{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T04:33:20Z","timestamp":1790138000697,"version":"4.0.1"},"reference-count":37,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T00:00:00Z","timestamp":1785888000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100021573","name":"Muhimbili University of Health and Allied Sciences","doi-asserted-by":"publisher","award":["Postgraduate Scholarship"],"award-info":[{"award-number":["Postgraduate Scholarship"]}],"id":[{"id":"10.13039\/501100021573","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"\n Background<\/jats:title>\n 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\u2019 day-to-day experiences and challenges with long-term warfarin use in low-resource settings.<\/jats:p>\n <\/jats:sec>\n \n Aim of the study<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Materials and methods<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Two main categories emerged from this study. The first category, adapting to life with long-term warfarin use, describes participants\u2019 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\u2019 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.<\/jats:p>\n <\/jats:sec>\n \n Conclusion and recommendations<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>","DOI":"10.1371\/journal.pone.0355506","type":"journal-article","created":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T17:27:16Z","timestamp":1785950836000},"page":"e0355506","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["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"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-0459-2478","authenticated-orcid":true,"given":"Benedicto 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Z\u00fchlke","year":"2016","journal-title":"Circulation [Internet]"},{"issue":"6","key":"pone.0355506.ref002","doi-asserted-by":"crossref","first-page":"2178","DOI":"10.3390\/jcm12062178","article-title":"The global burden of valvular heart disease: from clinical epidemiology to management","volume":"12","author":"G Santangelo","year":"2023","journal-title":"J Clin Med"},{"key":"pone.0355506.ref003","doi-asserted-by":"crossref","first-page":"2849","DOI":"10.2147\/IJGM.S420591","article-title":"Etiologies and patterns of valvular heart disease among cardiac patients at the cardiac center of ethiopia during February 2000 to April 2022","volume":"16","author":"A Adere","year":"2023","journal-title":"Int J Gen Med"},{"issue":"12","key":"pone.0355506.ref004","doi-asserted-by":"crossref","first-page":"853","DOI":"10.1038\/s41569-021-00570-z","article-title":"Global epidemiology of valvular heart disease","volume":"18","author":"S Coffey","year":"2021","journal-title":"Nat Rev Cardiol"},{"key":"pone.0355506.ref005","doi-asserted-by":"crossref","first-page":"8834443","DOI":"10.1155\/2023\/8834443","article-title":"Rheumatic heart disease in East Africa: a systematic review and meta-analysis","volume":"2023","author":"G Mebrahtom","year":"2023","journal-title":"Int J Rheumatol"},{"issue":"12","key":"pone.0355506.ref006","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0208931","article-title":"Heart diseases and echocardiography in rural Tanzania: occurrence, characteristics, and etiologies of underappreciated cardiac pathologies","volume":"13","author":"DM Raphael","year":"2018","journal-title":"PLoS One"},{"key":"pone.0355506.ref007","doi-asserted-by":"crossref","unstructured":"Nishimura RA, Otto CM, Bonow RO, Iii JPE, Fleisher LA, Jneid H, et al. 2017 AHA \/ ACC Focused Update of the 2014 AHA \/ ACC Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology \/ American Heart Association Task Force on Clinical Practice Guidelines. 2017. 1159\u201395. https:\/\/doi.org\/10.1016\/j.jacc.2017.03.011","DOI":"10.1161\/CIR.0000000000000503"},{"issue":"3","key":"pone.0355506.ref008","doi-asserted-by":"crossref","DOI":"10.1111\/eci.14114","article-title":"Comparison between interventional versus medical therapy in patients with rheumatic mitral valve stenosis in Tanzania","volume":"54","author":"RK Mutagaywa","year":"2024","journal-title":"Eur J Clin Invest"},{"issue":"4","key":"pone.0355506.ref009","doi-asserted-by":"crossref","first-page":"470","DOI":"10.4274\/cjms.2021.2227","article-title":"Mechanical heart valve surgery patients\u2019 experience with warfarin: a qualitative study","volume":"7","author":"EA Kankaya","year":"2022","journal-title":"Cyp J Med Sci"},{"key":"pone.0355506.ref010","doi-asserted-by":"crossref","first-page":"105202","DOI":"10.1016\/j.ejps.2019.105202","article-title":"Optimal