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Original Research Open Access

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Factors, beliefs, and barriers associated with adherence to secondary

prophylaxis amongst children and adolescents with rheumatic heart
disease at public tertiary hospitals in Rwanda: A cross-sectional
observational study
Janvier Dushimire1,*, Samson Habimana1, Emmanuel Rusingiza1

1
College of Medicine and Health Sciences (CMHS), University of Rwanda, Kigali, Rwanda

ABSTRACT

INTRODUCTION: Rheumatic heart disease (RHD) is the most prevalent

cardiovascular disease among young people under 25 years. This study
aimed to explore the factors, beliefs, and barriers associated with adherence
to penicillin among children and adolescents with RHD undergoing
*Corresponding author:
secondary prophylaxis at public tertiary hospitals in Rwanda.
Samson Habimana METHODS: This cross-sectional observational study included children
School of Public Health, College
of Medicine and Health Sciences aged 5 to 18 years diagnosed with RHD and on secondary prophylaxis for at
(CMHS), University of Rwanda,
Kigali, Rwanda
least six months, from two public tertiary hospitals in Rwanda. Regression
analyses were performed to identify factors associated with adherence.
Email: habimanasamson355@
gmail.com RESULTS: Employment status was significantly associated with adherence
Received: November 26, 2024
to prophylaxis (OR [95% CI]: 12.17 [1.42-103.9], p=0.022). Living in an
Accepted: December 16, 2024 urban area also increased the likelihood of adherence compared to rural
Published: December 31, 2024
areas (OR [95% CI]: 9.05 [2.28-35.91], p=0.001). A long distance to the
Cite this article as: Dushimireet
al. Factors, beliefs, and barriers
clinic was strongly associated with poor adherence (OR [95% CI]: 5.55
associated with adherence to [1.94-15.89], p=0.001). Additionally, long waiting times at the clinic are
secondary prophylaxis amongst
children and adolescents with also significantly associated with poor adherence (OR [95% CI]: 4.77
rheumatic heart disease at public
tertiary hospitals in Rwanda – a
[1.69-13.43], p=0.003). Patients with good adherence have significantly
cross-sectional observational higher belief scores than those with poor adherence (M ± SE: 1.56 ± 0.54,
study Rw. Public Health Bul.
2024. 5 (4): 43-51. https:// t=2.878, p=0.005), and patients with higher barrier scores are significantly
dx.doi.org/10.4314/rphb.v5i4.6 less adherent than those with lower barrier scores (M ± SE: 4.6 ± 0.85,
t=5.531, p<0.001).
CONCLUSION: Factors negatively affecting adherence included parental
unemployment and rural residence. Long travel distances and extended
waiting times at clinics were the most common barriers to adherence. To
improve adherence, educational efforts targeting RHD patients and their
caregivers should be strengthened, and RHD prevention activities should
be decentralized to health centers.

INTRODUCTION (ARF) and RHD are the leading causes of cardiac

mortality among children and young people in
Rheumatic Heart Disease (RHD) is the most developing countries [2]. ARF mainly affects the
common acquired cardiovascular disease in young joints, skin, heart, and central nervous system,
people aged <25 years [1]. Acute Rheumatic Fever and cardiac involvement leads to permanent valve

Potential Conflicts of Interest: No potential conflicts of interest disclosed by all authors. Academic Integrity: All authors confirm their substantial academic
contributions to development of this manuscript as defined by the International Committee of Medical Journal Editors. Originality: All authors confirm this manuscript
as an original piece of work, and confirm that has not been published elsewhere. Review: All authors allow this manuscript to be peer-reviewed by independent reviewers
in a double-blind review process. © Copyright: The Author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(CC BY-NC-ND), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Publisher: Rwanda Health
Communication Centre, KG 302st., Kigali-Rwanda. Print ISSN: 2663 - 4651; Online ISSN: 2663 - 4653. Website: https://rbc.gov.rw/publichealthbulletin/

Rw. Public Health Bul. Vol. 5 (4); December 2024. https://dx.doi.org/10.4314/rphb.v5i4.6 43

Rwanda Public Health Bulletin Nzeyimana et al.

