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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 1 | Page : 61-69
Knowledge, attitude, and practice regarding prevention of rheumatic heart disease among primary health-care workers in sokoto metropolis, Sokoto State, Nigeria
Khadijat Omeneke Isezuo1, Kehinde Joseph Awosan2, Umar Mohammed Ango2, Yahaya Mohammed3, Usman Muhammad Sani1, Usman Muhammad Waziri1, Bilkisu Ilah Garba1, Asma'u Adamu1, Fatima Bello Jiya1
1 Department of Paediatrics, Usmanu Danfodiyo University/ Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria
2 Department of Community Medicine, Usmanu Danfodiyo University/ Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria
3 Department of Medical Microbiology, Usmanu Danfodiyo University/ Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria
Correspondence Address:
Khadijat Omeneke Isezuo
Department of Paediatrics, Usmanu Danfodiyo University/ Usmanu Danfodiyo University Teaching Hospital Sokoto
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_222_21
Abstract
Background: Rheumatic heart disease (RHD) is the only preventable cardiovascular disease that still causes significant morbidity and mortality in low- and middle-income countries like Nigeria where it is classified as a neglected disease. The inciting agent causes pharyngitis often not properly treated. Aim and Objectives: To study the knowledge and preventive practices of RHD amongst primary healthcare workers who are in contact with larger ratio of populace in order to recommend appropriate interventions. Methodology: A cross-sectional study conducted among health workers in primary health centres in Sokoto metropolis. Multi-stage sampling technique was used to recruit the study participants. A structured questionnaire and focus group discussion guide was used to collect the information. Data was analysed using IBM SPSS version 25. Results: Majority (109/182; 59.8%) had RHD inadequate knowledge of causes, risk factors and treatment of pharyngitis which predisposes to RHD. Only 49 (26.9%) of the respondents knew the name of the causative agent. The knowledge gap was related to length of training and attendance at a training (ꭓ2 = 8.38; P=0.015 & ꭓ2 = 7.92; P=0.004). Majority of the respondents with 168 out of 182 (92.3%) had positive attitude. Practice grading was adequate in only less than half of the respondents (88/182; 48.4%). Male gender and negative attitude were predictors of adequacy of preventive practices (aOR= 0.49; 95% C.I =0.267-0.929; P=0.03 & aOR= 3.87; 95% C.I =1.027-14.586; P=0.046). Conclusion: The health workers had inadequate knowledge and poor practice on prevention of rheumatic heart disease. It is necessary to upscale information available to them by medical specialists and upgrade their curriculum.
Abstract in French Résumé
Arrière-plan: La cardiopathie rhumatismale (RHD) est la seule maladie cardiovasculaire évitable qui cause encore une morbidité et une mortalité importantes dans les pays à revenu faible et intermédiaire comme le Nigeria où elle est classée comme une maladie négligée. L'agent incitant provoque une pharyngite souvent mal traitée. But et objectifs: Étudier les connaissances et les pratiques préventives de RHD parmi les agents de santé primaires qui sont en contact avec une plus grande proportion de la population afin de recommander des interventions appropriées. Méthodologie: Une étude transversale menée auprès des agents de santé des centres de santé primaires de la métropole de Sokoto. La technique d'échantillonnage à plusieurs degrés a été utilisée pour recruter les participants à l'étude. Un questionnaire structuré et un guide de discussion de groupe ont été utilisés pour recueillir les informations. Les données ont été analysées à l'aide d'IBM SPSS version 25. Résultats: La majorité (109/182 ; 59,8 %) avaient une connaissance inadéquate des causes, des facteurs de risque et du traitement de la pharyngite qui prédispose à la RHD. Seuls 49 (26,9%) des répondants connaissaient le nom de l'agent causal. Le déficit de connaissances était lié à la durée de la formation et à la participation à une formation (ꭓ2 = 8,38 ; P=0,015 & ꭓ2 = 7,92 ; P=0,004). La majorité des répondants avec 168 sur 182 (92,3%) avaient une attitude positive. La notation de la pratique n'était adéquate que pour moins de la moitié des répondants (88/182 ; 48,4 %). Le sexe masculin et l'attitude négative étaient des prédicteurs de l'adéquation des pratiques préventives (aOR = 0,49 ; IC à 95 % = 0,267-0,929 ; P = 0,03 et aOR = 3,87 ; IC à 95 % = 1,027-14,586 ; P = 0,046). Conclusion: Les agents de santé avaient des connaissances insuffisantes et de mauvaises pratiques en matière de prévention des cardiopathies rhumatismales. Il est nécessaire de valoriser les informations mises à leur disposition par les médecins spécialistes et d'améliorer leur cursus.
