Acceptability and Implementation Challenges of Benzathine Penicillin G Secondary Prophylaxis for Rheumatic Heart Disease in Ethiopia: A Qualitative Study

Eshetie Melese Birru; Kevin T. Batty; Laurens Manning; Stephanie L. Enkel; Brioni R. Moore

doi:10.5334/gh.1393

Acceptability and Implementation Challenges of Benzathine Penicillin G Secondary Prophylaxis for Rheumatic Heart Disease in Ethiopia: A Qualitative Study

Global Heart

Volume 20 (2025): Issue 1

By: Eshetie Melese Birru , Kevin T. Batty , Laurens Manning , Stephanie L. Enkel and Brioni R. Moore

Open Access

|Jan 2025

Cunningham MW. Post-streptococcal autoimmune sequelae: Rheumatic fever and beyond. In Ferretti JJ, Stevens DL, Fischetti VA (Eds.) Streptococcus pyogenes: Basic biology to clinical manifestations [Internet]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK333434/2016.
Search in Google Scholar Back to article
Cunningham MW. Streptococcus and rheumatic fever. Current Opinion in Rheumatology. 2012; 24(4):408–416. DOI: 10.1097/BOR.0b013e32835461d3
Open DOI Search in Google Scholar Back to article
Ou Z, Yu D, Liang Y, et al. Global burden of rheumatic heart disease: Trends from 1990 to 2019. Arthritis Research & Therapy. 2022; 24(1):138. DOI: 10.1186/s13075-022-02829-3
Open DOI Search in Google Scholar Back to article
de Dassel JL, Ralph AP, Carapetis JR. Controlling acute rheumatic fever and rheumatic heart disease in developing countries: Are we getting closer? Current Opinion in Pediatrics. 2015; 27(1):116–123. DOI: 10.1097/MOP.0000000000000164
Open DOI Search in Google Scholar Back to article
Kerrigan V, Kelly A, Lee AM, et al. A community-based program to reduce acute rheumatic fever and rheumatic heart disease in northern Australia. BMC Health Services Research. 2021; 21:1–15. DOI: 10.1186/s12913-021-07159-9
Open DOI Search in Google Scholar Back to article
Roberts KV, Maguire GP, Brown A, et al. Rheumatic heart disease in Indigenous children in northern Australia: Differences in prevalence and the challenges of screening. Medical Journal of Australia. 2015; 203(5):221.e1–7. DOI: 10.5694/mja15.00139
Open DOI Search in Google Scholar Back to article
Remenyi B, Carapetis J, Wyber R, Taubert K, Mayosi BM. Position statement of the World Heart Federation on the prevention and control of rheumatic heart disease. Nature Reviews Cardiology. 2013; 10(5):284–292. DOI: 10.1038/nrcardio.2013.34
Open DOI Search in Google Scholar Back to article
Adem A, Dukessa Gemechu T, Jarso H, Reta W. Rheumatic heart disease patients’ adherence to secondary prophylaxis and associated factors at hospitals in Jimma zone, Southwest Ethiopia: A multicenter study. Patient Preference and Adherence. 2020:2399–2406. DOI: 10.2147/PPA.S281413
Open DOI Search in Google Scholar Back to article
Kevat PM, Reeves BM, Ruben AR Gunnarsso R. Adherence to secondary prophylaxis for acute rheumatic fever and rheumatic heart disease: A systematic review. Current Cardiology Reviews. 2017; 13(2):155–166. DOI: 10.2174/1573403X13666170116120828
Open DOI Search in Google Scholar Back to article
Rémond M, Severin K, Hodder Y, et al. Variability in disease burden and management of rheumatic fever and rheumatic heart disease in two regions of tropical Australia. Internal Medicine Journal. 2013; 43(4):386–393. DOI: 10.1111/j.1445-5994.2012.02838.x
Open DOI Search in Google Scholar Back to article
Rémond MG, Coyle ME, Mills JE, Maguire GP. Approaches to improving adherence to secondary prophylaxis for rheumatic fever and rheumatic heart disease: A literature review with a global perspective. Cardiology in Review. 2016; 24(2):94–98. DOI: 10.1097/CRD.0000000000000065
Open DOI Search in Google Scholar Back to article
Berhanu H, Mekonnen Y, Workicho A, et al. The prevalence of rheumatic heart disease in Ethiopia: A systematic review and meta-analysis. Tropical Diseases, Travel Medicine and Vaccines. 2023; 9(1):16. DOI: 10.1186/s40794-023-00192-y
Open DOI Search in Google Scholar Back to article