damage. It commonly occurs between the ages of sectional observational study involving children and
4-15 years and takes place 2-3 weeks after GAS adolescents with RHD presenting to the outpatient
upper respiratory tract infection. Although ARF or inpatient pediatric departments at two public
has almost disappeared in the developed world tertiary hospitals in Rwanda [Kigali University
due to improved sanitation and socioeconomic Teaching Hospital (CHUK) and Butare University
conditions, it continues to be a serious public Teaching Hospital (CHUB)]. Data collection was
health problem in developing countries [3]. In conducted over five months, from January to May
Rwanda, RHD is a significant health problem, 2019. The study focused on children aged 5 to 18
with an estimated prevalence of 6.8 per 1000 years who had been diagnosed with RHD and had
schoolchildren [4]. been receiving secondary prophylaxis for at least
Prevention of ARF includes primordial prevention, six months. In Rwanda, the pediatric age range is
which involves improving socioeconomic defined as 0 to 15 years. Patients aged 15 years
conditions; primary prevention, which involves and older are typically treated in internal medicine.
prompt treatment of GAS pharyngitis; and However, those aged 15 to 18 years continue to
secondary prevention, which involves a continuous receive follow-up care in the pediatric department
administration of benzathine penicillin G to following cardiac surgery.
patients with a previous attack of ARF or well-
documented RHD [5]. Another intervention in Study population: The study included patients
the prevention of early mortality due to RHD is aged 5-18 years with confirmed RHD by
cardiac surgery, which is not accessible to many echocardiography, treated at the CHUK and
patients, especially in low-income countries [6]. CHUB OPD pediatric cardiology, who consent
Even after heart surgery, patients are exposed to to participate, receive monthly intramuscular
many complications, such as thrombo-embolic penicillin injections, and consult two tertiary level
events and severe bleeding, when using warfarin hospitals. Exclusion criteria include patients/
treatment [7]. The cost-effective strategy remains guardians who decline to sign consent forms,
the prevention of ARF and progression to severe patients on secondary prophylaxis for less than
rheumatic valvular heart disease [8]. 6 months, and patients on oral penicillin for
Although based on a low level of evidence, prophylaxis.
intramuscular penicillin was shown to be more
effective than oral penicillin [9]. The rate of Sample size calculation: A sample size calculation
adherence to secondary prophylaxis is unknown in has been calculated using the Raosoft formula as
many countries of sub-Saharan Africa, particularly follows:
in Rwanda. Different factors associated with
adherence have been reported in various regions X=Z(c/100)2r(100-r)
of the world. These include socioeconomic status, N=N x/((N-1)E2 + x)
knowledge about the disease, waiting time at the E=Sqrt[(N - n)x/n(N-1)]
clinic, the painful aspect of the injections, and
distance to the clinic [1,10]. Where:
Knowing different factors, beliefs, and barriers E is the margin of error and is of about 5%
associated with adherence would help clinicians N is the population size. In this case, it is 80,
find ways of improving adherence to secondary the total number of patients received in pediatric
prophylaxis and thus improve the quality of life outpatient in a period of 4 months
of our patients. This research project aimed to r is the fraction of response we are interested in, in
explore factors, beliefs, and barriers associated this case, 54%, based on a study done in Uganda
with adherence to injectable forms of penicillin [10].
in children and adolescents with RHD receiving Z(c/100) is the critical value for the confidence
secondary prophylaxis at public tertiary hospitals level c, 95% confidence interval.
in Rwanda. n is the minimum sample size and is equal to 67

METHOS Sampling: All participants fulfilling inclusion

criteria were included and sampled by convenience
Study design and settings: This was a cross- sampling technique

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Rwanda Public Health Bulletin Nzeyimana et al.