Mots-clés: rhumatisme articulaire aigu, attitude, GABHS, savoir, pharyngite, pratique, prévention, soins de santé primaires, cardiopathie rhumatismale, Sokoto
Keywords: Acute rheumatic fever, attitude, GABHS, knowledge, pharyngitis, practice, prevention, primary health care, rheumatic heart disease, Sokoto
Introduction 
Rheumatic heart disease (RHD) is a chronic cardiac disease and one of the leading noncommunicable diseases in lower- and middle-income countries (LMICs).[1] It is peculiar because it has an infectious origin which is communicable in nature.[2] The causative agent which is a bacterium called group A Streptococcus (GAS) is among the top 10 infectious causes of death in the world.[3] This organism causes acute pharyngitis, which if poorly treated or untreated, stimulates an abnormal immune response in some of the affected individuals leading to nonsuppurative inflammatory processes involving the heart valves, joints, and skin called acute rheumatic fever (ARF).[4]
Repeated episodes of ARF usually follow the initial episode and if not properly managed, especially with recurrent pharyngitis, culminates in permanent valvular heart damage, which is RHD.[2] RHD is, therefore, a chronic inflammatory disease of the valves of the heart resulting from GAS pharyngitis. In 2015, RHD affected 33.4 million people globally, and caused 319,400 deaths and this appears to be increasing.[1],[5] Children aged between 5 and 15 years are at increased risk of the disease and suffer lifelong sequelae.[3] The burden is worse in LMICs, where the major risk factors, which include overcrowding, limited access to health care, ignorance, poverty, and malnutrition, are also predominant.[6] This assertion is supported by a higher prevalence of RHD among children of 12.4/1000 reported in Sokoto,[7] the study area which has a predominance of lower socio-economic class inhabitants compared to 1.1/10,000 from Lagos and 0.07/1000 from Jos, which are relatively more cosmopolitan areas.[8],[9]
The interventions for prevention range from primordial to tertiary.[10] Primordial prevention encompasses the elimination of risk factors through policy formulation and health education of community members, including health workers, to increase awareness. Primary prevention mainly focuses on prompt recognition and appropriate treatment of GAS pharyngitis to avoid the antibodies stimulating the immune response, leading to initial attack or recurrent ARF. This also includes the use of vaccine, which is still under development.[11] Secondary prevention is geared toward preventing recurrent ARF by monthly penicillin injections in those at risk of recurrent ARF. Tertiary prevention aims to prevent complications as the disease is already established. Symptoms are managed effectively to minimize disability and prevent complications and early death by treating heart failure and also surgical repair of damaged heart valves.[10]
The role of primary health care in prevention of RHD cannot be overemphasized. Health workers at this level need to have optimal knowledge as they are more in contact with cases and community members. Throughout the past 2 decades, there have been several reviews of the disease burden and calls to action with no significant improvement.[5] One of the challenges identified was inadequate number of health workforce especially at the level of primary health care where lower cadre health workers like nurses, community health officers and community health extension workers are needed in the primordial, primary and secondary prevention steps.[5]
Some studies in Nepal, Iran, and Cameroon have documented low knowledge among caregivers of children with regard to awareness of the risk of pharyngitis and prevention measures for RHD.[12],[13],[14] Other studies that have been carried out include one showing poor adherence to the recommendation of penicillin V as the first line of pharyngitis treatment among physicians in Benin City, Nigeria,[15] while a study in Tanzania[16] among medical officers and nurses and one in Sudan[17] among resident doctors showed an average level of knowledge of risk factors and prevention of RHD.
