	Female	13
	Male	4
Age	≤45 years	9
	46–60 years	4
	≥61 years	4
Marital status	Married	13
	Single	2
	Widowed	2
Duration post-MVR	3 months – <1 year	6
	1–5 years	7
	≥6 years	4
Education level	No formal education	2
	Primary education	5
	Secondary education	5
	College education or higher	5
Occupation	Employed (formal sector)	7
	Self-employed	10

MVR, mitral valve replacement.

Analysis of the data yielded three overarching themes and associated subthemes: (1) quality of life after MVR (eg, physical consequences and psychosocial consequences), (2) quality of care after MVR (eg, patient-provider interaction, accessibility of services), and (3) adapting to post-MVR life (eg, psychological adaptation and lifestyle modification). For a comprehensive overview of themes and subthemes, refer to table 2.

Table 2. Themes and subthemes.

Themes	Sub-themes
Quality of life after MVR	Physical consequences
	Psychological consequences
	Economic consequences
	Social consequences
Quality of care after MVR	Patient-provider interaction
	Accessibility of services
Adapting to Post-MVR Life	Psychological adaptation
	Lifestyle modification

MVR, mitral valve replacement.

Theme 1: Quality of life

The impact of MVR on quality of life was mixed, with most participants reporting improvement and a minority a decline. These experiences were categorised into four sub-themes: physical, psychological, social and economic, to provide a holistic analysis of patient well-being. The findings for each domain are detailed below with supporting quotes.

Physical consequences

Most participants regained their physical capacity after MVR, allowing them to resume their roles and responsibilities at the family and societal levels. As one participant noted:

I can now walk and perform activities I couldn’t before surgery. My health has truly improved. (P6)

However, some faced limitations, particularly in the early postoperative phase, including restrictions on strenuous activities or persistent fatigue. One participant reported:

It hasn’t helped me. At first, I could still manage my activities, even though I wasn’t very strong. But ever since the surgery, the situation has become worse. (P11)

Psychological consequences

Some participants expressed fear about function, durability and valve dislodgement. This caused significant distress as narrated by one participant:

I worried the valve might be pulled out and cause serious health problems to me or even death. (P8)

Mechanical valve noise and lifelong medication regimens exacerbated psychological strain as described by the participants:

The valve’s ‘ta! ta! ta!’ sound disturbs me daily. (P13)

Economic consequences

Limited earnings due to reduced work capacity after valve replacement subjected patients to economic decline, leading to an economic crisis. One participant narrated:

My income has decreased because I'm not working, and to earn money, I need to work. I know I haven’t fully recovered, but I still have to work. (P17)

Social consequences

Some participants experienced marital conflicts following valve replacement, primarily due to sexual restrictions. These restrictions led to relationship breakdowns, with some men engaging in relationships with other women. One participant shared:

After an operation, my husband left me for another woman because I could not satisfy him. (P10)

In addition to marital challenges, other participants reported reduced participation in social activities. Much of their time was devoted to ongoing medical care, including monthly clinic visits and follow-up investigations. Some avoided social events, particularly those involving noise or large crowds, out of concern for their health and well-being. One participant explained:

I don't like noisy or crowded places, and I always hold back to protect my health. (P2)

Theme 2: Quality of care after MVR

The quality of care received by patients following mitral valve replacement was described by participants across multiple dimensions, reflecting their individual experiences. This theme is organised into two sub-themes: patient-healthcare provider interaction and treatment accessibility.

Patient-provider interaction

Participants described generally positive interactions with healthcare providers after valve replacement. Many highlighted the counselling, encouragement and empathetic communication provided by their care teams. These interactions made patients feel more comfortable with their treatment regimens. Participants also appreciated the providers’ attentiveness and support in addressing medication-related challenges and health concerns. For instance:

They serve us with love and respect…if we face any challenge, we explain it to them, and they understand, offer explanations, and provide support. (P3)

Accessibility of services

While participants expressed satisfaction with post-operative follow-up care, they also highlighted significant challenges related to accessibility. A major issue identified was the centralised location of cardiac care services, specifically, as the only clinic providing open-heart surgery services in Tanzania is in Dar es Salaam. This posed financial and logistical burdens for patients travelling from distant regions:

Monthly trips to Dar es Salaam cause headaches to some of us in addition to lodging, which further drains our savings. (P14)

Another challenge mentioned was the high cost of medication. Some participants were unable to afford essential anticoagulants, such as warfarin, leading to non-adherence and increased health risks.

