{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T06:08:58Z","timestamp":1789193338329,"version":"build-2803163510"},"reference-count":65,"publisher":"Ubiquity Press, Ltd.","issue":"1","license":[{"start":{"date-parts":[[2025,1,29]],"date-time":"2025-01-29T00:00:00Z","timestamp":1738108800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["gh"],"abstract":"<jats:p>Background: Monthly intramuscular injections of benzathine penicillin G (BPG) remain the cornerstone of secondary prophylaxis for acute rheumatic fever and rheumatic heart disease (RHD). The barriers to successful delivery of BPG may be patient- or service-delivery-dependent.\nObjective: The aim of the present study was to explore the perceived acceptability and implementation challenges of BPG treatment for RHD, from the perspective of healthcare providers (HCPs).\nMethodology: A descriptive qualitative study using semi-structured interview guides was conducted in four public hospitals in Ethiopia. Physicians and nurses who had at least 1 year of experience in delivering RHD secondary prophylaxis were recruited. The interviews were audio recorded, transcribed verbatim, and translated into English for analysis using framework method thematic analysis. Identified behavioral factors were mapped onto a theoretical framework of acceptability (TFA), and the Capability, Opportunity, Motivation-Behavior (COM-B) model.\nResult: Twenty-two interviews were conducted with HCPs (mean age 39 years, 55% nurses). Insights into BPG use and acceptability were categorized into four major themes related to: (1) individual factors (e.g., fear of anaphylactic reaction), (2) health system barriers (e.g., BPG shortage), (3) patient\/caregiver perceptions (e.g., reliance on injectables, over expectation of treatment outcomes), and (4) product (e.g., injection pain, needle blockage).\nConclusions: HCPs identified facilitators and barriers which highlight the complexities associated with BPG as secondary prophylaxis for RHD in Ethiopia. Based on these data, we suggest RHD control programs should (1) provide cross-disciplinary training and education programs to support safe and context-appropriate delivery of BPG (2) improve resourcing of health facilities to facilitate safe drug delivery, (3) establish a comprehensive system for auditing severe adverse reactions post-BPG injection to generate robust pharmacovigilance data, and consider alternative approaches to BPG delivery including access to improved formulations (e.g., BPG suspension formulations in pre-filled syringes).\nHighlights:\n\nKey barriers included (a) resistance from healthcare providers to administer benzathine penicillin G (BPG) due to their concerns about injection-related severe adverse events, and potential repercussions should an event occur, (b) poor community and healthcare provider awareness of the disease and its treatment, (c) lack of resources to manage adverse events, and (d) injection pain.\nKey enablers included (a) perceived superior treatment benefits of BPG and (b) co-administration of lidocaine\/analgesics to reduce injection pain.\nRecommendations to address identified challenges include (a) improved training\/education on RHD diagnosis, disease progression, and treatment, (b) improved access to supportive resources, (c) active adverse reaction monitoring and reporting, and (d) encouraging the provision\/access of globally subsidized BPG suspension formulations in pre-filled syringes.\n<\/jats:p>","DOI":"10.5334\/gh.1393","type":"journal-article","created":{"date-parts":[[2025,1,29]],"date-time":"2025-01-29T12:32:01Z","timestamp":1738153921000},"page":"8","source":"Crossref","is-referenced-by-count":4,"title":["Acceptability and Implementation Challenges of Benzathine Penicillin G Secondary Prophylaxis for Rheumatic Heart Disease in Ethiopia: A Qualitative Study"],"prefix":"10.5334","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7613-0384","authenticated-orcid":false,"given":"Eshetie Melese","family":"Birru","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3850-1778","authenticated-orcid":false,"given":"Kevin T.","family":"Batty","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4334-5351","authenticated-orcid":false,"given":"Laurens","family":"Manning","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4075-0781","authenticated-orcid":false,"given":"Stephanie L.","family":"Enkel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9792-7838","authenticated-orcid":false,"given":"Brioni R.","family":"Moore","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"3285","published-online":{"date-parts":[[2025,1,29]]},"reference":[{"key":"key20250129123154_B1","unstructured":"Cunningham MW. 