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 study

Abstract

Background: Rheumatic Heart Disease continues to be a serious public health problem especially in developing countries and Sub-Saharan Africa in particular. Secondary prophylaxis with monthly Benzathine penicillin IM injection remains the most cost-effective strategy to reduce the morbidity and mortality. The efficiency of secondary prophylaxis using intramuscular penicillin depends largely on good adherence, yet not well known in many of the sub-Saharan countries including Rwanda. Our study aimed at determining the self-reported adherence rates in children and adolescents with RHD, determining the socioeconomic and demographic characteristics of patients with RHD on secondary prophylaxis and exploring factors, beliefs and barriers associated with adherence to secondary prophylaxis. Methods: This was a cross-sectional study of 67 children and adolescents, aged 5 to 18 years, diagnosed with RHD presenting to two public tertiary hospitals in Rwanda; CHUK and CHUB either to the outpatient or inpatient department of pediatrics over a period of 5 months. The socio-demographic data, details about RHD prophylaxis were noted using a questionnaire. Good adherence was defined as patients receiving ≥ 80% of the expected injections in a period of 6 months. Statistical analysis to determine factors, barriers and beliefs associated with adherence was undertaken using multivariate logistic regression. Results: The median age was 13.3 +/- 3 years, with 64.2% being females. Only 46.3% of participants had good adherence to secondary prophylaxis. The socioeconomic factors associated with good adherence were: having an employed parent/guardian (OR, 12.17; 95% CI, 1.42- 103.9; p=0.022), living in urban area (OR, 9.05; 95% CI, 2.28-35.91; p=0.001), and having a parent/guardian with a high educational level (OR, 3.4; 95% CI, 1.15-10.12; p=0.027). Mostly encountered barriers to adherence are: long distance to the clinic (OR, 5.55; 95% CI, 1.94-15.89; p=0.001) and long waiting time at the clinic (OR, 4.77; 95% CI, 1.69-13.43; p=0.003). Conclusions and recommendations: The level of adherence to secondary prophylaxis using intramuscular penicillin at tertiary level of care in Rwanda is very low. Education of patients and their caretakers along with reinforced decentralization of prevention at health centers should be enhanced for better adherence. Keywords: Rheumatic Heart Disease; Medication Adherence; Child; Adolescent; Rwanda