Data Collection Tool: We used a modified disadvantaged backgrounds, belonging to Ubudehe

questionnaire originally developed by Balbaa categories 1 and 2. Additionally, 46.3% (N=31) of
et al. [1] in Egypt in 2015. A certified translator guardians or caretakers completed only primary
translated the questionnaire into Kinyarwanda and education, and only 13.4% (N=9) of parents or
then back-translated it by a medical professional guardians hold formal employment.
to ensure accuracy. The principal investigator
collected data, entered it into Epidata version 3.1, Table 1: Socio-demographic characteristics
and coded it for analysis. Characteristics N %
Age (Mean ± SD) 13.3 ± 2.7 years
Data Analysis: Data from Epidata were
exported to IBM SPSS version 25 for analysis. Gender
For descriptive analysis, continuous variables Female 43 64.2
were summarized using means and medians, Male 24 35.8
while categorical data were summarized with
Place of recruitment
frequencies and percentages. To analyze factors
associated with adherence, bivariate analysis was CHUK 55 82.1
performed using logistic regression to calculate CHUB 12 17.9
odds ratios (ORs). Multivariate analysis was then Economic class (Ubudehe)
conducted to control for confounding factors and
Category 1 7 10.4
to identify independent variables associated with
poor compliance. Variables with a p-value <0.05 Category 2 36 53.7
from the bivariate analysis were included in the Category 3 24 35.8
multivariate model. The final multivariate analysis Time since diagnosis was made
results were reported using ORs and p-values.
0-5 years ago 50 74.6
Comparisons of Likert-scale responses were also
made to evaluate differences in scores between >5 years 17 25.4
participants with good and poor adherence. Employment status of caretaker
Employed 9 13.4
Ethical Considerations: Permission to conduct
Unemployed 58 86.6
this study was obtained from the Institutional
Review Board of the College of Medicine and Address
Health Sciences (CMHS), University of Rwanda Urban 17 25.4
(CMHS IRB approval notice number: 377/ Rural 50 74.6
CMHS IRB/2018). Additional approvals were
Recruitment setting
received from the CHUK Research Ethical
Committee (CHUK research committee: Ref- OPD 65 97.0
EC/CHUK/736/2018) and from CHUB Research Inpatient 2 3.0
ethical committee (CHUB: RC/UTHB/051/2018). Level of education of participant
Participants provided written consent, and their
Primary completed 39 58.2
participation was entirely voluntary.
None 28 41.8
RESULTS Level of education of parent/caretaker
University
Socio-Demographic Characteristics of the 1 1.5
completed
Study Population
High school
A total of 67 participants meeting the inclusion 9 13.4
completed
criteria were interviewed. The median age was
Vocational
13.3 ± 3 years (IQR 11-16), with 64.2% (N=43) 11 16.4
completed
being female. The majority of participants (82.1%,
N=55) were recruited from CHUK, while the Primary completed 31 46.3
remaining were from CHUB. Most participants None 15 22.4
(74.6%, N=50) reside in rural areas, and a large SD: Standard deviation; OPD: Outpatient department
proportion (64.1%, N=43) come from economically

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Table 2: Patient Practices, Beliefs, and Awareness Regarding Prophylaxis and Management of Rheumatic Heart Disease
N %
Missed injections in last 6 months
No 30 44.8
Yes 37 55.2
Period of starting prophylaxis
Less than 1 year 8 11.9
1-2 years 20 29.9
2-5 years 24 35.8
>5 years 15 22.4
Action taken when missed appointment
I wait till next appointment 22 32.8
I go a few days later 45 67.2
Awareness of side effects
No 40 59.7
Yes 27 40.3
If no injections
May heart condition will get worse 51 76.1
It’s ok to miss some doses, nothing will happen 16 23.9
Awareness for need of surgery
No 11 16.4
Yes 56 83.6
Waiting time at the clinic
20-40 min 5 7.5
40-60 min 28 41.8
1-2 hours 29 43.3
>2 hours 5 7.5
Awareness on the stop of progression by the injections
No 8 11.9
Yes 59 88.1
Belief on effectiveness of traditional medication
No 64 95.5
Yes 3 4.5
Hospitalized due to this condition
No 7 10.4
Yes 60 89.6
Ever had severe side effects from injections
No 65 97.0
Yes 2 3.0
Time from home to the clinic
1 hour 27 40.3
1-3 hours 35 52.2
3-5 hours 4 6.0
>5 hours 1 1.5

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Rwanda Public Health Bulletin Nzeyimana et al.

