Heart Failure in Lebanon: A Review of the Literature

This research aimed to provide a comprehensive overview of the current literature on heart failure (HF) management in Lebanon and identify the implications for policy, practice, education, and research. The design of this research was a systematic review following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Databases were searched using the search terms “heart failure” and “Lebanon” and associated MeSH terms. The abstracts of the selected articles were examined independently by two researchers; the sample characteristics, HF indices, and results of the included studies were extracted. Key findings and trends were synthesized. Eleven papers were reviewed with 2,774 participants (mean age = 57.98, SD = 13.09 years, and the majority [n = 1,494, 53.85%] were male). Over one-third reported having coronary artery disease, and half had hypertension. The mean ejection fraction was 47.28% (SD = 10.44), and the mean length of hospital stay was 7.97 days (SD = 10.28). Self-care was a common theme showing varying but low scores, especially in the self-management subscale. The findings of this study outline the unique characteristics of the population with HF in a Middle Eastern country. These characteristics should be considered when planning interventions in countries facing geopolitical instability in the context of population aging and the rise of noncommunicable diseases.


Introduction
Heart failure (HF) is a global pandemic affecting at least 26 million people worldwide (Sava-rese & Lund, 2017). This prevalence is expected to rise globally in the next 20 years regardless of trends in coronary disease morbidity and mortality due to improved survival after cardi-ovascular events, rising HF incidence, and/or an increasingly aging population (Heidenreich et al., 2013). Consequently, HF is a global clinical and public health problem associated with substantial mortality and morbidity and subsequent increased healthcare expenditure. This phenomenon is an increasing concern in low-and middle-income countries, particularly when models of care do not follow a traditional Western paradigm (Koirala et al., 2019). Epidemiological studies evaluating the prevalence of HF and associated mortality in the Middle East and North Africa (MENA) region, including Lebanon, are lacking. A range of factors, including climate change, civil unrest, and increased refugee populations, have placed additional pressures on an already stretched healthcare system (Anholt, 2020).
Lebanon, previously known as the pearl of the Middle East, is a small country located on the eastern shore of the Mediterranean Sea. Despite its size, Lebanon is home to more than 5.8 million people due to the high growth rate and the soaring migration rates to the country (United States Central Intelligence Agency, 2014). The continuous geopolitical conflicts have put the country in a state of political, social, and financial instability, causing burden on all sectors, including the health sector (World Health Organization-Regional Office for the Eastern Mediterranean, 2010). The burden on the healthcare sector is manifested through the high annual expenditure on the Lebanese Ministry of Public Health (MoPH) for more than 40% of the Lebanese population (United States Central Intelligence Agency, 2014).
Lebanon remains in a state of epidemiological transition where communicable diseases remain endemic and is paired with an increase in the prevalence of noncommunicable and degenerative diseases (Bassatne et al., 2020). Noncommunicable diseases are a rising healthcare problem in Lebanon and are projected to increase markedly over the coming few decades. This situation is exacerbated by geopolitical instability, economic disruption, and, more recently, the impact of the COVID-19 pandemic (Deek, 2020). In view of the current changes in Lebanon to be comparable to those of the surrounding countries, understanding the current state on HF will enable researchers in Lebanon and the MENA region to set priorities for research and health systems planning. Therefore, this review aimed to provide a comprehensive overview of the current literature on HF from Lebanon.

