---
title: "Day-to-day challenges of long-term warfarin use in patients with prosthetic heart valves in Tanzan"
id: "plos-one-0-day-to-day-experiences-and-challenges-of-long-term-warfarin-use-among-patients"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-0-day-to-day-experiences-and-challenges-of-long-term-warfarin-use-among-patients"
content_type: "clinical_feed_article"
specialty: "Cardiology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506"
published_at: "2026-08-05T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Day-to-day challenges of long-term warfarin use in patients with prosthetic heart valves in Tanzan
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-0-day-to-day-experiences-and-challenges-of-long-term-warfarin-use-among-patients
- **Specialty:** [Cardiology](https://medichelpline.com/clinical-feed/cardiology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506)
- **Published At:** 2026-08-05T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This qualitative study explored daily experiences of 12 patients with **prosthetic heart valves** on long-term **warfarin** at a national cardiac institute in Dar es Salaam, Tanzania, recruited purposively between April and June 2025. - Researchers used in-depth semi-structured interviews and a combined inductive–deductive content analysis to examine how patients manage anticoagulation in everyday life after discharge. - Participants reported clinical improvement and symptom relief after valve surgery but faced ongoing difficulties related to strict **dietary** advice, medication side effects, emotional distress, and reduced participation in socio-economic activities. - Maintaining a therapeutic **INR** was impeded by financial constraints, inconsistent access to INR monitoring and warfarin services outside the referral center, and contradictory information from different healthcare providers. - Some patients described self-adjusting doses or missing follow-up appointments because of cost and travel barriers, undermining anticoagulation continuity. - The study identifies two overarching categories: adapting to life with long-term warfarin use, and navigating warfarin care within an unstructured continuum of care. - Authors recommend strengthening patient-centered education, improving consistency of anticoagulation counselling, decentralizing **warfarin** and **INR** monitoring services, and establishing structured long-term follow-up systems to improve adherence and outcomes in low-resource settings. - Funding was provided by Muhimbili University of Health and Allied Sciences; full qualitative datasets are not publicly available for confidentiality reasons but de-identified data may be requested through the institutional contact reported in the manuscript.
## Clinical Analysis & Structured Key Points
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Mgala , Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Writing – original draft * E-mail: benedictomgala@gmail.com Affiliation Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0009-0000-0459-2478 ](https://orcid.org/0009-0000-0459-2478 "ORCID Registry") ⨯ * Salome E. Buluba, Roles Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – review & editing Affiliation Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania ⨯ * Aisha A. Omar, Roles Data curation, Investigation, Project administration, Resources, Validation, Writing – review & editing Affiliation Department of Nursing Services, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania ⨯ * Dickson A. Mkoka Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – review & editing Affiliation Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania ⨯ # Day-to-day experiences and challenges of long-term warfarin use among patients with prosthetic heart valves at a National Cardiac Institute in Tanzania: A qualitative study * Benedicto T. Mgala, * Salome E. Buluba, * Aisha A. Omar, * Dickson A. Mkoka ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: August 5, 2026 * * [Article](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506) * [Authors](https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0355506) * [Metrics](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0355506) * [Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0355506) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pone.0355506) * [Peer Review](https://journals.plos.org/plosone/article/peerReview?id=10.1371/journal.pone.0355506) * [Abstract](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#abstract0) * [Introduction](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#sec006) * [Materials and methods](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#sec007) * [Results](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#sec016) * [Discussion](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#sec028) * [Acknowledgments](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#ack) * [References](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#references) * [Reader Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0355506) * [Figures](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506) ## Abstract ### Background Long-term warfarin therapy following prosthetic heart valve placement is essential for preventing valve-related thromboembolic complications. Due to its narrow therapeutic window, maintaining a therapeutic International Normalized Ratio (INR) requires strict adherence to healthcare medication, dietary recommendations, and regular monitoring. Despite receiving education at discharge, patients with prosthetic heart valves continue to demonstrate poor adherence to warfarin therapy. While previous quantitative studies have identified factors associated with non-adherence, little is known about patients’ day-to-day experiences and challenges with long-term warfarin use in low-resource settings. ### Aim of the study This study explored day-to-day