Patient Practices, Beliefs, and Awareness prophylaxis. There is a strong association between
Regarding Rheumatic Heart Disease the employment status of the parent or guardian
Management and adherence, with participants who have an
The study revealed that 55.2% of participants employed parent or guardian showing significantly
missed at least one scheduled injection in the past better adherence (OR [95% CI]: 12.17 [1.42-
six months, with 67.2% attending a few days later 103.9], p=0.022). Additionally, living in an urban
and 32.8% waiting until the next appointment. area is associated with higher adherence to RHD
Awareness of side effects was low (59.7%), secondary prophylaxis compared to residing in
though severe side effects were rare (3.0%). a rural area (OR [95% CI]: 9.05 [2.28-35.91],
Most participants (76.1%) believed missing p=0.001). The table also indicates that a higher
injections would worsen their heart condition, and educational level of the parent or guardian is
88.1% trusted penicillin injections to halt disease positively associated with adherence (OR [95%
progression. Awareness of the need for surgery CI]: 3.4 [1.15-10.12], p=0.027).
was high (83.6%), and nearly all participants
(95.5%) distrusted traditional medicines. Long Barriers, beliefs, and behaviors associated with
waiting times (41.8%-43.3% waited 40 minutes to adherence
2 hours) and travel distances (52.2% traveled 1-3 Table 4 highlights various barriers, beliefs, and
hours) were noted challenges. Additionally, 89.6% behaviors linked to adherence to secondary
had been hospitalized, highlighting the disease's prophylaxis. A long distance to the clinic is strongly
severity (Table 2). associated with poor adherence (OR [95% CI]:
5.55 [1.94-15.89], p=0.001). Additionally, long
Socioeconomic factors associated with waiting times at the clinic are also significantly
adherence associated with poor adherence (OR [95% CI]:
Table 3 presents the socioeconomic factors 4.77 [1.69-13.43], p=0.003).
associated with adherence to RHD secondary

Table 3: Socioeconomic factors associated with adherence to RHD secondary prophylaxis

Self-reported adherence
Socio-economic variables OR (95% CI) P value
Adherent Non-adherent
Gender
Female 20 (46.5%) 23 (53.5%) 1.02 (0.37-2.79) 0.957
Male 11 (45.8%) 13 (54.2%)
Home address
Urban 14 (82.4%) 3 (17.6%) 9.05 (2.28-35.91) 0.001
Rural 17 (34.0%) 33 (66.0%)
Employment status of parent/guardian
Employed 8 (88.9%) 1 (11.1%) 12.17 (1.42-103.9) 0.022
Unemployed 23 (39.7%) 35 (60.3%)
Who accompanies the patient to the clinic?
None 5 (26.3%) 14 (73.7%)
Family member 26 (54.2%) 22 (45.8%) 3.31 (1.02-10.64) 0.044
Level of education of parent/guardian
Secondary/University 14 (66.7%) 7 (33.3%) 3.4 (1.15-10.12) 0.027
Primary/None 17 (37.0%) 29 (63.0%)
Economic class (Ubudehe)
Category 1 & 2 16 (37.2%) 27 (62.8%)
Category 3 15 (62.5%) 9 (37.5%) 2.81 (1.0-7.89) 0.049

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Table 4: Barriers, beliefs, and behaviors associated with adherence

Self-reported adherence
Barriers, beliefs, and behaviors OR (95% CI) P value
Adherent Non-adherent
Long distance to the clinic
Yes 9 (26.5%) 25 (73.5%)
No 22 (66.7%) 11 (33.3%) 5.55 (1.94-15.89) 0.001
Long waiting time at the clinic
Yes 10 (28.6%) 25 (71.4%)
No 21 (65.6%) 11 (34.4%) 4.77 (1.69-13.43) 0.003
Awareness of side effects of the injections
Yes 17 (42.5%) 23 (57.5%) 0.68 (0.25-1.83) 0.452
No 14 (51.9%) 13 (48.1%)
Consequences of not getting the injections
Worsening my heart condition 27 (52.9%) 24 (47.1%) 3.37 (0.95-11.87) 0.058
It’s ok, nothing will happen 4 (25.0%) 12 (75.0%)
Awareness of possible surgery
Yes 24 (42.9%) 32 (57.1%) 0.43 (0.11-1.63) 0.214
No 7 (63.6%) 4 (36.4%)
Knowledge of the role of secondary prophylaxis
Yes 26 (44.1%) 33 (55.9%) 0.63 (0.15-2.58) 0.521
No 5 (62.5%) 3 (37.5%)
Belief in traditional healers
Yes 3 (100%) 0 (0.0%) 8.96 (0.44-180.7) 0.152
No 28 (43.8%) 36 (56.3%)

