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 Table of Contents  
Year : 2022  |  Volume : 19  |  Issue : 3  |  Page : 98-103

Knowledge, attitude, and experiences of using penicillin G, as a prophylaxis for rheumatic fever and rheumatic heart diseases among nurses in Addis Ababa, Ethiopia: A cross-sectional survey

Department of Pediatrics and Child Health, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia

Date of Submission19-Aug-2021
Date of Acceptance05-May-2022
Date of Web Publication25-Aug-2022

Correspondence Address:
Dr. Tamirat Moges Aklilu
Department of Pediatrics, School of Medicine, Addis Abeba University, Addis Abeba, Oromia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcls.jcls_30_21

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Background: The rate of benzathine penicillin G (BPG) injection to prevent rheumatic heart disease (RHD) is insufficient owing to poor knowledge and the negative attitude of health workers. We aim to investigate the gap of knowledge, attitude, and experience of clinical nurses at the primary health-care level who had not received training on rheumatic fever (RF)/RHD prevention to get information on their training need. Methods: A cross-sectional survey was conducted on clinical nurses at randomly selected health centers in Addis Ababa. After interviewing with semi-structured questionnaires, the data were analyzed on SPSS software version 25. Results: A total of 278 nurses (92% response) with a mean age of 28 years were analyzed. The knowledge scores on “organisms causing tonsillopharyngitis (TP),” “the route of administration of penicillin,” and “when to give BPG after preparation” were good (≥75%). Participants' score was poor (<50% score) in the knowledge of “duration of treatment of tonsillopharyngitis, frequency of chemoprophylaxis of RF/RHD, and the relationship between throat infection and RF.” Knowledge on “prevention of pain using lidocaine,” “warming the syringe and allowing alcohol to dry from the swab before injecting” were also good. In contrast, knowledge of “delivering injection very slowly,” “using vibration before/during injection, and “distracting patient using conversation” was poor. Attitude was positive to statements such as “single dose BPG injection given every 3–4 weeks,” “BPG injection is effective in the treatment of streptococcal pharyngitis and the prevention of RF/RHD,” “good patient – health provider relationship enables the success of prophylaxis.” and “educating patients, health-care providers and their caregivers help adherence to BPG prophylaxis. Fear of anaphylactic reaction, pain at the injection site, and blockage of the syringe during injection were the negative experiences reported. Conclusions: The knowledge of clinical nurses on the prevention of RF/RHD was generally good. However, their knowledge of safe injection techniques was partial. On the other hand, most attitude statements were positive. Fear of anaphylactic shock while injecting BPG, pain, and blockade of the syringe was the common barriers experienced.

Keywords: Attitude, benzathine penicillin, knowledge, nurses, rheumatic fever, rheumatic heart disease

How to cite this article:
Ibrahim MA, Aklilu TM. Knowledge, attitude, and experiences of using penicillin G, as a prophylaxis for rheumatic fever and rheumatic heart diseases among nurses in Addis Ababa, Ethiopia: A cross-sectional survey. J Clin Sci 2022;19:98-103

How to cite this URL:
Ibrahim MA, Aklilu TM. Knowledge, attitude, and experiences of using penicillin G, as a prophylaxis for rheumatic fever and rheumatic heart diseases among nurses in Addis Ababa, Ethiopia: A cross-sectional survey. J Clin Sci [serial online] 2022 [cited 2023 Mar 20];19:98-103. Available from: https://www.jcsjournal.org/text.asp?2022/19/3/98/354670

  Introduction Top

Acute rheumatic fever (ARF) is the major cause of cardiac mortality among children and young adults in developing countries, and rheumatic heart disease (RHD) is the long-term complication compromising the function of cardiac valves.[1] Annually, deaths from RHD occur between 250,000 and 468,000.[2] In sub-Saharan Africa, up to 3% of school-aged children had definite or borderline RHD with consequent heart failure causing 35% 1-year mortality.[3],[4] The prevalence of RHD in Ethiopia is 19 cases/1000 school children.[5] Regular use of benzathine penicillin G injection (BPG) can prevent the recurrence of RF and its progression to RHD.