experiences and challenges encountered during long-term warfarin use among patients with prosthetic heart valves attending a National Cardiac Institute in Dar es Salaam, Tanzania. ### Materials and methods An explorative qualitative study design using inductive content analysis was conducted among twelve (12) patients with prosthetic valves on long-term warfarin therapy, who were purposively recruited based on the principle of data saturation between April 2025 and June 2025 at a national cardiac institute. In-depth interviews were conducted using a semi-structured interview guide. Data were analyzed manually using a deductive-inductive content analysis approach. ### Results Two main categories emerged from this study. The first category, adapting to life with long-term warfarin use, describes participants’ experiences of symptom relief and improved quality of life after surgery, alongside issues related to dietary restrictions, medication side effects, emotional distress, and reduced engagement in socio-economic activities. Participants perceived dietary recommendations as restrictive and reported difficulties with lifestyle modifications required during long-term warfarin therapy. The second category, navigating warfarin care within an unstructured continuum of care, reports participants’ struggles in maintaining therapeutic INR levels amid financial difficulties, inconsistent medication use, contradictory information from healthcare providers, and limited access to INR monitoring and warfarin services in peripheral regions. Some participants reported self-adjusting warfarin doses or missing follow-up appointments due to cost and accessibility barriers. ### Conclusion and recommendations Although participants experienced clinical improvement post-surgery, they continued to face substantial challenges related to long-term warfarin use and access to anticoagulation care. Strengthening patient-centered education, improving continuity and consistency of anticoagulation counselling, decentralizing warfarin and INR monitoring services, and enhancing structured long-term follow-up systems may improve warfarin adherence and patient outcomes in low-resource settings. ## Figures ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0355506.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0355506.t002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0355506.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0355506.t002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0355506.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0355506.t002) **Citation:** Mgala BT, Buluba SE, Omar AA, Mkoka DA (2026) Day-to-day experiences and challenges of long-term warfarin use among patients with prosthetic heart valves at a National Cardiac Institute in Tanzania: A qualitative study. PLoS One 21(8): e0355506. https://doi.org/10.1371/journal.pone.0355506 **Editor:** Mergan Naidoo, University of Kwazulu-Natal, SOUTH AFRICA **Received:** February 17, 2026; **Accepted:** July 22, 2026; **Published:** August 5, 2026 **Copyright:** © 2026 Mgala et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Data Availability:** Important supporting data relevant to this study have been provided within the manuscript and its Supporting Information files, including the interview guide, COREQ checklist, and codebook. Due to ethical considerations related to participant confidentiality and the sensitive nature of qualitative interview data, the full qualitative datasets cannot be made publicly available. However, de-identified data may be made available upon reasonable request through a non-author institutional point of contact: The Directorate of Research and Publications, Muhimbili University of Health and Allied Sciences (MUHAS), P.O. Box 65001, Dar es Salaam, Tanzania. Email: drp@muhas.ac.tz. **Funding:** This study was funded by the Muhimbili University of Health and Allied Sciences (MUHAS) through institutional research support awarded to BTM. The co-authors affiliated with MUHAS contributed to the study in their academic and supervisory capacities and did not receive specific funding for this work. The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of the authors are articulated in the ‘author contributions’ section. **Competing interests:** The authors have declared that no competing interests exist. ## Introduction Valvular heart disease (VHD) is a leading global cause of cardiovascular symptoms and functional disability, contributing to an estimated 1.4 million deaths and over 10 million disability-adjusted life years annually [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref001)–[3](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref003)]. While degenerative and functional VHD dominate in high-income countries, rheumatic heart disease (RHD) caused by rheumatic fever remains the primary form in low- and middle-income countries [[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref004)]. In 2019, the global prevalence of RHD was estimated at 40.5 million, with the highest burden among marginalized populations in sub-Saharan Africa (SSA) [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref002),[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref004)]. Rheumatic heart disease complicating to VHD remains highly prevalent in Tanzania, with pooled estimates around 9% and echocardiographic studies reporting subclinical valvular diseases in approximately 2–3% of school-aged children, highlighting a substantial disease burden [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref001),[5](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref005),[6](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref006)]. Valvular heart diseases are generally progressive, and surgical treatment is required in cases of severe insufficiency or stenosis [[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref007),[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref008)]. Patients