Tadele H, Mekonnen W, Tefera E. Rheumatic mitral stenosis in children: More accelerated course in sub-Saharan patients. BMC Cardiovascular Disorders. 2013; 13:1–6. DOI: 10.1186/1471-2261-13-95
Open DOI Search in Google Scholar Back to article
Ministry of Health Ethiopia. Standard treatment guidelines for general hospitals, 4th edition. Addis Ababa; 2021 [Accessed on 20 July 2024]. Available from: https://doctorsonlinee.com/wp-content/uploads/2022/04/STG-Final-4th-edtion-2021-3.pdf.
Search in Google Scholar Back to article
Mekonen KK, Yismaw MB, Abiye AA, Tadesse TA. Adherence to Benzathine Penicillin G secondary prophylaxis and its determinants in patients with rheumatic heart disease at a cardiac center of an Ethiopian Tertiary Care Teaching Hospital. Patient Preference and Adherence. 2020:343–352. DOI: 10.2147/PPA.S238423
Open DOI Search in Google Scholar Back to article
Wyber R, Taubert K, Marko S, Kaplan EL. Benzathine penicillin G for the management of RHD: Concerns about quality and access, and opportunities for intervention and improvement. Global Heart. 2013; 8(3):227–234. DOI: 10.1016/j.gheart.2013.08.011
Open DOI Search in Google Scholar Back to article
Hand RM, Senarathna SG, Page-Sharp M, et al. Quality of benzathine penicillin G: A multinational cross-sectional study. Pharmacology Research & Perspectives. 2020; 8(6):e00668. DOI: 10.1002/prp2.668
Open DOI Search in Google Scholar Back to article
Techane T, Legesse B, Ayalew Y, Hailu A. Rheumatic heart disease knowledge and associated factors among nurses working in cardiac centers at public and private hospitals of Addis Ababa: Cross sectional study. BMC Nursing. 2022; 21(1):130. DOI: 10.1186/s12912-022-00910-5
Open DOI Search in Google Scholar Back to article
Ochora M, Kyasimire L, Lutasingwa D, et al. Primary healthcare workers’ awareness of acute rheumatic fever & rheumatic heart disease: A study in public health facilities in southwestern Uganda. Pediatric Health, Medicine and Therapeutics. 2024:223–229. DOI: 10.2147/PHMT.S461168
Open DOI Search in Google Scholar Back to article
Osman GM, Abdelrahman SM, Ali SK. Evaluation of physicians’ knowledge about prevention of rheumatic fever and rheumatic heart disease before and after a teaching session. Sudan Journal of Paediatrics. 2015; 15(2):37–42. Available from: https://pubmed.ncbi.nlm.nih.gov/27493434/.
Search in Google Scholar Back to article
Nalubwama H, Pulle J, Atala J, et al. A qualitative study of patients’ experiences, enablers and barriers of rheumatic heart disease care in Uganda. Global Heart. 2023; 18(1):6. DOI: 10.5334/gh.1181
Open DOI Search in Google Scholar Back to article
Edwards JG, Barry M, Essam D, et al. Health system and patient-level factors serving as facilitators and barriers to rheumatic heart disease care in Sudan. Global Health Research and Policy. 2021; 6(1):35. DOI: 10.1186/s41256-021-00222-2
Open DOI Search in Google Scholar Back to article
Watkins D, Zuhlke L, Engel M, et al. Seven key actions to eradicate rheumatic heart disease in Africa: The Addis Ababa communiqué: Cardiovascular topics. Cardiovascular Journal of Africa. 2016; 27(3):184–187. DOI: 10.5830/CVJA-2015-090
Open DOI Search in Google Scholar Back to article
Marantelli S, Hand R, Carapetis J, Beaton A, Wyber R. Severe adverse events following benzathine penicillin G injection for rheumatic heart disease prophylaxis: Cardiac compromise more likely than anaphylaxis. Heart Asia. 2019; 11(2):e011191. DOI: 10.1136/heartasia-2019-011191
Open DOI Search in Google Scholar Back to article
Wyber R, Johnson T, Marantelli S, Carapetis J. RHD Action. Global Status of BPG report. The benzathine penicillin G report; 2016. Available from: https://rhdaction.org/sites/default/files/RHD%20Action_Global%20Status%20of%20BPG%20Report_Online%20Version.pdf. Accessed on 10 Nov 2024.
Search in Google Scholar Back to article
Ali S, Long A, Nikiema JB, Madeira G, Wyber R. Availability and administration of benzathine penicillin G for the prevention of rheumatic fever in Africa: Report of the Working Group on Penicillin, Pan-African Society of Cardiology Task Force on Rheumatic Heart Disease. Cardiovascular Journal of Africa. 2019; 30(6):369–372. DOI: 10.5830/CVJA-2019-042