This study, therefore, seeks to study the knowledge, attitude, and practice of prevention of RHD among health workers in primary health centers in Sokoto, Nigeria (where there is a high burden) in order to recommend appropriate interventions for reducing the burden of RHD in this community.
Methods Background information on the study area
The study was conducted in the Sokoto metropolis located in Sokoto State, Nigeria. It is one of the six states in the North Western zone of the country. It has a total of 23 LGAs. The State shares borders with the Republic of Niger to the north, Kebbi state to the west and south, and Zamfara to the south and east.[18]
Sokoto metropolis, which is the capital of the State, lies between latitudes 10° and 14°N, and longitude 3°3¹ and 7°7¹ east of the Equator. Sokoto metropolis has a projected population of 628,179 in 2019 based on the 2006 census.[19]
The metropolis consists of urban, peri-urban, and rural settlements within the local government areas (LGAs) that constitute the metropolis.[20] These include Sokoto North, Sokoto South and parts of Wamakko, Dange-Shuni and Kware. The inhabitants of the area are predominantly of Hausa and Fulani ethnic groups and mainly Muslims. The main economic activities in the area are farming, business, and cattle rearing.
There are 67 PHC facilities in the selected LGAs, comprising 6 in Sokoto North, 15 in Sokoto South, 21 in Wamakko, 8 in Dange Shuni LGA, and 17 in Kware LGA. These facilities include primary health care centers, health posts, dispensaries, and basic health clinics.
Study design
A cross-sectional study design with mixed methods of data collection (i.e., quantitative by questionnaire survey and qualitative by focus group discussion [FGD]) was employed.
Study population
The study population was primary health-care workers in the Sokoto metropolis.
Inclusion criteria
1. Primary health-care workers working in the clinical units and attending to patients and have been in employment for at least 6 months were included
Exclusion criteria
2. PHCs workers who are not community health extension workers (CHEWs), community health officers (CHOs), and nurses were excluded, for example, environmental health officers, and laboratory and pharmacy technicians.
Sample size determination
The minimum sample size was determined using the formula;[21]
p = percentage of health workers that had good knowledge of the symptoms of ARF[22] = 62.2%. After correction for a finite population of health workers, 182 participants were selected by multistage sampling technique and enrolled into the study.
Sampling technique
Multistage sampling technique was used. Four LGAs were selected out of five metropolitan LGAs by simple random sampling using the balloting procedure.
There are 50 PHC facilities in the selected LGAs and from these five health facilities were selected through simple random sampling or balloting per LGA, giving a total of 20 facilities. Proportional allocation of the sample size to each LGA was done based on the total number of required health workers in each LGA based on the list from the State Primary Health Care Development Agency. At each selected health facility, the staff nominal roll was accessed from the officer in charge. The list of required staff cadre was extracted and their total number were summed up. The proportionate allocation of the calculated sample size for that LGA was allocated to each selected facility. Universal sampling was adopted to select all the relevant cadre on duty per day. The facility was visited consecutively till the proportion of sample size attained was achieved. The participants for the focused group discussion were selected by convenient sampling. Purposive sampling was done to select 3 HFs that were not previously selected for the quantitative study (one from each of the LGAs selected for the study to be included in the qualitative data collection) to participate in the study and each FGD consisted of eight of the selected clinical PHCs staff attending to patients willing to participate in the discussion.
Study instruments
Questionnaire
The study instrument was a set of pretested, interviewer-administered, semi-structured questions, which was built into an open data kit (ODK) software for data collection using an android mobile phone. The questions were adapted from questionnaire sections from previous studies on health workers' knowledge on RHD.[17],[22],[23] These were modified in this study for the cadre of health care workers in PHCs.
Focus group discussion guide
It contained fourteen questions which included engagement, exploratory, and exit questions. They were conceptualized to extract more detailed responses from the participants, especially on their knowledge of risk factors and causes of ARF and RHD, attitude toward prevention, and practice of prevention. The qualitative data were collected using the FGD guide. Each session lasted 45 min when there was no longer any novel contribution from the participants.