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Available from: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK333434\/2016."},{"issue":"4","key":"key20250129123154_B2","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1097\/BOR.0b013e32835461d3","article-title":"Streptococcus and rheumatic fever","volume":"24","year":"2012","journal-title":"Current Opinion in Rheumatology"},{"issue":"1","key":"key20250129123154_B3","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1186\/s13075-022-02829-3","article-title":"Global burden of rheumatic heart disease: Trends from 1990 to 2019","volume":"24","year":"2022","journal-title":"Arthritis Research & Therapy"},{"key":"key20250129123154_B4","first-page":"116","article-title":"Controlling acute rheumatic fever and rheumatic heart disease in developing countries: Are we getting closer?","year":"2015"},{"key":"key20250129123154_B5","first-page":"1","article-title":"A community-based program to reduce acute rheumatic fever and rheumatic heart disease in northern Australia","volume":"21","year":"2021","journal-title":"BMC Health Services Research"},{"issue":"5","key":"key20250129123154_B6","article-title":"Rheumatic heart disease in Indigenous children in northern Australia: Differences in prevalence and the challenges of screening","volume":"203","year":"2015","journal-title":"Medical Journal of Australia"},{"issue":"5","key":"key20250129123154_B7","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1038\/nrcardio.2013.34","article-title":"Position statement of the World Heart Federation on the prevention and control of rheumatic heart disease","volume":"10","year":"2013","journal-title":"Nature Reviews Cardiology"},{"key":"key20250129123154_B8","first-page":"2399","article-title":"Rheumatic heart disease patients\u2019 adherence to secondary prophylaxis and associated factors at hospitals in Jimma zone, Southwest Ethiopia: A multicenter study","volume":"2020","journal-title":"Patient Preference and Adherence"},{"issue":"2","key":"key20250129123154_B9","first-page":"155","article-title":"Adherence to secondary prophylaxis for acute rheumatic fever and rheumatic heart disease: A systematic review","volume":"13","year":"2017","journal-title":"Current Cardiology Reviews"},{"issue":"4","key":"key20250129123154_B10","doi-asserted-by":"crossref","first-page":"386","DOI":"10.1111\/j.1445-5994.2012.02838.x","article-title":"Variability in disease burden and management of rheumatic fever and rheumatic heart disease in two regions of tropical Australia","volume":"43","year":"2013","journal-title":"Internal Medicine Journal"},{"issue":"2","key":"key20250129123154_B11","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1097\/CRD.0000000000000065","article-title":"Approaches to improving adherence to secondary prophylaxis for rheumatic fever and rheumatic heart disease: A literature review with a global perspective","volume":"24","year":"2016","journal-title":"Cardiology in Review"},{"issue":"1","key":"key20250129123154_B12","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1186\/s40794-023-00192-y","article-title":"The prevalence of rheumatic heart disease in Ethiopia: A systematic review and meta-analysis","volume":"9","year":"2023","journal-title":"Tropical Diseases, Travel Medicine and Vaccines"},{"key":"key20250129123154_B13","first-page":"1","article-title":"Rheumatic mitral stenosis in children: More accelerated course in sub-Saharan patients","volume":"13","year":"2013","journal-title":"BMC Cardiovascular Disorders"},{"key":"key20250129123154_B14","unstructured":"Ministry of Health Ethiopia. Standard treatment guidelines for general hospitals, 4th edition. Addis Ababa; 2021 [Accessed on 20 July 2024]. 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Evaluation of physicians\u2019 knowledge about prevention of rheumatic fever and rheumatic heart disease before and after a teaching session. Sudan Journal of Paediatrics. 2015; 15(2):37\u201342. Available from: https:\/\/pubmed.ncbi.nlm.nih.gov\/27493434\/."},{"issue":"1","key":"key20250129123154_B21","doi-asserted-by":"crossref","first-page":"6","DOI":"10.5334\/gh.1181","article-title":"A qualitative study of patients\u2019 experiences, enablers and barriers of rheumatic heart disease care in Uganda","volume":"18","year":"2023","journal-title":"Global Heart"},{"issue":"1","key":"key20250129123154_B22","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1186\/s41256-021-00222-2","article-title":"Health system and patient-level factors serving as facilitators and barriers to rheumatic heart disease care in Sudan","volume":"6","year":"2021","journal-title":"Global Health Research and Policy"},{"issue":"3","key":"key20250129123154_B23","doi-asserted-by":"crossref","first-page":"184","DOI":"10.5830\/CVJA-2015-090","article-title":"Seven key actions to eradicate rheumatic heart disease in Africa: The Addis Ababa communiqu\u00e9: Cardiovascular topics","volume":"27","year":"2016","journal-title":"Cardiovascular Journal of Africa"},{"issue":"2","key":"key20250129123154_B24","article-title":"Severe adverse events following benzathine penicillin G injection for rheumatic heart disease prophylaxis: Cardiac compromise more likely than anaphylaxis","volume":"11","year":"2019","journal-title":"Heart Asia"},{"key":"key20250129123154_B25","unstructured":"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."