Open DOI Search in Google Scholar Back to article
Berkovitch M, Ashkenazi-Hoffnung L, Youngster I, et al. Fatal and near-fatal non-allergic reactions in patients with underlying cardiac disease receiving benzathine penicillin G in Israel and Switzerland. Frontiers in Pharmacology. 2017; 8:843. DOI: 10.3389/fphar.2017.00843
Open DOI Search in Google Scholar Back to article
Lue H-C, Chen C-L, Wei H. Some problems in long-term prevention of streptococcal infection among children with rheumatic heart disease in Taiwan. Japanese Heart Journal. 1976; 17(5):550–559. DOI: 10.1536/ihj.17.550
Open DOI Search in Google Scholar Back to article
Manyemba J, Mayosi BM. Intramuscular penicillin is more effective than oral penicillin in secondary prevention of rheumatic fever-a systematic review. South African Medical Journal. 2003; 93(3):212–218. Available from: https://www.proquest.com/scholarly-journals/intramuscular-penicillin-is-more-effective-than/docview/73336241/se-2.
Search in Google Scholar Back to article
Kado J, Salman S, Hla TK, et al. Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: A phase 1 open-label population pharmacokinetic study. Journal of Antimicrobial Chemotherapy. 2023; 67(12):e0096223. DOI: 10.1128/aac.00962-23
Open DOI Search in Google Scholar Back to article
Kado JH, Salman S, Henderson R, et al. Subcutaneous administration of benzathine benzylpenicillin G has favourable pharmacokinetic characteristics for the prevention of rheumatic heart disease compared with intramuscular injection: A randomized, crossover, population pharmacokinetic study in healthy adult volunteers. Journal of Antimicrobial Chemotherapy. 2020; 75(10):2951–2959. DOI: 10.1093/jac/dkaa282
Open DOI Search in Google Scholar Back to article
Cooper J, Enkel SL, Moodley D, et al. “Hurts less, lasts longer”; a qualitative study on experiences of young people receiving high-dose subcutaneous injections of benzathine penicillin G to prevent rheumatic heart disease in New Zealand. PLoS One. 2024; 19(5):e0302493. DOI: 10.1371/journal.pone.0302493
Open DOI Search in Google Scholar Back to article
Gasse B, Baroux N, Rouchon B, et al. Determinants of poor adherence to secondary antibiotic prophylaxis for rheumatic fever recurrence on Lifou, New Caledonia: A retrospective cohort study. BMC Public Health. 2013; 13:1–9. DOI: 10.1186/1471-2458-13-131
Open DOI Search in Google Scholar Back to article
Russell K, Nicholson R, Naidu R. Reducing the pain of intramuscular benzathine penicillin injections in the rheumatic fever population of Counties Manukau District Health Board. Journal of Paediatrics and Child Health. 2014; 50(2):112–117. DOI: 10.1111/jpc.12400
Open DOI Search in Google Scholar Back to article
Derya E-Y, Ukke K, Taner Y, Izzet AY. Applying manual pressure before benzathine penicillin injection for rheumatic fever prophylaxis reduces pain in children. Pain Management Nursing. 2015; 16(3):328–335. DOI: 10.1016/j.pmn.2014.08.013
Open DOI Search in Google Scholar Back to article
Rémond M, Wheaton G, Walsh W, Prior D, Maguire G. Acute rheumatic fever and rheumatic heart disease—priorities in prevention, diagnosis and management. A report of the CSANZ Indigenous Cardiovascular Health Conference, Alice Springs 2011. Heart, Lung and Circulation. 2012; 21(10):632–638. DOI: 10.1016/j.hlc.2012.05.006
Open DOI Search in Google Scholar Back to article
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality Health Care. 2007; 19(6):349–357. DOI: 10.1093/intqhc/mzm042
Open DOI Search in Google Scholar Back to article
Health Sector Development Program IV 2010/11–2014/15. [Internet]. Federal democratic republic of Ethiopia ministry of health. 2010. Available from: https://www.healthynewbornnetwork.org/hnn-content/uploads/HSDP-IV-Final-Draft.
Search in Google Scholar Back to article
Francis JJ, Johnston M, Robertson C, et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychology & Health. 2010; 25(10):1229–1245. DOI: 10.1080/08870440903194015