need to cope with further difficulties despite successful surgery. One of these difficulties in care post-surgery is the patients’ lifelong use of anticoagulant medication [[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref007),[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref009),[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref010)]. Anticoagulation is crucial in preventing valve-related thromboembolic complications. It is assessed using the international normalized ratio (INR) test [[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref007)]. The target therapeutic INR value varies according to the valve type, ranging between 2.5–3.5 in the mitral valve, and 2.0–3.0 in the aortic valve [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref009)]. A high INR value is associated with anticoagulant toxicity and poses the risk of bleeding, while a low INR value increases the risk of thrombosis to the patient [[11](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref011)]. In SSA, suboptimal anticoagulation control among patients on warfarin has been widely reported, further increasing the risk of both thromboembolic and bleeding complications in this population [[12](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref012)]. Although direct oral anticoagulants (DOACs) are increasingly used in other cardiovascular conditions, their use in patients with mechanical prosthetic heart valves remains limited due to insufficient evidence on safety and effectiveness in this population. As a result, warfarin remains the standard anticoagulant therapy for these patients. Moreover, the availability and affordability of newer anticoagulants such as DOACs remain major challenges in low-resource settings [[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref007),[13](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref013)]. Warfarin is used as a long-term oral anticoagulant in patients with prosthetic heart valves in Tanzania [[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref008)]. For an effective therapeutic outcome, warfarin adherence is mandatory [[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref010),[14](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref014)]. Patients are usually discharged with health information given regarding consistent medication use with the recommended dose, dietary and lifestyle modification, and regular blood tests for INR monitoring [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref009),[12](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref012),[15](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref015)–[17](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref017)]. The health information given at discharge aims to promote warfarin compliance, prevent complications, and improve patients’ quality of life [[15](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref015),[18](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref018),[19](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref019)]. Despite the health education given upon discharge regarding the appropriate use of warfarin among these patients, various studies reported low patient adherence to warfarin use, ranging from 20% to 65% [[17](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref017),[19](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref019)–[22](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref022)]. Most of these studies are quantitative in nature and have mainly identified factors associated with anticoagulant adherence, including knowledge, age, gender, heart valve surgery, alcohol consumption, and cost of treatment [[19](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref019),[22](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref022)–[25](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref025)]. Few studies conducted in Tanzania have reported poor clinical outcomes among patients with prosthetic valves on long-term warfarin therapy, with limited documentation of the underlying reasons contributing to the low adherence and anticoagulation outcomes among these patients [[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref008),[26](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355506#pone.0355506.ref026)]. However, quantitative studies alone cannot adequately explain how patients experience long-term warfarin use in their daily lives, how they negotiate treatment recommendations, and why challenges to adherence persist despite receiving health education. Furthermore, little is known about the lived day-to-day experiences and challenges encountered by patients with prosthetic heart valves on long-term warfarin therapy within the Tanzanian context. Qualitative exploration of these experiences might provide deeper insight into both patients and health system-related factors that require context-specific interventions to improve anticoagulation outcomes. Therefore, this study explored the day-to-day experiences and challenges encountered by patients with prosthetic heart valves regarding long-term warfarin use. ## Materials and methods ### Study design An exploratory descriptive qualitative study design was employed to examine the day-to-day experiences and challenges of patients with prosthetic heart valves who were on long-term warfarin therapy following hospital discharge. This design was appropriate because the study sought to obtain detailed accounts of how patients experience, interpret, and manage long-term warfarin therapy in their everyday lives. Qualitative content analysis was used to analyze participants’ information so as to allow systematic description and interpretation of participants’ narratives while preserving the context in which their experiences occur. The analysis followed a combined inductive-deductive a
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