The challenge is getting warfarin. I have to wait to be registered for a government exemption to receive it. Sometimes I go a whole week without it. (P17)

Additionally, participants reported long waiting times during clinic visits. These delays were attributed to inconsistent adherence to the queuing system and the late arrival or delayed start of services by physicians:

Sometimes you arrive at the clinic, but the doctors haven’t arrived yet. You leave home at 5 a.m. and stay at the clinic until late evening. You return home very late and hungry, because you can’t leave to eat while waiting to be attended. (P11)

Theme 3: Adapting to Post-MVR Life

Following MVR, patients undergo significant lifestyle adjustments, requiring sustained support and motivation to mitigate complications such as thrombus formation or valve failure. This theme encompasses two sub-themes: Psychological adaptation and Lifestyle modification.

Psychological adaptation

Participants described various coping strategies that supported their adjustment to life with an artificial valve. A key strategy was acceptance, embracing the reality of their new life and adhering to medical guidance. This acceptance helped patients reframe their identity and establish a sense of control over their condition. One participant explained:

I have accepted that I’ve come from one life and now must enter another. So, I must respect and obey what the doctors tell me. (P2)

Participants further narrated that interactions with other patients with similar conditions facilitated the normalisation of post-surgical experiences, reducing isolation and mitigating anxiety through shared understanding.

Hearing others’ how they overcame their challenges post-surgery made me feel I could adapt too. (P15)

For many participants, faith and spirituality played a central role in managing the emotional burden of living with an artificial valve. Trust in God helped them to remain hopeful and resilient in the face of uncertainty. Religion served as a source of comfort, acceptance and peace of mind:

I prayed and surrendered my worries to God. Overthinking won’t help, I trust His plan about my life. (P9)

Lifestyle modification

Following MVR, participants reported adjusting their lifestyle to cope with their current condition and seeking medical professional support.

After my surgery, I've had to change how I do things. For me, heavy lifting is off limits. I've learned to ask for help or use tools to make tasks easier. It’s not just about following doctor’s orders, but about protecting my heart. (P7)

Another participant narrated that:

I used to eat and drink freely, almost everything, but I can't now, although I desire beer and smoking… I have managed to quench my desire by doing other things. (P11)

On medical check-ups, one participant explained that:

I was not used to going for health check-ups unless I was very sick, but now, following the surgery, things have changed. I'm more conscious about my health and consult doctors regularly. (P5)

Discussion

This study explored patients’ experiences following mitral valve replacement (MVR) in Tanzania and uncovered complex, multifaceted impacts on quality of life, care experiences and post-operative adaptation. While the majority reported improvements in health and functional ability, a notable minority faced significant physical, psychological, social and economic challenges, underscoring the diversity of recovery patterns post-MVR.

Regarding quality of life, improvements were evident in the majority of the participants through restored physical capacity and reintegration into family and societal roles, consistent with other previous studies.^{16 22 23} However, persistent fatigue and limitations among some participants reflect the variability in postoperative recovery. These findings align with global literature suggesting that age, baseline health status and perioperative complications significantly influence post-surgical recovery.^{24 25}

Psychological stressors, such as fears about valve functionality, distress from mechanical valve noise and anxiety related to medication adherence, emerged as significant quality of life issues. Such issues are consistent with prior studies that identify mechanical valve-related stress and anticoagulation management as long-term psychological burdens.²⁶ For example, a study conducted in Norway on patients who underwent aortic valve replacement noted an association between valve noise disturbance and symptoms of anxiety. The study recommended that it is imperative to address and prepare all patients to deal with the sound of the mechanical valves.²⁷ The reported social consequences, including marital strain and withdrawal from social activities, further highlight the ripple effects of physical health interventions on interpersonal relationships and social identity.