Methods
This research used the design of a literature search that was conducted for studies on HF in Lebanon, following the PRISMA statement criteria (Sarkis-Onofre et al., 2021). The search was conducted independently by two researchers (HD and AM), and any conflict was resolved by a third researcher (PMD). A bibliographic search of English language publications indexed in Medline, CINAHL, Academic Search Complete, and Scopus computerized databases was conducted. The search strategy adopted for this review with all the MeSH terms is presented in Table 1. The search was also complemented by a search via Google Scholar for further references that were identified through tracking citations from key articles. Further search was conducted for published works in the following websites: MoPH, Google Search, World Health Organization, Central Intelligence Agency of Lebanon, and Statista, in addition to the gray literature websites: Agency for Healthcare Research and Quality, Gray Literature Report, and Open Gray using the search term "HF in Lebanon." The search was completed in August 2020. The following MeSH terms were used: HF, cardiac failure, CHF, chronic HF, congestive HF, or cardiomyopathy, and Lebanon or Lebanese. The terms were used in all possible combinations with mappings to headings wherever possible. Limits were set for English language and availability of full text. Sociodemographic, medical, and clinical data of the study participants were retrieved using a data extraction tool. Descriptive statistics were undertaken. Standard deviations were calculated for unavailable data using the following formula: SD = range/6 (Hozo et al., 2005).
All abstracts were reviewed independently, and papers were included for full review if the authors reported data on the incidence, treatment modalities, readmission rates, interventions, and cost related to HF. Studies that reported findings on cardiovascular diseases without referring to HF in specific were excluded. The PRISMA flowchart of the search strategy is shown in Figure 1.
The abstracts of the selected articles were examined independently by two researchers. The study characteristics (author, year, study title, study design, setting, sample size, and study outcome), sample characteristics (age, gender, level of education, employment, social status, and comorbidities), HF indices (length of stay, New York Heart Association (NYHA) functional class, medications, cause of HF, and ejection fraction), and results of the included studies were extracted. Next, data were assembled from the sources and arranged to identify themes and their relationships. The final sample of 11 articles for this review comprised cross-sectional, correlational, interventional, and descriptive quantitative designs.

Description of Studies.
All the eleven studies on HF in Lebanon reported sociodemographic characteristics of the study participants; eight studies reported select clinical and medical characteristics. Excluded papers reported the development of a culturally appropriate intervention in the Lebanese context , a suggestion for an HF toolbox (Kabbani et al., 2019), and an article that discussed electrocardiogram determinants (Khalil et al., 2016) without details on HF. Matta et al.'s (2016) study reported a single case with limited findings and was thus excluded.
All the studies were conducted in the capital city of Beirut, with the exception of one study conducted in the North Lebanese (Kossaify & Nicolas, 2013). Nine of the eleven studies were descriptive, four used a retrospective chart review design (Abou Dagher et al., 2018;Deek & Skouri et al., 2016;Mansour et al., 2020;Moukarbel & Arnaout, 2003), and two studies used a randomized controlled intervention design (Deek et al., 2017;Sadek et al., 2020). Two studies measured self-care in patients living with HF (Deek et al., 2017;Massouh et al., 2020). Two studies addressed quality of life using the Minnesota Living with Heart Failure (MLW HF) questionnaire (Sadek et al., 2020;Zahwe et al., 2020). The same study by Sadek et al. (2020) linked inspiratory muscle function to exercise capacity and quality of life. Three studies addressed diastolic dysfunction. Mansour et al. (2020) studied the link between diastolic dysfunction and coronary artery calcium scoring, whereas another study addressed the effect of physical inactivity on diastolic dysfunction (Matta et al., 2016). One study adressed the effect of body mass index and waist circumference on diastolic dysfunction (Kossaify & Nicolas, 2013). One study reported the mortality rates of acute HF complicated by sepsis (Abou Dagher et al., 2018). Tatari et al. (2015) studied the economic impact of HF care and its associated costs in Lebanon. Along the same lines, two other studies addressed readmission rates with HF (Deek et al., , 2017. Finally, one study looked at peripartum cardiomyopathy (Moukarbel & Arnaout, 2003).

Synthesis of Results
Sociodemographic Burden. The differences in the samples were evident with the varying sociodemographic characteristics in different studies. Age ranged between 33.7 and 73 years. This wide range is due to the youngest sample of women with peripartum cardiomyopathy. In 7 out of 11 studies, most of the sample were males. Cardiac comorbidities were prevalent with the varying rates of atrial fibrillation, coronary artery disease, and hypertension. The mean EF was middle ranged given that three of the studies presenting their participants' EF ranged around 30%, whereas the other three were over 60%.

