Rheumatic heart disease in Southwestern Ethiopia: Burden, Severity and Self Management Education Effectiveness

Abstract

Background: Rheumatic heart disease (RHD) is a long-term complication that arises from a systemic, inflammatory, and autoimmune reaction triggered by Group A Streptococcus bacteria. RHD causes impairment of one or more heart valves, resulting in significant structural and hemodynamic abnormalities. According to the estimated data from the Global Burden of Disease, RHD has impacted over 40.5 million individuals and resulted in approximately 1,100,000 cases of heart failure as well as 320,000 deaths annually. Despite RHD being the leading cause of cardiovascular disease in Ethiopia, the country lacks established policies, guidelines, or programs aimed at reducing the morbidity and mortality associated with this preventable condition. Ethiopia, a nation heavily affected by RHD, experiences a significant burden from the disease. However, the full extent of this burden and its underlying determinants has not been adequately studied. In addition, there is a lack of research and evidence regarding educational interventions that could potentially improve clinical outcomes for patients with RHD in Ethiopia's existing health care system. Objectives: To determine the prevalence, severity and determinants of rheumatic heart disease, as well as to investigate the effectiveness of chronic disease self-management education among patients with RHD in Southwestern Ethiopia, Jimma Medical Centre. Methods: This study utilized systematic review and meta-analysis, cross-sectional and quasi experimental study designs. Data collection was done using structured questionnaires containing both open- and closed-ended questions. Data were gathered through interviews and reviews of patient’s medical records. Study participants were recruited from a purposively selected hospital at Jimma Medical Center in Southwest Ethiopia based on caseloads. Data collectors were trained nurses from cardiac clinics. For the systematic review and meta-analysis, various databases such as PubMed/Medline, Scopus, HINARI, and Google Scholar were searched for peer-reviewed articles. The pooled prevalence of RHD in Ethiopia was calculated using a random-effects model at a 95% confidence interval (CI), taking into account the weight of each study. Statistical meta-analysis was conducted using STATA Version 16.0 software to determine the pooled prevalence of RHD. Descriptive statistics for frequency, means and standard deviations were used to summarize the dependent and independent variables. Bivariable and multivariable logistic regressions were conducted to determine the association between the dependent and independent variables. Variables with a p-value of ≤ 0.25 on bivariable analysis were then entered into multiple logistic regressions to control confounders. Finally, variables with a p-value of < 0.05 on multivariable regression were considered as determinants of RHD. Model fitness was assessed with the Hosmer-Lemeshow test. Adjusted Odds ratios with a 95% CI were used to indicate the degree of association between the dependent and independent variables. For the echocardiographic study, 115 patients were recruited and evaluated by two cardiologists following the recommendations established by the American Society of Echocardiography. The data were entered into Epidata 3.1, and then transferred to SPSS Version 25.0 for analysis. The Kolmogorov-Smirnov test was used to evaluate the normality of variables and revealed that the data were normally distributed. The outputs of the analysis were then summarized by categorizing and presenting the data using counts, percentages, and standard deviations. A Chi square test was utilized to compare the proportions of categorical variables, evaluate the statistical significance of the association, and determine the level of significance. For the interventional study, 174 study participants were recruited. A one-group quasi experimental study using a pre-test and post-test was implemented using a consecutive sample xv technique. Clinical and laboratory measurements were taken before and after education. One-to one nurse-led multicomponent chronic disease self-management education (CDSME) was endured for four consecutive months. Hospital Anxiety and Depression Scale (HADS) was used to detect the levels of anxiety and depressive symptoms. Data analysis was done on SPSS Version 25.0. Values are presented as means ± SD for continuous variables and percentages for categorical variables. Continuous data were considered statistically significant at p-value <0.05 with two-tailed t-tests. Results: For the systematic review and meta-analysis, the pooled prevalence of RHD was 3.19% (95% CI: 1.46-5.56%). The prevalence was higher among the population who visited hospitals at 5.42% (95% CI: 1.09-12.7%) compared to schoolchildren at 0.73% (95% CI: 0.30-1.34%) and community based studies at 3.83% (95% CI: 3.16-4.55%). Addis Ababa had the lowest prevalence of RHD (0.75% (95% CI: 0.38-1.25%), whereas the highest prevalence was observed in the Amhara (8.95% (95% CI: 7.21-11.06%) and Oromia (5.29% (95% CI: 0.65-13.92%) regions. In the cross-sectional study, the most frequent morbidity encounter was RHD in 27.9% of cases. Female sex [AOR=3.06: 95% CI 1.73–5.47], using wood (biomass fuel) for cooking [AOR=1.94: 95% CI 2.22-6.86], dental caries [AOR=2.09: 95% CI 1.12-3.87], and living in crowded households [AOR=2.02: 95% CI 1.15-3.52] were identified as determinants of RHD. For the echocardiographic study, it was found that the mitral valve was affected in 98.26% of cases, while abnormalities in the aortic and tricuspid valves were diagnosed in 49.5% and 21.17% of cases, respectively. The most common combinations of valve lesions were mitral regurgitation (MR) + mitral stenosis (MS) + aortic regurgitation (AR) (15.7%), followed by MR + AR + TR (8.7%). The occurrence of MR + MS + AR was higher in males (24.1%) compared to females (20.9%). Females also had a significantly lower ejection fraction compared to males (84% vs. 15.2%, p = 0.044). Additionally, nearly two-thirds (63.5%) of individuals experienced RHD-related complications the most commonly encountered complications were pulmonary hypertension (26.1%) and atrial fibrillation (19.1%). In the quasi-experimental study, systolic blood pressure decreased from 131.31 mmHg (SD±15.68) before education to 113.77 mmHg (SD±20.98) after education (t-12.25, p<0.001). The diastolic blood pressure also decreased from 94.87 mmHg (SD±19.41) pre-education to 79.28 mmHg (SD±9.33) post-education (t-12.306, p<0.001). Hemoglobin levels changed from 11.97 g/dl (SD±1.99) before the intervention to 13.84 g/dl (SD±1.37) after the intervention (t-11.96, p<0.001). Similarly, the mean score for the HADS depression subscale decreased from 11.93 (SD±3.43) at the pre-test to 9.48 (SD±3.67) at the post-test (t-8.37, p<0.001). As for the HADS anxiety subscale, the mean score before the education program was 8.59 (SD±2.91) and decreased to 7.30 (SD±1.97) after education (t-6.44, p<0.001). Conclusion: Rheumatic Heart Disease poses a major public health challenge in both Ethiopia and the study area. Female sex, biomass use, malnutrition, dental caries, and overcrowding were identified the determinants factors. The majorities of patients in the study has multiple valve lesions and have experienced RHD-related complications. Chronic disease self-management education has been shown to improve patients' clinical outcomes, including a reduction in anxiety and depression levels. These findings implicates need to strengthen RHD surveillance and improve access to early diagnosis. Addressing female healthcare, reducing biomass fuel exposure, improving nutritional status, providing regular dental care, and enhancing living conditions are all potential strategies to reduce the disease burden. The study also underscores the importance of developing policies, programs, and guidelines for RHD prevention and treatment.