Quality of care post-MVR was described positively in terms of healthcare provider interaction. Compassionate communication, ongoing support and patient education were appreciated, suggesting that relational continuity and empathy are vital components of effective post-operative care, which may translate to improved health outcomes, as reported in a study conducted in Denmark.²⁸ However, challenges in accessibility, centralisation of services, high medication costs and long clinic wait times pose significant barriers to equitable care. For example, centralisation of cardiac surgery services, while aiming for quality, can create geographic inequities. Studies in sub-Saharan Africa highlight that concentrating care in urban centres imposes prohibitive travel burdens, leading to missed appointments, treatment delays and poor follow-up.^{29 30} These geographic barriers exacerbate financial hardship from lost income and transport costs, which systematic reviews confirm as critical access constraints. ³¹Furthermore, such system failures contribute directly to dangerous delays in emergency cardiovascular responses.³² Consequently, our findings reinforce the call in the literature for structural reform. Strategic decentralisation of follow-up services, expanded use of telehealth and strengthened primary care integration are essential steps to mitigate these geographic and economic barriers and improve equitable access to cardiac care.^{29 30}

Different strategies were used in adapting to life after MVR. Most of the participants showed positive coping through accepting their new reality by acknowledging physical limitations, adhering to food restrictions and using lifelong medications. Similar findings were reported in Australia, where participants who accepted their new life showed better adherence to medical advice and had fewer health complications post-heart valve surgery.³³ Faith-based coping and social reinforcement have been shown to buffer distress in chronic illness populations, emphasising their relevance in the Tanzanian sociocultural context. Supportive peer interactions and spiritual practices helped normalise the recovery experience and mitigate isolation, reinforcing the value of community and shared experience in chronic care management. These findings align with previous studies where patients used such coping strategies to adjust to life after valve replacement.^{34 35}

Overall, the study demonstrates that physical recovery, psychological adaptation, social support and health system factors operate in a dynamic and interconnected manner. Persistent symptoms intensify anxiety; psychological distress limits social engagement; social reinforcement strengthens adherence and structural barriers influence both physical outcomes and emotional well-being. Understanding these interactions provides deeper insight into the lived reality of MVR patients and underscores the need for holistic, patient-centred postoperative care.

Methodological considerations

The current study has notable strengths. Conducting in-depth interviews in private and comfortable settings fostered trust and openness, enhancing the credibility and richness of the data. Recruiting participants from Tanzania’s national cardiac referral centre allowed for the inclusion of individuals from diverse socioeconomic and cultural backgrounds, thereby broadening the range of perspectives captured.

However, the study also has limitations. Participants were asked to recall experiences following mitral valve replacement, which may have introduced recall bias. To minimise this, interviewers used probing questions and sought clarifications to support accurate recollection. All interviews were conducted in Kiswahili and later translated into English during coding, creating the potential for loss of nuance or meaning. This risk was mitigated through careful translation, cross-checking by bilingual researchers and discussion among the research team to ensure consistency. Additionally, although purposive sampling was appropriate for the qualitative design, the gender imbalance in the available patient population may limit transferability. This imbalance is noted as a reflection of the underlying patient demographic at the referral centre.

Practical implications of research findings

The findings of this study have several important implications for clinical practice, health policy and future research in the context of cardiac care in Tanzania and similar low-resource settings. First, the diversity in post-MVR recovery experiences highlights the need for individualised patient follow-up that considers not only physical recovery but also psychological, social and economic well-being. Routine psychosocial assessments and tailored interventions could help identify patients at risk of poor adaptation and provide timely support. second, the positive impact of compassionate communication and ongoing patient education underscores the importance of strengthening relational aspects of care. Training healthcare providers in empathetic communication and culturally sensitive education may enhance patient engagement and improve adherence to long-term treatment plans. The reported challenges in access to care, particularly the centralisation of services and high treatment costs, point to an urgent need for decentralisation and subsidisation strategies to promote equity. Finally, the identified coping mechanisms, especially those rooted in faith and social support, indicate the value of incorporating community and spiritual resources into post-operative care frameworks.

Conclusion and recommendation

This study sheds light on the complex experiences of patients after MVR in Tanzania, revealing both physical recovery and challenges across psychological, social and economic domains. While supportive interactions with healthcare providers were noted, barriers such as centralised services and financial strain hindered optimal care and adherence.

Coping strategies like acceptance, religious faith and social support were vital to adaptation. To improve outcomes, healthcare systems should decentralise services and provide comprehensive education and psychosocial support to patients. Involving families in care planning can further enhance recovery and quality of life for post-MVR patients. Importantly, the findings show that with appropriate health system support, the strong coping mechanisms demonstrated by patients can form a strong foundation for successful long-term adaptation to life after MVR, even in resource-limited settings.

Data availability statement

Data are available upon reasonable request.