Self-care and Symptom Management.
Promoting self-care and engagement in symptom management is a key recommendation of best practice Self-care behaviors and their determinants Self-care was suboptimal in Lebanese patients with HF. Common self-care maintenance behaviors performed by Lebanese patients with HF included using a system to help remember medicines, keeping doctor or nurse appointments, checking for ankle swelling, and eating a low salt diet. Self-care behaviors predominantly low in this population were weighing oneself and exercising for 30 minutes. Higher HF specific knowledge, higher self-care confidence, and lower NYHA 2 Class II predicted better self-care maintenance. HF specific knowledge score, higher self-care maintenance, no recent hospitalization, and being unemployed predicted better selfcare confidence. Self-care management was predicted by self-care confidence alone.    guidelines. Two studies reported self-care (Deek et al., 2017;Massouh et al., 2020). A common scale called the Arabic version of the Self-Care in HF Index (SCHFI) was used. The scale reports self-care through three subscales: maintenance, management, and confidence (Deek & Chang et al., 2016).
Self-care scores in both studies were low. However, the mean scores varied significantly between the two samples. One sample had mean self-care scores of 67.26 on self-care maintenance, 66.96 on management, and 69.5 on selfcare confidence (Massouh et al., 2020). In the other sample, lower scores were reported as 35 on self-care maintenance, 16 on management, and 41 on self-care confidence (Deek et al., 2017). An important note was that participants in both samples scored lowest on the self-care management subscale. In addition, Lebanese females generally scored higher than men ( (Massouh et al., 2020). Conversely, higher self-care maintenance and management scores were reported for those with previous hospitalization (Deek et al., 2017).
Marital status also seemed to affect the subscales  (Massouh et al., 2020). Participants who were not married had higher self-care maintenance (67.27 ± 13.48), confidence (70.76 ± 14.4), and management (72.69 ± 14.4) than married participants. Patients who were currently hospitalized scored lower on all three scales (self-care maintenance: 64.99 ± 13.35; self-care confidence: 60.76 ± 16.98; and self-care management: 65.65 ± 21.23) than those who were not hospitalized (Massouh et al., 2020). HF severity was a predictor of self-care in both samples. Better functional status (lower NYHA score) Diastolic Dysfunction and HF. Physical inactivity, higher body mass index, increased age, and multiple comorbidities were significantly associated with diastolic dysfunction (Matta et al., 2016). Diastolic dysfunction or age was found to be significantly associated with subclinical atherosclerosis. However, when the diastolic dysfunction and age were combined, the risk of developing atherosclerosis was 9 times higher (Mansour et al., 2020). Conversely, physical activity, specifically high-intensity aerobic interval training and inspiratory muscle training, improved exercise time, 6-minute walk test, and quality of life (Sadek et al., 2020). The latter was decreased with readmission, depression, and higher NYHA class (Zahwe et al., 2020) but was not changed with education (Deek et al., 2017).