OR: Odd ratio; CI: Confidence Interval

Relationship between barriers and beliefs with poor adherence (M ± SE: 1.56 ± 0.54, t=2.878,
adherence p=0.005). Additionally, patients with higher
Table 5 compares adherent and non-adherent barrier scores are significantly less adherent than
patients based on their beliefs and barriers. It those with lower barrier scores (M ± SE: 4.6 ±
shows that patients with good adherence have 0.85, t=5.531, p<0.001).
significantly higher belief scores than those with

Table 5: Comparison of beliefs and barriers scores among adherence groups

Adherence (M ± SE) Mean difference

Score 95% CI T-test P value
Adherent Non-Adherent (M ± SE)
Total beliefs score/40 32.26 ± 0.45 30.7 ± 0.32 1.56 ± 0.54 0.48-2.64 2.878 0.005

Mean beliefs score/5 4.03 ± 0.56 3.83 ± 0.04 0.19 ± 0.07 0.05-0.33 2.878 0.005

Total barriers score/45 26.58 ± 0.64 31.28 ± 0.56 4.6 ± 0.85 6.39-3.0 5.531 <0.001

Mean barriers score/5 2.95 ± 0.07 3.47 ± 0.06 0.52 ± 0.09 0.71-0.33 5.531 <0.001
M: Mean, SE: Standard error, CI: Confidence interval

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Rwanda Public Health Bulletin Nzeyimana et al.

DISCUSSION to better adherence [18]. In Fiji, urban residence

also correlated with improved adherence [19].
This study aimed to explore factors, beliefs, and Barriers impacting adherence in our study included
barriers associated with adherence to injectable long distances to clinics and extended waiting
penicillin in children and adolescents with RHD. times. Similar findings were reported in Jamaica,
Most patients (64.2%) were female, with a mean where barriers included injection pain, school
age of 13.3 ± 3 years. Similar demographics have absences, and clinic wait times [11]. Other global
been reported in studies from Uganda, Jamaica, studies have cited factors like healthcare costs
and India, where females represented 78.9%, and perceptions of illness as significant barriers to
74.4%, and 54%, respectively [3,11,10]. adherence [20].

A large proportion of patients in our study resided This is the first study to examine factors, beliefs,
in rural areas (74.6%), consistent with findings and barriers to secondary prophylaxis adherence
from India (69%) and Uganda (60%). In contrast, in children with RHD in Rwanda. However, it has
studies in Egypt have shown a predominance of limitations, including potential acquiescence bias
patients from semi-urban or urban areas [1]. Most due to self-reported adherence and interviewer-
participants (61.4%) came from low-income administered questionnaires. Although the
families, with many belonging to social class principal investigator completed the questionnaires,
Ubudehe categories 1 and 2, a finding similar questions were kept concise to minimize bias and
to the Indian study where 73.6% of patients had ensure participant understanding. Additionally,
low socioeconomic status [3]. In Uganda, 68.4% the small sample size and specific site limit the
of patients were unemployed [10], while in New generalizability of results.
Caledonia, Gasse et al. reported a substantial
number of households with a higher monthly CONCLUSION
income [12]. Only 13.4% of guardians in our study
had formal employment, contrasting with findings Adherence to secondary prophylaxis is the most
from Jamaica, where 35% were unemployed [11]. effective way to reduce RHD-related morbidity
Educational attainment was limited, with 46.3% and mortality. Our study found low adherence
of guardians having completed only primary to RHD secondary prophylaxis using injectable
education, similar to findings from Musoke et al. penicillin at the tertiary care level in Rwanda, with
in Uganda [10]. Conversely, the study from India rural residence and parental unemployment being
reported a much higher education rate among significant contributors to poor adherence. Long
participants (65%) [3]. distances and clinic wait times were the primary
Antibiotic prophylaxis is an effective, cost-efficient barriers. To enhance adherence to secondary
measure for preventing recurrent ARF episodes and prophylaxis among patients with rheumatic heart
reducing the burden of RHD. Our study revealed disease (RHD), several key recommendations
low adherence (46.3%) to secondary prophylaxis should be implemented. First, healthcare providers
with intramuscular penicillin, a trend consistent must prioritize education for RHD patients and
with similar studies in low-income settings. In the their parents or caretakers, emphasizing the critical
Philippines, Respicio and Sicat found adherence importance of adhering to secondary prophylaxis.
to be 46.6% [13], while adherence was 48.7% in Second, district hospitals should decentralize
Jamaica [11], 56% in Northern Australia [14], and RHD prevention activities by extending them
58% in Uganda [15]. A Brazilian study noted non- to health centers, ensuring greater accessibility
adherence among 35% of children [16]. and continuity of care. Third, health facilities
managing RHD patients should establish registries
In this study, poor adherence was significantly and Benzathine penicillin injection cards to better
associated with unemployed guardians, rural track adherence and identify patients who require
residents, and low educational levels (p=0.022, additional support to improve their adherence
p=0.001, p=0.027, respectively). Similar patterns levels. Lastly, the Rwanda Biomedical Center
have been observed in other regions, such as Egypt, (RBC) and the University of Rwanda should
where parental educational and occupational status conduct a comprehensive study on a larger sample
influenced adherence [17], and Uganda, where city size to accurately determine the level of adherence
residence and higher education levels were linked to secondary prophylaxis across the country.

