title: A qualitative examination of secondary prophylaxis in rheumatic heart disease: factors influencing adherence to secondary prophylaxis in Uganda.
abstract: BACKGROUND
  Rheumatic heart disease (RHD) is the most common cause of heart disease among Ugandans age 15 to 49 years. Secondary prophylaxis with monthly injection of benzathine penicillin is effective in preventing recurrence of acute rheumatic fever and worsening of RHD, but adherence rates are poor in Uganda.
  
  
  OBJECTIVE
  This study sought to identify health behaviors, attitudes, and health care system factors that influence adherence to RHD secondary prophylaxis.
  
  
  METHODS
  We conducted 5 structured focus groups with 36 participants on monthly penicillin injections for RHD in Kamplala, Uganda. Transcripts were analyzed using qualitative description analysis and health behavior models.
  
  
  RESULTS
  Most participants were female (64%), from an urban area (81%), and had family income less than US$1 daily (69%). Ages ranged from 14 to 58 years. Median prophylaxis duration was 1.42 years and 58% were adherent (≥80% of injections). Key facilitators include perceived worsening of disease with missing injections, personal motivation, a reminder system for injections, supportive family and friends, and a positive relationship with health care providers. Barriers to adherence include lack of resources for transportation and medications, fear of injection pain, poor patient-provider communication, and poor availability of clinics and providers able to give injections.
  
  
  CONCLUSIONS
  We identified key facilitators and barriers to secondary prophylaxis for RHD from the patient perspective framed within the socioecological model. Our findings provide direction for intervention development to improve national RHD secondary prophylaxis.
authors.affiliation: School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Huck
authors.affiliation: School of Public Health, Makerere University, Kampala, Uganda.
authors.forename: Haddy
authors.initials: H
authors.lastname: Nalubwama
authors.affiliation: Division of Cardiovascular Medicine, University Hospitals, Cleveland, OH, USA.
authors.forename: Chris T
authors.initials: CT
authors.lastname: Longenecker
authors.affiliation: Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, USA.
authors.forename: Scott H
authors.initials: SH
authors.lastname: Frank
authors.affiliation: Uganda Heart Institute, Mulago Hospital, Kampala, Uganda.
authors.forename: Emmy
authors.initials: E
authors.lastname: Okello
authors.affiliation: Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA. Electronic address: Allison.webel@case.edu.
authors.forename: Allison R
authors.initials: AR
authors.lastname: Webel
mesh_terms: D000293:Adolescent; D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D001294:Attitude to Health; D005260:Female; D017144:Focus Groups; D015438:Health Behavior; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D010401:Penicillin G Benzathine / Q000008:administration & dosage*; D012214:Rheumatic Heart Disease / Q000517:prevention & control*; D055502:Secondary Prevention; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D010401:Penicillin G Benzathine