Discussion
This review aimed to gather and analyze the available literature on HF in Lebanon and subsequently highlight the gaps in knowledge, which will help guide future research and practice improvements in Lebanon and surrounding countries of similar sociopolitical and economic conditions. The unique features of collectivist cultures make strategies for improvement challenging, whereas many self-management strategies are based on Western cultures where there exists a strong emphasis on individuals. By contrast, in collectivist cultures, there exists an increased importance of family involvement. In many countries such as Lebanon, the rapidly changing political and economic circumstances challenge the ability to plan strategically. This phe-nomenon, along with the high rates of illiteracy that were established in the older adult population with HF, render regular educational strategies to be ineffective. The variance in samples in this review showed varying results in terms of sociodemographic characteristics and selfcare practices. The latter significantly varied with educational status, marital status, and clinical profile. This result was evident with the great difference in the level of education among the study samples. This variance could be explained by the availability of a multidisciplinary disease management program at one of the data collection sites (Massouh et al., 2020) and the lack of such advanced service at the other.
Other variables that could contribute to self-care practices included motivation, experience, and skills, in addition to cultural beliefs and values (Jaarsma et al., 2017). Cultural beliefs and values may be key aspects to consider when evaluating or planning interventions related to selfcare in collectivist cultures (Jaarsma et al., 2017) as was evaluated with patients with HF to show improved self-care and read-mission outcomes .
Other factors to consider are the support and access to healthcare (Jaarsma et al., 2017). These factors were evidently a challenge in the Lebanese setting due to the dire financial situation in the country and the resultant lack of medical supplies and medications. These common faces of instability challenge the countries of the MENA region (Dhaoui, 2019). Changes in the healthcare system and, consequently, care and follow-up tailored to the needs of these patients are inevitable. The low scores on the self-management subscale were similar to findings of a study conducted in 15 countries (Jaarsma et al., 2013), as well as other developing countries such as Taiwan (Tung et al., 2012) and Iran (Zamanzadeh et al., 2012). However, the improved self-care scores on the three subscales of the SCHFI, in one study, with better functional status could be attributed to higher levels of energy in participants with better functional status to devote to self-care. They may also believe that being less symptomatic is a consequence of them managing their HF well. However, participants with lower NYHA classification had lower scores on management compared with those with NYHA Classes III and IV. This result was consistent with studies that reported that patients with HF engage in self-care when their cases are worsened, reflected by lower ejection fraction (Seto et al., 2011). An interesting finding was the higher scores across the three subscales of the SCHFI in single patients with HF compared with those who were married. This finding contradicted the previous literature, which presents the importance of family involvement and the importance of a caregiver, in general, in collectivist cultures. However, this finding was retrieved from a sample that was considered welleducated and of higher sociodemographic status (Massouh et al., 2020) than that of the study showing contradicting findings (Deek et al., 2017). These findings should be further investigated in a study with a larger sample size that would allow generalizability to people with HF.
The Arabic-translated version of the SCHFI was previously validated in the Lebanese setting with good psychometric properties. The findings of the validation study showed that the modified version of this tool indicated favorable outcomes. Such outcomes include dropping items from three subscales, which should be considered when evaluating self-care in future studies and allowing larger samples for better judgment on the psychometric properties of this Arabictranslated version of the SCHFI (Deek & Chang et al., 2016). Such evaluation could be performed across different countries of the region to allow for cross-cultural comparison and enhance better understanding of the different, and possibly similar, needs of patients with HF.
More national descriptive studies should be conducted to outline the needs of the Lebanese population with HF in light of all the rapid sociopolitical and economic changes in the country. Moreover, a national registry may assist in monitoring health outcomes. The challenges facing HF care in low-and middle-income countries are vast. These challenges include but not limited to economic, political, health system, and social issues. Fortunately, these modifiable variables, when and if amended, can allow for stability and security in terms of chronic disease management and the ability of the population with HF to maintain a minimum level of wellbeing. Addressing the educational needs of people living with HF while considering their educational level and health literacy is pivotal.
The differences in regions are many but the culture of the country is somehow unified and can be targeted through personalized and flexible educational interventions.
This review can be investigated within the context of the current times in Lebanon and the MENA region. In the midst of the COVID-19 pandemic, on August 4, 2020, Beirut, the capital of Lebanon, witnessed one of the biggest explosions in history, causing further devastation (Farha & Abi Jaoude, 2020). Isolating the cumulative experience of trauma for patients and healthcare workers alike is not valid. As scholars seek to develop interventions for HF in Lebanon and the region, these factors should be considered. Nurses can have a powerful voice to lead systems change and address critical social issues (Dhaini et al., 2020). This notion has been proven once and again through nurse-led multidisciplinary interventions aimed at improving HF outcomes (Rice et al., 2018). In addition, education is one of the main and pivotal roles of the nursing profession, which should be tailored to meet the needs of people with low literacy levels, as seen in the countries of this region (Asbu et al., 2017).

Conclusion
Research on HF remains highly limited in Lebanon and the MENA region and is considerably needed to inform healthcare practitioners regarding the needs of the population. Therefore, national and regional studies should be conducted to assess the current trends in patterns of care and health utilization and healthcare inter-ventions developed that are culturally appropriate. Scholars should also consider the many changes and challenges facing the nursing profession and the healthcare system in general in delivering the optimal care it is aiming for. Future studies should address the limitations of this work, such as the lack of generalizability considering the heterogeneity of the samples' clinical and sociodemographic characteristics from different locations of the country. In addition, the limited number of intervention studies did not allow for a rigorous analysis to yield accurate results. Despite these limitations, these data are useful in developing future interventions. The design of interventions should be tailored to meet the continuously changing needs of people with HF with the rapid changes in the country. This factor should be initially addressed through continuous evaluation of the financial and sociopolitical changes and their effects on the healthcare system and patients. Following the understanding of these implications, these factors should be adapted to practice while aiming to improve patient outcome.