oral anticoagulant therapy in Chinese patients with mechanical heart valves","volume":"144","author":"H Zhang","year":"2020","journal-title":"Eur J Pharm Sci"},{"issue":"2","key":"pone.0355506.ref011","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-057166","article-title":"Vitamin K-dependent anticoagulant use and level of anticoagulation control in sub-Saharan Africa: protocol for a retrospective cohort study","volume":"12","author":"JC Mwita","year":"2022","journal-title":"BMJ Open"},{"issue":"4","key":"pone.0355506.ref012","doi-asserted-by":"crossref","first-page":"596","DOI":"10.1177\/1076029617747413","article-title":"Quality of anticoagulation with warfarin at a tertiary hospital in Botswana","volume":"24","author":"JC Mwita","year":"2018","journal-title":"Clin Appl Thromb Hemost"},{"issue":"24","key":"pone.0355506.ref013","doi-asserted-by":"crossref","first-page":"2670","DOI":"10.1016\/j.jacc.2016.09.958","article-title":"Prosthetic heart valve thrombosis","volume":"68","author":"GD Dangas","year":"2016","journal-title":"J Am Coll Cardiol"},{"issue":"4","key":"pone.0355506.ref014","first-page":"37","article-title":"Warfarin therapy: survey of patients\u2019 knowledge of their drug regimen","volume":"21","author":"W Shuaib","year":"2014","journal-title":"Malays J Med Sci"},{"key":"pone.0355506.ref015","article-title":"Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario American Association for Thoracic Surgery American College of Cardiology.","author":"D Saksena","year":"2019","journal-title":"Indian J Thorac Cardiovasc Surg"},{"issue":"1","key":"pone.0355506.ref016","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1186\/s12913-017-2330-0","article-title":"Quality of anticoagulation management with warfarin among outpatients in a tertiary hospital in Addis Ababa, Ethiopia: a retrospective cross-sectional study","volume":"17","author":"TG Fenta","year":"2017","journal-title":"BMC Health Serv Res"},{"issue":"514","key":"pone.0355506.ref017","first-page":"1","article-title":"Factors affecting medication adherence in patients with mechanical heart valves taking warfarin: the role of knowledge on warfarin, medication belief, depression, and self-efficacy","volume":"18","author":"S Park","year":"2021","journal-title":"Int J Environ Res Public Heal [Internet]"},{"issue":"9","key":"pone.0355506.ref018","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0257798","article-title":"Barriers and facilitators for optimizing oral anticoagulant management: perspectives of patients, caregivers, and providers","volume":"16","author":"A Holbrook","year":"2021","journal-title":"PLoS One"},{"issue":"2","key":"pone.0355506.ref019","doi-asserted-by":"crossref","first-page":"174","DOI":"10.5114\/fmpcr.2021.105919","article-title":"Assessment of the warfarin anticoagulation knowledge of patients with mechanical mitral valve prosthesis and its effect on therapy adherence and relevant complications","volume":"23","author":"\u0130 Kaya","year":"2021","journal-title":"Fam Med Prim Care Rev"},{"issue":"08","key":"pone.0355506.ref020","doi-asserted-by":"crossref","first-page":"184","DOI":"10.4236\/wjcs.2022.128014","article-title":"Warfarin compliance after mechanical AVR in the pediatric population: case series from a developing country","volume":"12","author":"S Zubairi","year":"2022","journal-title":"World J Carciovasc Surg"},{"key":"pone.0355506.ref021","doi-asserted-by":"crossref","first-page":"58","DOI":"10.5606\/tgkdc.dergisi.2015.10390","article-title":"Do patients with mechanical heart valves have the appropriate knowledge regarding warfarin therapy and can they adhere to the correct dosage?","author":"F Demir Korkmaz","year":"2015","journal-title":"Turk Gogus Kalp Dama"},{"key":"pone.0355506.ref022","first-page":"52","article-title":"Patient associated factors that affect adherence to warfarin therapy in a tertiary referral hospital in Kenya.","volume":"6","author":"K Mariita","year":"2015","journal-title":"J Pharm Sci"},{"issue":"1","key":"pone.0355506.ref023","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1186\/s12909-025-07074-1","article-title":"Factors influencing nurses\u2019 knowledge and competence in warfarin-drug and nutrient interactions and patient counseling practices","volume":"25","author":"M Subih","year":"2025","journal-title":"BMC Med Educ"},{"issue":"3","key":"pone.0355506.ref024","first-page":"4725","article-title":"Does in-service training affect to nurses\u2019 knowledge level about the anticoagulant drugs","volume":"13","author":"E Baysal","year":"2016","journal-title":"J