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REFERENCES [11] S. B. Thompson, C. H. Brown, A. M.

Edwards, and J. L. M. Lindo, “Low adherence to
[1] A. Balbaa, A. ElGuindy, D. Pericak, M. Yacoub, secondary prophylaxis among clients diagnosed
and J. Schwalm, “An evaluation of secondary with rheumatic fever , Jamaica,” Pathog. Glob.
prophylaxis for rheumatic heart disease in rural Health, vol. 108, no. 5, pp. 229–234, 2014, doi:
Egypt,” Glob. Cardiol. Sci. Pract., no. 3, p. 40, 10.1179/2047773214Y.0000000146.
2015, doi: 10.5339/gcsp.2015.40. [12] B. Gasse, N. Baroux, B. Rouchon, J.-M.
[2] M. D. Seckeler and T. R. Hoke, “The Meunier, I. De Frémicourt, and E. D’Ortenzio,
worldwide epidemiology of acute rheumatic fever “Determinants of poor adherence to secondary
and rheumatic heart disease,” Clin. Epidemiol., antibiotic prophylaxis for rheumatic fever
vol. 3, no. 1, pp. 67–84, 2011, doi: 10.2147/CLEP. recurrence on Lifou, New Caledonia: a
S12977. retrospective cohort study,” BMC Public Health,
[3] A. AK. Nemani L, Maddury J, Barik R, vol. 13, no. 1, p. 131, 2013, doi: 10.1186/1471-
“Original Article. A Cross-sectional study to look 2458-13-131.
at the determinants of poor adherence to secondary [13] R. T. Respicio and L. V Sicat, “Clinical
penicillin prophylaxis for rheumatic heart disease Profile and Factors Related to Compliance with
at a tertiary care center in South India. J Clin Prev Benzathine Penicillin G Prophylaxis among
Cardiol 2018;7:5-10.,” J. Clin. Prev. Cardiol., vol. RF / RHD Patients at the Tarlac Provincial
7, pp. 5–10, 2018, doi: 10.4103/JCPC.JCPC. Hospital , Philippines,” Br. J. Med. Med. Res.,
[4] J. Mucumbitsi et al., “Prevalence of rheumatic vol. 6, no. 7, pp. 699–708, 2015, doi: 10.9734/
valvular heart disease in Rwandan school BJMMR/2015/12084.
children : echocardiographic evaluation using the [14] T. Stewart, R. Mcdonald, and B. Currie,
World Heart Federation criteria,” vol. 28, no. 5, pp. “Original Article Acute rheumatic fever :
285–292, 2017, doi: 10.5830/CVJA-2017-007. Adherence to secondary prophylaxis and follow
[5] K. M. A. et al. Sulafa, “Acute Rheumatic up of Indigenous patients in the Katherine region
Fever and Rheumatic Heart Disease : Sudan ’ of the Northern Territory,” Aust. J. Rural Health,
s Guidelines for Diagnosis , Management and vol. 15, pp. 234–240, 2007, doi: 10.1111/j.1440-
Control,” vol. 2, 2017. 1584.2007.00896.x.
[6] M. Mirabel et al., “Chirurgie cardiaque : [15] D. M. Huck, H. Nalubwama, C. T.
dix ans d’expérience dans deux pays en voie de Longenecker, S. H. Frank, E. Okello, and A. R.