The delivery rates of BPG injection as prophylaxis of RF/RHD are low for various reasons.[6] Clinical nurses at the primary care level administer BPG injections in routine practice. Fear of injection pain and allergic reactions are the feared complications for avoiding giving these injections.[2],[7],[8]

Ethiopia is among countries with a high prevalence of ARF and RHD. The Federal Ministry of Health, in collaboration with the Cardiology Society of Ethiopia, launched a national RF/RHD prevention campaign through a large-scale training of the mid-level health workers in selected regions.[9] However, at the health center's (HCs) level where penicillin injections are frequently given, information on the gap of knowledge, attitude, and experience is very limited. Therefore, we aimed to investigate the gap of knowledge, attitude, and experience of clinical nurses at the primary health-care level to identify their training needs.

  Methods Top

Study design and clinical settings

An institution-based cross-sectional survey was conducted using interviewer-administered questionnaires between September and October 2019. The study was conducted at selected HCs in Addis Ababa.

Addis Ababa is the capital of Ethiopia, having a 527 km2 area with a population density of 5165 individuals/km2. The population is estimated at 4,793,699 in 2020. The city is divided and subdivided into 10 administrative subcities, and 10–15 woredas in each subcity.[10] An average of 10 HCs are found in each subcity. Pneumonia and upper respiratory tract infections are among the leading top 10 causes of morbidity in all age groups. The nurses and midwives per 1000 population ratio for Ethiopia is 0.7 (expected to be higher for Addis Ababa.[11],[12]

Study population and sample size

Registered nurses who served at least 6 months in the same or different HC were the source population. All nurses in the selected HCs who volunteered to be interviewed were included. By convenience sampling method, we selected nine clinical nurses from each of the 32 selected HCs (288 samples). The remaining seven samples were additionally taken from seven of the 32 selected HCs at random to get the calculated Sample size (SS) (295). We selected the HCs, from three of the 10 subcities, identified by a simple random sampling technique. Thus, Lideta, Akaki Kality and Arada subcities were identified. Ultimately, we took all the 32 HCs in the three subcities. SS was calculated using a single population proportion formula with a 95% confidence interval, 5% margin of error (D), P = 50% (the proportion of nurses with good knowledge). n = (Zα/2)2 × P (1 − p)/D2 = (1.96) 2 × 0.5 × 0.5/(0.05) 2 to get 384 samples. Based on the data available in the selected HCs the average number of clinical nurses working in each HC at a given time was 40. Total nurses available in the 32 HC will add up to 1280; which is <10,000. Hence, we used the finite population correction formula for a population <10,000, NF = n/1 + n/N; where n = Designed SS, NF = The final SS, N = estimated number of nurses in the 32 HCs at a given time. NF = 384/1 + 384/1280; NF = 295.

Inclusion criteria

Clinical nurses at the primary care level, who served at least 6 months in the same or different HC and volunteered to be interviewed, were included.

Exclusion criteria

Nurses with more than 6 months of practice as a nurse but not volunteered for the interview were excluded.

Operational definitions

Knowledge questions were given a score of “1” for correct answers and “0” for the wrong answer. Knowledge was graded as “Poor if the score was <7.5(<50% of 15 questions), “Fair” if the score was between 7.6 and 11.25 (51%–75%) and “Good” if the score was >11.25 (75%). Attitude was graded as Negative” if the score was <17.5 (50% of the 35 score points), and positive” if the score was ≥17.5 (≥50% of 35 score points). The total score was calculated out of 100 by dividing the number of correct answers by the total number of questions multiplied by 100.

Data collection

We used an interview method of data collection. The data collection instrument was initially prepared in English and translated into Amharic again back into English. The questionnaire focused on sociodemographic variables such as age, sex, educational status, year of experience, general knowledge of RF/RHD, and Penicillin safe injection technique. We measured attitude on an ordinal scale with a 5-point Likert scale (5-Strongly Agree, 4-Agree, 3-not sure, 2-Disagree, 1-Strongly disagree). We adopted fifteen knowledge questions from RHD Australia.[13] Seven attitude and eight personal experience questions were also developed and pretested before the interview. The experience questions focused on enabling factors and barriers during the nurse's practice. Additional questions were asked on the availability of a guideline to help reduce injection pain and a separate registration book for RF/RHD patients. We pretested the questionnaires in one of the HCs outside of the study area. We have not included the pretest result in the actual study finding.