Validation of the research instruments
Content validity was done was assessed by six experts (Associate professors and senior lecturers in Community medicine and Paediatrics and Nursing sciences). The content validity for scales was computed as the proportion of items on the questionnaire that got a rating of 3 or 4, and a content validity for scales (S-CVI) of 0.92 was obtained. The structure of the questions was adjusted in line with the observations of these experts.
Data management
Data were exported from the ODK software into the IBM Statistical Package for the Social Sciences (SPSS, Armonk, NY: IBM Corp.) version 25.0 software.
Measurement of variables
Knowledge, attitude, and practice scores
The knowledge of the respondents was divided into the following themes; knowledge on the causative agents of pharyngitis, risk factors of pharyngitis, symptoms of pharyngitis treatment, and complications. Each question under the knowledge segment was scored 1. The level of knowledge was calculated as number of correct responses divided by the total score of the segment multiplied by 100 to get the percentages of correct responses. It was classified dichotomously into 0%–49% as poor knowledge while 50% to 100% was good knowledge.[24] The attitude section which is in a 5-point Likert scale ranging from strongly agree to strongly disagree. The total score of each respondent for each question was divided by the total obtainable score and graded dichotomously as negative attitude (0%–49%) and positive attitude (50%–100%). The questions on practice were scored and graded after converting to percentages as follows: 0%–49% was poor practice, 50%–100% was good practice.
Statistical analysis
Quantitative data
The continuous variables like age in years and number of years of experience were analyzed with mean and standard deviation for univariate analysis.
Categorical variables such as age group categories, gender, type of health worker, educational status, and responses on knowledge, attitude, and practice were presented as frequencies and proportions using tables and charts for univariate analysis. Whereas for bivariate analysis, test of association Chi-square analysis or Fishers' exact test at 95% confidence interval was done to assess the relationship between different variables such as knowledge, attitude, and practice grade of respondents being the dependent variable compared to independent variables such as type of qualification and source of information.
Logistic regression was used to determine the predictors of good knowledge, attitude and practice. The level of statistical significance (α) for the test was set at P ≤ 0.05.
Qualitative data
Data from the FGD were analyzed using content analysis of thematic areas. The data were transcribed by two independent individuals and coded into thematic areas.
Ethical consideration
Approval for the study was obtained from the Research and Ethics committee of Usmanu Danfodiyo University Teaching Hospital Sokoto and the Ministry of Health in Sokoto State/State Primary Health Care Development Agency. Informed consent was obtained from the health workers before recruitment. Strict confidentiality was maintained regarding the workers' identity.
Results All the 182 questionnaires administered were completed and used for analysis giving a response rate of 100%.
Socio-demographic characteristics of respondents
The participants were aged 20–58 years (mean 32.04 ± 8.52) and majority (80/182; 44.0%) were in their second decade while (71/182; 39.0%) were in their third decade. Most of the participants were females 116 (63.7%) and were married 119 (60.4%). The predominant cadre were CHEWs (86/182; 47.3%), followed by Junior CHEWs (JCHEWs) (40/182; 22.0%) and nurses and midwives (46/182; 25.3%). Majority (135/182; 74.2%) had been in practice for less than a decade with a median duration of 5 years (interquartile range = 8.0 years), as shown in [Table 1]. The different cadres were distributed among the four LGAs (Σ2 = 5.98, P = 0.9), with the lowest number being CHOs.
Distribution of overall knowledge according to socio-demographic characteristics
Those aged 40–49 years (57.9%) and those who had practiced from 10 to 19 years (60.6%) constituted a higher proportion of those with adequate knowledge. Females (64.7%) and those who did not have training (69.9%) were higher among the proportion of those with inadequate knowledge. However, this was only significant for length of practice (X2 = 8.38, P = 0.015) and attendance at a training (X2 = 7.92, P = 0.004), as shown in [Table 2]. The cadre with the highest proportion of adequate knowledge was the CHOs (5/10; 50%) and the lowest among CHEWS (31/86; 36%), while the LGA with the highest proportion of respondents with adequate knowledge was Dange Shuni LGA (23/49; 46.9%).