développement,” Arch. Cardiovasc. Dis., vol. Webel, “A Qualitative Examination of Secondary
110, no. 2, pp. 82–90, 2017, doi: 10.1016/j. Prophylaxis in Rheumatic Heart Disease,” Glob.
acvd.2016.05.006. Heart, vol. 10, no. 1, pp. 63-69.e1, 2015, doi:
[7] E. K. Rusingiza et al., “Outcomes for patients 10.1016/j.gheart.2014.10.001.
with rheumatic heart disease after cardiac surgery [16] C. F. Pelajo, J. M. Lopez-benitez, J. M.
followed at rural district hospitals in Rwanda,” Torres, and S. K. F. De Oliveira, “Adherence to
Heart, vol. 0, pp. 1–7, 2018, doi: 10.1136/ secondary prophylaxis and disease recurrence
heartjnl-2017-312644. in 536 Brazilian children with rheumatic fever,”
[8] E. Marijon, M. Mirabel, D. S. Celermajer, Pediatr. Rheumatol., vol. 22, no. 8, pp. 1–5, 2010.
and X. Jouven, “Rheumatic heart disease,” The [17] M. A.-F. and G. T. A.Bassili, S.R. Zaher, A.
Lancet, vol. 379, no. 9819, pp. 953–964, 2012, Zaki, “Profile of secondary prophylaxis among
doi: 10.1016/S0140-6736(11)61171-9. children with rheumatic heart disease in Alexandria
[9] J. Manyemba and B. M. Mayosi, “Intramuscular , Egypt,” East. Mediterr. Health J., vol. 6, no. 2/3,
penicillin is more effective than oral penicillin pp. 437–446, 2000.
in secondary prevention of rheumatic fever - A [18] K. Mohammed, W. R. Demissie, and M. B.
systematic review,” S. Afr. Med. J., vol. 93, no. 3, Gare, “Adherence of Rheumatic Heart Disease
pp. 212–218, 2003. Patients to Secondary Prophylaxis and Main
[10] C. Musoke et al., “Benzathine penicillin Reasons for Poor Adherence at Jimma Medical
adherence for secondary prophylaxis among Center,” EJCM, vol. 7, no. 1, pp. 22–27, 2019, doi:
patients affected with rheumatic heart disease 10.32596/ejcm.galenos.2019.00004.
attending Mulago Hospital : cardiovascular [19] D. Engelman et al., “Adherence to secondary
topics,” Cardiovasc. J. Afr., vol. 24, no. 4, pp. 124– antibiotic prophylaxis for patients with rheumatic
129, 2013, doi: 10.5830/CVJA-2013-022. heart disease diagnosed through screening in Fiji,”

Rw. Public Health Bul. Vol. 5 (4); December 2024. https://dx.doi.org/10.4314/rphb.v5i4.6 50

Rwanda Public Health Bulletin Nzeyimana et al.

Trop. Med. Int. Health, vol. 21, no. 12, pp. 1583– follow-up treatment for Rheumatic heart disease in
1591, 2016, doi: 10.1111/tmi.12796. Jimma , Ethiopia : A grounded theory analysis of
[20] K. Petricca, Y. Mamo, A. Haileamlak, E. Seid, the patient experience,” Ethiop. J. Health Sci., vol.
and E. Parry, “Original Article. Barriers to effective 19, no. 1, pp. 39–44, 2009.

Rw. Public Health Bul. Vol. 5 (4); December 2024. https://dx.doi.org/10.4314/rphb.v5i4.6 51