Adherence to benzathine penicilline for secondary prophylaxis among patients affected with rheumatic heart disease ( RHD) at Mulago Hospital

Abstract

Background: Rheumatic Heart Disease (RHD) frequently occurs following recurrent episodes of acute rheumatic fever (ARF). It continues to cause gross distortions of the heart which is avoidable in this age of highly efficacious medications. Benzathine penicillin is the most efficacious method for secondary prophylaxis. The efficacy of this treatment is largely determined by adherence to treatment. Various factors determine adherence to therapy. To date, there is no data regarding current use of Benzathine penicillin for secondary prophylaxis in patients with RHD attending Mulago hospital. However, it is known that patients with RHD should receive at least 80% of their monthly injections in a given period. Objective: To determine the levels of adherence to benzathine penicillin prophylaxis, identify patient factors associated with adherence and the reasons for non adherence among Rheumatic heart disease patients in Mulago hospital. Study Methods: This was a longitudinal observational study carried out in Mulago Hospital cardiac clinics over a period of 10 months (June 2011-March 2012). Ninety five consecutive patients who satisfied the inclusion criteria were recruited over a period of 4 months from June to September 2011. All patients consented or assented and data on demographic characteristics and disease status was collected by means of a standardized questionnaire. A card was given to each participant to document the injections of benzathine penicillin received from their health care providers. All patients received education on the importance of monthly benzathine penicillin before being placed back under the care of their primary clinicians. Follow up was done at the end of six months and information retrieved from the cards as regards the monthly benzathine penicillin. Another questionnaire to determine the reasons for non adherence was administered at follow up time. The outcome measures included the number of penicillin injections received to that prescribed over the six months period, the proportion of adherent and non adherent patients, the different patient factors associated with adherence to Benzathine penicillin prophylaxis and the reasons for non adherence among RHD patients in Mulago hospital. Results: Patient Characteristics: The majority of patients were females 75 (78.9%). The patient’s age ranged from 5-55years, with a mean age of 28.1 years (SD ± 12.2) and median age was 28 years. The highest education level was primary school for most patients, 44 (46.3%) with 8 (8.4%) of the patients being illiterate. Most of the patients were either NYHA classification II 39 (41.1%) or III 32 (33.7%). Level of adherence to monthly benzathine penicillin: Forty four patients (54%) adhered to the monthly benzathine penicillin prophylaxis with adherence rates ≥ 80%. Thirty eight (46%) of the patients were classified as non adherent to the monthly benzathine penicillin with rates less than 80%. The mean adherence was 70.12% (SD ± 29.25) and the median was 83.30% with a range of 0 to100%. Twenty seven (33%) of the patients had extremely poor adherence rates of ≤ 60%. Patient factors associated with adherence: Although statistically significant associations with adherence were not found, trends towards adherence were demonstrated among patients who resided in a town/city [OR 1.73; CI 0.64-4.72] and those with at least secondary level of education. [OR 2.21; CI 0.83-5.93] The painful nature of the benzathine penicillin injections and lack of transport money to travel to the health center were the main reasons for non adherence among RHD patients in Mulago hospital. Conclusion1. Although the level of adherence was fairly good (54%), the level of non adherence among these rheumatic heart disease was considerably high (46%) which places a significant proportion of patients at risk of recurrent episodes of ARF and worsening heart lesions. 2. Although no particular patient factor was found to be significantly associated with adherence, we determined that residing in a town/city and having at least secondary level of education was associated with a trend towards adherence. 3. The painful nature of the benzathine penicillin injections and lack of transport money to travel to the health center are the main reasons for non adherence among RHD patients in Mulago.