CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 2, May/June 2023 AFRICA 91 Discussion Early diagnosis of disease depends on the knowledge base of the first/primary contact health-worker and referral to the specialist. Healthcare worker training helps raise community awareness of the symptoms and treatment of ARF and RHD. The primary healthcare worker plays a pivotal role in ensuring medication administration is safe and timely. Limited studies in sub-Saharan Africa have evaluated health-worker practices regarding RHD prevention, such as raising awareness of effective prevention of ARF. As a pilot study, an assessment was conducted on the knowledge level of ARF/RHD prevention among healthcare providers in the Tororo district, eastern Uganda. Only 31% of the rural health workers in our study had knowledge of the diagnosis of ARF prior to the initial training, and 75% passed the posttest, which was statistically significant, implying they had learned the clinical features of ARF. Our findings are comparable with a study conducted at the University Teaching Hospital in the heart of Zambia.14 Participants primarily comprised nurses (65%), and at baseline, only 15% had knowledge of RHD.14 This group, contrary to our study, conducted bi-monthly training during the follow-up period. Diagnosis of ARF appears to be an overall challenge across the healthcare sector. In Khartoum, northern Sudan, Osman and colleagues evaluated physicians’ knowledge on the prevention of ARF. Fifty-five per cent of these doctors were familiar with the treatment of ARF recurrence prior to training, and 60% after the training.15 In Cameroon, 87% of medical students had a knowledge of BPG use in preventing ARF.16 In our study during the baseline evaluation, 31% of the participating health workers had familiarity with the clinical features of ARF, whereas only 23% had knowledge of the role of BPG in the treatment and prevention. There was no difference in knowledge across the health units. In the pre-test, a great number of health workers confused BPG for benzyl penicillin. Interestingly, following the initial training, there was marked improvement in knowledge pertaining to the clinical features of ARF and the use of BPG. However, the attained information waned over the eight-month period as we did not offer refresher courses during that time. This was statistically significant. There was a trend towards a decrease in knowledge retention steadily as one moved away from the general district hospital in Tororo town to the peripheral health centres in the rural areas. Additionally, training at eight months demonstrated minimal increment in the knowledge base. The health workers seemed familiar with prevention of ARF recurrence, but not with the clinical features of ARF. This emphasises the need for ongoing support supervision at the district hospital and health centres, coupled with regular training, as was done in the Zambian study, where bi-monthly health-worker training sessions were conducted. This in the long run, improved retention of information.14 The knowledge of ARF clinical features is critical in early diagnosis, treatment and prevention of irreversible RHD.17 Primordial and primary prevention of ARF involves modifying the housing environment, reducing poverty levels for high-risk communities and eradicating group A streptococcal infection and carriage with the use of antibiotics to treat streptococcal throat infections.5 On the other hand, secondary prophylaxis involves preventing recurrence and disease progression for individuals who have suffered from ARF. In this case, intramuscular BPG prophylaxis is paramount in preventing recurrence of ARF. In our study, we were not able to directly correlate the health-worker knowledge base with the prevalence of RHD in the Tororo district. Our findings indicated that eight months after initial training, the health workers still had challenges in identifying the clinical features, never mind the use of BPG in the treatment of ARF. This would directly impact negatively on early diagnosis of ARF/RHD. Even though we noted a low knowledge level on the clinical features and BPG use in ARF and RHD, the challenging health referral system in Uganda, together with widespread poverty, hinder patient access to early diagnosis and treatment of ARF.18 Late patient referrals with advanced RHD depict a multi-stage knowledge gap in ARF diagnosis. Of the participants in this study, approximately half were nurses and only 5.5% were medical doctors, serving 600 000 people in the Tororo district.13 Learning from the human immunodeficiency virus (HIV) model, raising awareness is a major preventative strategy that worked effectively for Uganda at the peak of the HIV epidemic.19 During the early years of the HIV epidemic, care was initially confined to the city and a few regional referral hospitals.20 However, with intense campaigns and educative programmes, anti-retroviral therapy can now be prescribed by health workers at lower health centres. Given the limited number of cardiac specialists in Uganda,21 if we extrapolate the HIV preventative model, the lowest qualified nurse would be comfortable making the diagnosis of ARF and RHD, prescribe basic treatment such as BPG and make appropriate referrals to a centre where a detailed cardiac evaluation can be done. The strength of our model or approach is the fact that health workers were trained at their respective health centres, which reduced their distraction from work. Secondly, the support team (JN, EN) was able to review patients with the health workers and demonstrate ARF clinical signs, emphasising the importance of early diagnosis by having a high index of suspicion. Our strongest support was the active involvement of both the legislative and administrative arms of the Tororo district local government. With political involvement in health-related campaigns, the local community and religious leaders tend to Table 2. Assessment of knowledge of BPG use in ARF in phase 1 Health unit Number passed pre-test (total) Number passed post-test (total) χ2 test Nagongera 4 (20) 19 (20) 0.000 Mulanda 4 (23) 18 (21) 0.000 Mukuju 6 (26) 22 (36) 0.000 Tororo 11 (40) 31 (35) 0.000 Total 25 (109) 90 (112) Table 3. Level of knowledge of ARF clinical features from pre training to eight months post training Health unit Number passed phase 1 (total) Number passed at 8 months (total) χ2 test Nagongera 7 (20) 6 (31) 0.21 Mulanda 5 (23) 7 (22) 0.45 Mukuju 8 (26) 8 (26) 1.00 Tororo 14 (40) 13 (36) 0.94 Total 109 115
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