Open DOI Search in Google Scholar Back to article
Chamberlain-Salaun J, Mills J, Kevat PM, Rémond MG, Maguire GP. Sharing success–understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease. BMC Cardiovascular Disorders. 2016; 16:1–10. DOI: 10.1186/s12872-016-0344-x
Open DOI Search in Google Scholar Back to article
Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology. 2013; 13:1–8. DOI: 10.1186/1471-2288-13-117
Open DOI Search in Google Scholar Back to article
Michie S, Van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011; 6:1–12. DOI: 10.1186/1748-5908-6-42
Open DOI Search in Google Scholar Back to article
Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: An overview of reviews and development of a theoretical framework. BMC Health Services Research. 2017; 17:1–13. DOI: 10.1186/s12913-017-2031-8
Open DOI Search in Google Scholar Back to article
Barker H, Oetzel JG, Scott N, et al. Enablers and barriers to secondary prophylaxis for rheumatic fever among Māori aged 14–21 in New Zealand: A framework method study. International Journal for Equity in Health. 2017; 16:1–10. DOI: 10.1186/s12939-017-0700-1
Open DOI Search in Google Scholar Back to article
Belay W, Dessie A, Ahmed H, et al. Secondary prevention of rheumatic heart disease in Ethiopia: A multicenter study. BMC Cardiovascular Disorders. 2022; 22(1):26. DOI: 10.1186/s12872-022-02473-4
Open DOI Search in Google Scholar Back to article
Ilievski J, Mirams O, Trowman R, Barr RK, Manning L. Patient preferences for prophylactic regimens requiring regular injections in children and adolescents: A systematic review and thematic analysis. BMJ Paediatrics Open. 2024; 8(1). DOI: 10.1136/bmjpo-2023-002450
Open DOI Search in Google Scholar Back to article
WHO Expert Consultation. Rheumatic fever and rheumatic heart disease: Report of a WHO Expert Consultation, Geneva, 29 October —1 November 2001. WHO Technical Report Series; 923. Geneva: World Health Organization; 2004 [Accessed on September 20, 2024]. Available from: https://iris.who.int/handle/10665/42898.
Search in Google Scholar Back to article
Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: A scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Academy of Pediatrics. Circulation. 2009; 119(11):1541–1551. DOI: 10.1161/CIRCULATIONAHA.109.191959
Open DOI Search in Google Scholar Back to article
Ralph AP, Noonan S, Wade V, Currie BJ. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. Medical Journal of Australia. 2021; 214(5):220–227. DOI: 10.5694/mja2.50851
Open DOI Search in Google Scholar Back to article
Travis P, Bennett S, Haines A, et al. Overcoming health-systems constraints to achieve the millennium development goals. Lancet. 2004; 364(9437):900–906. DOI: 10.1016/S0140-6736(04)16987-0
Open DOI Search in Google Scholar Back to article
World Health Organization. 71st World Health Assembly adopts resolution calling for greater action on rheumatic heart disease. 2019 [Accessed July 2019]. Available from: https://www.who.int/ncds/management/rheumatic-heart-disease-resolution/en.
Search in Google Scholar Back to article
Noubiap JJ, Agbor VN, Bigna JJ, et al. Prevalence and progression of rheumatic heart disease: A global systematic review and meta-analysis of population-based echocardiographic studies. Scientific Report. 2019; 9(1):1–14. DOI: 10.1038/s41598-019-53540-4
Open DOI Search in Google Scholar Back to article
Sanyahumbi A, Ali S, Benjamin IJ, et al. Penicillin reactions in patients with severe rheumatic heart disease: A presidential advisory from the American Heart Association. Journal of American Heart Association. 2022; 11(5):e024517. DOI: 10.1161/JAHA.121.024517
Open DOI Search in Google Scholar Back to article
Wolf M, Gottwald S, Galyean T, Morris R, (Eds.) Global literacy and socially excluded peoples. Proceedings from the Socially Excluded Peoples Meeting, Pontifical Academy of Social Sciences; 2013 [Accessed on July 2024]. Available from: https://www.pas.va/content/dam/casinapioiv/pas/pdf-volumi/scripta-varia/sv123/sv123-wolf.pdf.