Hum Sci"},{"issue":"3","key":"pone.0355506.ref025","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1080\/14779072.2020.1734452","article-title":"Profiles of patients on warfarin anticoagulation therapy in a leading tertiary referral hospital in Kenya; findings and implications for Kenya","volume":"18","author":"DG Nyamu","year":"2020","journal-title":"Expert Rev Cardiovasc Ther"},{"issue":"3","key":"pone.0355506.ref026","doi-asserted-by":"crossref","first-page":"15","DOI":"10.4314\/tmj.v31i3.367","article-title":"Clinical and anticoagulation profile of patients on warfarin anticoagulation at muhimbili national hospital in Dar es Salaam Tanzania: a cross-sectional study","volume":"31","author":"O Minzi","year":"2020","journal-title":"Tanzania Med J"},{"key":"pone.0355506.ref027","doi-asserted-by":"crossref","first-page":"114523","DOI":"10.1016\/j.socscimed.2021.114523","article-title":"Sample sizes for saturation in qualitative research: a systematic review of empirical tests","volume":"292","author":"M Hennink","year":"2022","journal-title":"Soc Sci Med"},{"key":"pone.0355506.ref028","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.nedt.2017.06.002","article-title":"Methodological challenges in qualitative content analysis: a discussion paper","volume":"56","author":"UH Graneheim","year":"2017","journal-title":"Nurse Educ Today"},{"issue":"2","key":"pone.0355506.ref029","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1016\/j.ijnurstu.2008.08.006","article-title":"Methodological challenges in cross-language qualitative research: a research review","volume":"46","author":"A Squires","year":"2009","journal-title":"Int J Nurs Stud"},{"key":"pone.0355506.ref030","doi-asserted-by":"crossref","unstructured":"Lincoln Y, Guba E. Naturalistic inquiry. Beverly Hills Sage Publ. 1985.","DOI":"10.1016\/0147-1767(85)90062-8"},{"issue":"5","key":"pone.0355506.ref031","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-045018","article-title":"Application of Andersen\u2019s behavioural model of health services use: a scoping review with a focus on qualitative health services research","volume":"11","author":"M Lederle","year":"2021","journal-title":"BMJ Open"},{"issue":"4","key":"pone.0355506.ref032","first-page":"213","article-title":"Experiences of warfarin use among cardiac valve-replaced patients in Iran","volume":"6","author":"M Taghadosi","year":"2013","journal-title":"J Crit Care Nurs"},{"issue":"1","key":"pone.0355506.ref033","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1186\/s13019-023-02235-z","article-title":"Health related quality of life of patients following mechanical valve replacement surgery for rheumatic mitral stenosis in Tanzania","volume":"18","author":"RK Mutagaywa","year":"2023","journal-title":"J Cardiothorac Surg"},{"issue":"4","key":"pone.0355506.ref034","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1007\/s11239-023-02928-1","article-title":"Anticoagulation control among patients on vitamin K antagonists in nine countries in Sub-Saharan Africa","volume":"57","author":"JC Mwita","year":"2024","journal-title":"J Thromb Thrombolysis"},{"issue":"12","key":"pone.0355506.ref035","doi-asserted-by":"crossref","first-page":"997","DOI":"10.1160\/TH11-10-0690","article-title":"Bleeding risk assessment and management in atrial fibrillation patients","volume":"106","author":"GYH Lip","year":"2011","journal-title":"Thromb Haemost"},{"issue":"9","key":"pone.0355506.ref036","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-045807","article-title":"Assessment of equity in healthcare financing and benefits distribution in Tanzania: a cross-sectional study protocol","volume":"11","author":"P Binyaruka","year":"2021","journal-title":"BMJ Open"},{"issue":"3","key":"pone.0355506.ref037","doi-asserted-by":"crossref","first-page":"303","DOI":"10.4103\/ijmr.IJMR_1201_18","article-title":"Quality of anticoagulation with warfarin in rural Chhattisgarh, India","volume":"152","author":"P Chebrolu","year":"2020","journal-title":"Indian J Med Res"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0355506","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T17:27:23Z","timestamp":1785950843000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0355506"}},"subtitle":[],"editor":[{"given":"Mergan","family":"Naidoo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,8,5]]},"references-count":37,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,5]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0355506","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,5]]}}}