Data analysis

Data were entered and analyzed in SPSS version 25.0 software statistical software package version 25.0 (SPSS Inc., Chicago, IL, USA). Discrete variables were expressed as absolute numbers, frequencies, and percentages, whereas continuous variables were expressed as mean, median, and standard deviation (SD). We computed the mean and median attitude scores using the compute function. The Chi-square test was used for group comparison of the categorical variables. We used a P < 0.05 as a measure of statistical significance. The result was summarized using tables and figures.

Ethical consideration

Informed consent was gained from the participants before participating in the study. We also obtained ethical clearance from the pediatric department ethical review board of the college of health sciences (Addis Ababa University. Addis Ababa regional health bureau provided a permission letter before the start of the study.

  Results Top

Two hundred and seventy-eight clinical nurses (94% response rate), with an age range of 22–43 years and a male: female ratio of 1:2.2 were analyzed. The mean age was 28.45 (± SD 3.43) years. The nurse's work experience ranged between 1 and 20 years. Females were twice the number of males. Degree graduates accounted for three-fourths (210/278) of the participants. The sociodemographic characteristics of the study subjects are displayed in [Table 1]. The mean scores for the general knowledge, safe injection knowledge, and attitude were 1.74, 1.5, and 3.1, respectively.
Table 1: Baseline characteristics of participants using benzathine penicillin G injection at Addis Ababa selected health centers according to gender

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Participants' level of general knowledge and knowledge on the safe practice of giving BPG injection in the prevention of RF/RHD using BPG injection is displayed in [Table 2]. In general, the knowledge levels are comparable between males and females. The general knowledge around “cause of RF,” “organism killed by BPG,” “route of administration,” and “when to give BPG after preparation” was fair or good. Participants scored Poor (<50% score) in the knowledge of “duration of treatment of tonsillopharyngitis, “frequency of chemoprophylaxis of RF/RHD,” and “the relationship between throat infection and RF.”
Table 2: Knowledge, attitude, and experiences of participants using benzathine penicillin G injection at Addis Ababa selected health centers according to gender

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Good or fair knowledge on safe injection techniques is reported around “warm the syringe to room temperature before use” “apply pressure for 10 s before inserting the needle,” “allow alcohol from swab to dry before inserting the needle” and “Addition of 0.5–1 ml lidocaine.” On the other hand, knowledge of “delivering injection very slowly,” “use vibration before or during injection, and distracting patient using conversation” was poor. Similarly, the participant's attitude is displayed in the same table. Thus, their overall attitude toward using BPG injection is positive. Participants' experience during injecting BPG to patients is summarized in the same table. Accordingly, over 50% of the respondents claimed that they experienced fear of anaphylactic shock while injecting patients with BPG and they had stopped giving injection either because of pain complained by the patient or the syringe was blocked.”

The impact of educational level on the experience of clinical nurses at the primary care level is shown in [Table 3]. Thus, a higher number of diploma nurses claimed to have jumped to give BPG injection for pain complained by the patient and encountered patients refusing BPG injection.
Table 3: Factors affecting participant's experience on the use of benzathine penicillin G injection by level of education at Addis Ababa selected health centers

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  Discussion Top

In the current study, the general knowledge of nurses at the primary health care level in using BPG injection and its safe administration was differential, partly good, and partly bad. Participants' attitude toward using BPG injection for preventing RF/RHD was, in general, positive. Fear of anaphylactic shock during injecting patients was a barrier to their practice in over half of the participants.

The study focused on a topic that is very detrimental to the promotion of the use of BPG prophylaxis in the prevention of RF/RHD. Because there is huge negative propaganda against the use of BPG injection among the mid-level health professionals, the result of the study can be used to fill the gap of knowledge and barriers among the clinical nurses at the primary care level.

Knowledge was good around the cause of RF, its etiology, and the drug used to eradicate streptococcal throat infection. The reason may be because most nurses easily access reading material on the topic around RF/RHD or the subject is well taught in the nursing school during their formal training.[9],[14] Quality of the training curriculum may also give insight to understand those reasons.