Search in Google Scholar Back to article
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine. 2011; 155(2):97–107. DOI: 10.7326/0003-4819-155-2-201107190-00005
Open DOI Search in Google Scholar Back to article
Kassaye KD, Amberbir A, Getachew B, Mussema Y. A historical overview of traditional medicine practices and policy in Ethiopia. EJHD. 2006; 20(2):127–134. DOI: 10.4314/ejhd.v20i2.10023
Open DOI Search in Google Scholar Back to article
Taubert K, Marko SB. Access to essential medicines: Illuminating disparities in the global supply of benzathine penicillin G in the context of rheumatic fever/rheumatic heart disease prevention. Journal of American College of Cardiology. 2013; 61(10S):E2004. DOI: 10.1016/S0735-1097(13)62004-5
Open DOI Search in Google Scholar Back to article
International Rheumatic Fever Study Group. Allergic reactions to long-term benzathine penicillin prophylaxis for rheumatic fever. Lancet. 1991; 337(8753):1308–1310. DOI: 10.1016/0140-6736(91)92979-C
Open DOI Search in Google Scholar Back to article
WHO Drug Information. Benzathine penicillin: Fatal mega-unit injections. WHO Drug Information. 200;14(4), 230. Retrieved from: https://www.proquest.com/scholarly-journals/benzathine-penicillin-fatal-mega-unit-injections/docview/215681759/se-2.
Search in Google Scholar Back to article
Galvao TF, Silva MT, Serruya SJ, et al. Safety of benzathine penicillin for preventing congenital syphilis: A systematic review. PLoS One. 2013;8(2):e56463. DOI: 10.1371/journal.pone.0056463
Open DOI Search in Google Scholar Back to article
Liu M, Fan Y, Chen J, et al. Efficacy and safety of treatments for different stages of syphilis: A systematic review and network meta-analysis of randomized controlled trials and observational studies. Microbiology Spectrum Journal. 2022;10(6):e0297722. DOI: 10.1128/spectrum.02977-22
Open DOI Search in Google Scholar Back to article
Morsy M, Mohamed MA, Abosedira MM, et al. Lidocaine as a dilutant for benzathine penicillin G reduces injection pain in patients with rheumatic fever: A prospective, randomized, double-blinded crossover study. Australian Journal of Basic Applied Sciences. 2012; 6:236–240. DOI: 10.1097/00006454-199810000-00008
Open DOI Search in Google Scholar Back to article
Hanna Mekonnen. Prevalence of benzathine penicillin adverse reaction in patients with rheumatic heart disease taking monthly benzathine penicillin. Addis Ababa University, Addis Ababa, Ethiopia; 2021 [Accessed on 16 December 2024]. Available from: https://etd.aau.edu.et/server/api/core/bitstreams/95e075f3-fb43-439d-b456-311e890d0bad/content#:~:text=Allergic%20reaction%20following%20BPG%20administration,actively%20treated%20for%20cardiac%20failure.
Search in Google Scholar Back to article
FMHACA. Guideline for Adverse Drug Events Monitoring (Pharmacovigilance), Food, Medicine and Health Care Administration and Control Authority of Ethiopia, 3rd edition; 2014 [Accessed on 16 December 2024]. Available from: https://www.medbox.org/document/guideline-foradverse-drug-events-monitoring-pharmacovigilance-ethiopi.
Search in Google Scholar Back to article
Hailu AD, Mohammed SA. Adverse drug reaction reporting in Ethiopia: Systematic review. BioMed Research International. 2020; 2020(1):8569314. DOI: 10.1155/2020/8569314
Open DOI Search in Google Scholar Back to article

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DOI: https://doi.org/10.5334/gh.1393 | Journal eISSN: 2211-8179

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Language: English

Submitted on: Aug 28, 2024

Accepted on: Jan 15, 2025

Published on: Jan 29, 2025

Published by: Ubiquity Press

In partnership with: Paradigm Publishing Services

Publication frequency: 1 issue per year

Keywords:

Rheumatic heart disease,

Benzathine Penicillin G,

COM-B model,

Theoretical framework of acceptability

© 2025 Eshetie Melese Birru, Kevin T. Batty, Laurens Manning, Stephanie L. Enkel, Brioni R. Moore, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 20 (2025): Issue 1