},{"issue":"6","key":"key20250129123154_B26","doi-asserted-by":"crossref","first-page":"369","DOI":"10.5830\/CVJA-2019-042","article-title":"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","volume":"30","year":"2019","journal-title":"Cardiovascular Journal of Africa"},{"key":"key20250129123154_B27","doi-asserted-by":"crossref","first-page":"843","DOI":"10.3389\/fphar.2017.00843","article-title":"Fatal and near-fatal non-allergic reactions in patients with underlying cardiac disease receiving benzathine penicillin G in Israel and Switzerland","volume":"8","year":"2017","journal-title":"Frontiers in Pharmacology"},{"issue":"5","key":"key20250129123154_B28","doi-asserted-by":"crossref","first-page":"550","DOI":"10.1536\/ihj.17.550","article-title":"Some problems in long-term prevention of streptococcal infection among children with rheumatic heart disease in Taiwan","volume":"17","year":"1976","journal-title":"Japanese Heart Journal"},{"key":"key20250129123154_B29","unstructured":"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\u2013218. Available from: https:\/\/www.proquest.com\/scholarly-journals\/intramuscular-penicillin-is-more-effective-than\/docview\/73336241\/se-2."},{"issue":"12","key":"key20250129123154_B30","article-title":"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","volume":"67","year":"2023","journal-title":"Journal of Antimicrobial Chemotherapy"},{"issue":"10","key":"key20250129123154_B31","doi-asserted-by":"crossref","first-page":"2951","DOI":"10.1093\/jac\/dkaa282","article-title":"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","volume":"75","year":"2020","journal-title":"Journal of Antimicrobial Chemotherapy"},{"issue":"5","key":"key20250129123154_B32","article-title":"\u201cHurts less, lasts longer\u201d; 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","volume":"19","year":"2024","journal-title":"PLoS One"},{"key":"key20250129123154_B33","first-page":"1","article-title":"Determinants of poor adherence to secondary antibiotic prophylaxis for rheumatic fever recurrence on Lifou, New Caledonia: A retrospective cohort study","volume":"13","year":"2013","journal-title":"BMC Public Health"},{"issue":"2","key":"key20250129123154_B34","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1111\/jpc.12400","article-title":"Reducing the pain of intramuscular benzathine penicillin injections in the rheumatic fever population of Counties Manukau District Health Board","volume":"50","year":"2014","journal-title":"Journal of Paediatrics and Child Health"},{"issue":"3","key":"key20250129123154_B35","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1016\/j.pmn.2014.08.013","article-title":"Applying manual pressure before benzathine penicillin injection for rheumatic fever prophylaxis reduces pain in children","volume":"16","year":"2015","journal-title":"Pain Management Nursing"},{"key":"key20250129123154_B36","first-page":"632","article-title":"Acute rheumatic fever and rheumatic heart disease\u2014priorities in prevention, diagnosis and management","year":"2012"},{"issue":"6","key":"key20250129123154_B37","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups","volume":"19","year":"2007","journal-title":"International Journal for Quality Health Care"},{"key":"key20250129123154_B38","unstructured":"Health Sector Development Program IV 2010\/11\u20132014\/15. 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Rheumatic fever and rheumatic heart disease: Report of a WHO Expert Consultation, Geneva, 29 October \u20141 November 2001. WHO Technical Report Series; 923. Geneva: World Health Organization; 2004 [Accessed on September 20, 2024]. 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Benzathine penicillin: Fatal mega-unit injections. WHO Drug Information. 200;14(4), 230. 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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."},{"key":"key20250129123154_B64","unstructured":"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]. 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