Published in PLOS One on 2026-05-26, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Eshetie Melese Birru, Kevin T. Batty, Laurens Manning, Stephanie L. Enkel, Brioni R. Moore
Source: PLOS One • DOI 10.1371/journal.pone.0349776
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Rheumatic heart disease (RHD) remains a major public health challenge in Ethiopia, particularly among children. Monthly intramuscular benzathine penicillin G (BPG) is the cornerstone of secondary prophylaxis, yet adherence and delivery are suboptimal. This study explores the lived experiences of children and adolescents with RHD, capturing their direct voices and those of their caregivers to understand determinants of secondary prophylaxis uptake.
A qualitative descriptive study was conducted from May to July 2022 in four Ethiopian public hospitals providing RHD care. Focus group discussions were held with children living with RHD (C-RHD) and their caregivers to explore barriers and facilitators of BPG delivery. Audio recordings were transcribed, translated, and thematically analysed using the framework method, with findings mapped onto the Capability, Opportunity, Motivation, Behaviour (COM-B) model.
Forty-two participants (30 C-RHD, 12 caregivers) identified five interrelated determinants of BPG delivery: structural barriers (geographic inaccessibility, transport costs, limited policies), organizational challenges (drug shortages, inadequate follow-up and counselling), therapeutic issues (painful injections, needle blockages, limited alternatives), provider-related concerns (fear of adverse reactions), and individual factors (misconceptions, psychological distress, adherence behaviours). Despite a preference for injectable BPG, some children received less effective oral antibiotics due to poor access. Participants emphasized the need for reliable BPG supply, dedicated providers, and strengthened patient support programs.
Strengthening patient/carer education, improving BPG formulations and access, and addressing resource gaps within healthcare systems are critical to enhancing adherence, preventing ARF/RHD, and improving patient outcomes.
Background
Acute rheumatic fever (ARF) is an inflammatory autoimmune disease resulting from Group A Streptococcal infections of the throat or skin [1]. Recurrent, untreated episodes of ARF increase the risk of developing rheumatic heart disease (RHD) and, if persistent, permanent heart valve damage that may require surgical intervention [2]. Although streptococcal skin and throat infections are generally responsive to penicillin, RHD remains a neglected and significant public health issue due to gaps in prevention strategies and inadequate support for affected people [3,4].
An estimated 40.5 million people worldwide are living with RHD, resulting in over 300,000 deaths in 2019 [5]. ARF is most associated with children, adolescents and young adults, with peak incidence occurring between 5 and 14 years. Whilst the prevalence of RHD was previously more commonly associated with patients in their 2nd to 4th decade of life [6] recent disease trends have seen a 41% increase in the number of children <15 years of age with RHD (1990–2019) [7]. Socioeconomically disadvantaged individuals in low- and middle-income nations within Oceania, South Asia and sub-Saharan Africa, and marginalized communities in developed countries (e.g., Aboriginal, Torres Strait Islander peoples and immigrant populations within Australia, Māori and Pacific peoples in New Zealand, and Indigenous populations in Fiji), are at highest risk [1,8–12].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider hospital systems desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Eshetie Melese Birru, Kevin T. Batty, Laurens Manning, Stephanie L. Enkel, Brioni R. Moore. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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