On the other hand, participants' knowledge was inadequate toward the duration of treatment of TP, and frequency of chemoprophylaxis. The reason may be because treatment and prophylaxis are often prescribed by physicians while nurses may not be encouraged to read on these topics. Studies showed that applying targeted training on the specific issues, was shown to increase the knowledge score among nurses.[15],[16]

The use of vibrator equipment is unknown by most participants in the present study. In resource-poor settings, vibratory equipment during injection is not available, which may be the reason why this practice is not known by most. Our study participants did not know the importance of doing conversation techniques to alleviate injection pain. Using such conversation techniques might have not been well taught to nurses in the school despite being one of the nonpharmacologic techniques for alleviating pain. According to some studies, pain can be reduced up to 25% by the distraction of attention alone.[17] Because distraction can change the physiological response of pain transmission in the spinal cord, some of the pain signals do not get processed at all. Research has shown, especially in children, that interactive distraction is far better at managing pain and anxiety than a passive distraction. In other words, engaging someone in a conversation is far better than just having them listen to people talk.[18],[19],[20]

In the present study, “the duration of treatment of bacterial pharyngitis with BPG” was correctly answered only by a few. A similarly low level of knowledge was reported by others.[21] Similarly, knowledge of safe injection techniques was affected by participants' educational status. The fact that diploma graduates scored less on knowledge questions indicated the need for continuous professional development to improve knowledge on RF/RHD prevention. Formal lecture-based training of HCWs was reported to improve knowledge on the prevention of RF/RHD.[14]

The fact, the attitude of participants that remained positive toward the use of BPG injection, was encouraging. Reports have shown that high-level advocacy, education, research, and leadership roles were strong enablers of secondary prophylaxis when the attitude was positive.[22] Contrarily, “a negative patient-health worker interaction” was shown to contribute to nonadherence to secondary prophylaxis.[23] “Fear” of anaphylactic shock in the patient during injection is a huge barrier to uptake of BPG injection, according to the finding in this present study. The source of the fear of anaphylactic reaction by the HWs due to penicillin needs further study. In fact, in one study, 63% of HCWs believed patients' self-reported history to stop penicillin injection without objective evidence.[24]

<5% of the study participants in this study reported encountering “patients with penicillin allergy.” “True penicillin allergy” is said to be very rare, with an estimated frequency of 0.02%–0.04% of penicillin therapy. It was hypothesized that many patients report an allergy inaccurately when they have symptoms of the infection such as fever or diarrhea. Similarly, in the case of accidental intravenous penicillin injection, symptoms of shock with neuropsychiatric disorders may occur and confused for penicillin allergy.[8],[25],[26]

According to our interview, nearly 90% of the HCs did not have separate registration for RF/RHD cases despite reports showing the benefit of having separate registration for RF/RHD prevention.[16] The possibility of needle blockade during the administration of BPG is acknowledged, and preventive measures are available to follow.[26]

A significant number of diploma nurses claimed to have jumped to give BPG injection for pain complained by the patient and encountered patients refusing BPG injection. The reasons may be related to a difference in the skill of the technique of administering the injection or may be in the difference whether compassionate care is applied or not among. Delivering service with compassion and empathy is vital to all health-care workers to be accepted by their patients. The difference between the two groups should be viewed in this mirror and further study may be required.[27] Most of the participants reported to have no safe injection guideline. Those guidelines are, in fact, available from Pfizer Laboratories Div Pfizer Inc for free.[26],[28]

  Conclusions Top

Poor areas of knowledge of the participants in the present study includes “duration of treatment of TP with BPG,” “frequency of chemoprophylaxis of RF/RHD,” and “the relationship between throat infection and RF.” Participants also had poor safe injection knowledge in the importance of distracting patients during injection. Participants had a positive attitude to most of the attitude questions. Fear of anaphylactic shock while giving benzathine injection is common. Experience of injection pain and blocked syringe were among the barriers. Training of clinical nurses at the primary care level to improve secondary prophylaxis using BPG injection may address knowledge gaps and improve the experience.


An interviewer bias may occur. Furthermore, the study did not include nurses practicing in private health institutions, limiting the generalizability of the findings. A lot of missed data during data collection occurred. This may be due to inadequate training of the data collectors. Injection practice is not measured by direct observation. The presence and absence of the guidelines were also recorded by participants report, not by direct observation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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