Table 2: Distribution of overall knowledge on the cause, risk factors, symptoms, complications, and treatment of sore throatPredictors of adequate knowledge of prevention of rheumatic heart disease
After logistic regression to ascertain the predictors of good knowledge, the two parameters, lenght of practice more than 10 years and attendance at a training remained significant predictors of adequate knowledge among the respondents. For years of service, the adjusted Odds ratio was 2.52, signifying that those with a longer duration of service, more than 10 years, were 2.5 times more likely to have better knowledge. While for the exposure to training the (Adjusted odds ratio [aOR]) was 0.43, signifying that those who did not have a training were 57% more likely to have inadequate knowledge [Table 3].
Table 3: Predictors of good knowledge to the prevention of rheumatic heart disease among respondentsAttitude of respondents toward pharyngitis treatment and prevention of acute rheumatic fever and rheumatic heart disease
The distribution of responses shown in [Table 4] highlights that most of the respondents were in agreement with the assertions of examining the throat of children with complaints (176/182; 94.7%) and antibiotic treatment of pharyngitis (134/182; 84.6%). However, about a quarter of them (42/182; 23.1%) thought antibiotics did not have a role in preventing RHD.
Table 4: Attitude of respondents toward pharyngitis treatment and prevention of acute rheumatic fever and rheumatic heart diseaseDistribution of practice grading according to sociodemographic characteristics
The proportion of those with good practice was higher among those aged 40–49 years of age (11/19; 57.9%), male health workers (39/66; 59.1%), lenght of practice of 10–19 years (18/33; 54.5%), though it was only significant for gender (ꭓ2 = 4.78, P = 0.03). The proportion of those with poor practice was high among the CHOs (31/46; 67.4%; P = 0.09) and those with negative attitude (11/14; 78.4%; P = 0.04). This is shown in [Table 5].
Table 5: Distribution of practice of treatment of sore throat and acute rheumatic fever by the respondents' sociodemographic variables, knowledge and attitude to the prevention of rheumatic heart diseasePredictors of good practice of rheumatic heart disease prevention among the respondents
After logistic regression to ascertain the predictors of good practice, the two parameters, male gender, and negative attitude remained predictors of practices toward RHD prevention among the respondents. For attitude grade, the adjusted odds ratio was 3.87, signifying that those with negative attitude were 3.8 times more likely to have poor practice. While for gender, the (aOR) was 0.41, implying that males were 59% more likely to have good practice [Table 6].
Table 6: Predictors of good practice to the prevention of rheumatic heart disease among respondentsFocus group discussion
Knowledge of rheumatic heart disease prevention
All the respondents agreed that pharyngitis was a common problem that they encountered in their practice in the community, predominantly among under-five children.
Many of the respondents felt viral pharyngitis was more common than bacterial pharyngitis and was more associated with complications. When asked of the association with heart disease; one of them said,
001: “I once experienced such in a private hospital, they had this child with a virus affecting the throat and led to another problem in the heart.”
It was deduced that they thought sore throat infection later resulted to pneumonia and not heart disease (ARF or RHD) which they were all unaware of.
Attitude of rheumatic heart disease prevention
On whether they thought they should examine the pharynx of children, a few of them attested to being able to do it but with the right equipment.
004: “We need higher qualified trainers, we need to be updated to new methods of doing it to leave the outdated one, also we need more training in the laboratory aspect.”
Practice of rheumatic heart disease prevention
“We used to see them frequently, but since the COVID-19 Pandemic, they come less now. In the community, we realized that they are afraid it may be called COVID in the hospital.”
On whether they thought children should receive antibiotics for pharyngitis, many responded in the affirmative. However, a few responded thus,
003: “By observing the symptoms, you can differentiate them whether to give antibiotics”
On being asked whether they examine the pharynx and their findings. Some responded in the affirmative and their observations were thus,
004: “Observation of white patches in the throat,”
“Continuous vomiting,”
“Continuous pouring of saliva by the child”
“Throat almost closing, may look reddish, whitish or yellowish”
“We do not take throat swab because no facilities to do so”
When asked if they see children with symptoms suggesting ARF, some answered in the affirmative but attributed such symptoms to malaria and referred the patient if there was no improvement.
About the antibiotics, they prescribed for pharyngitis went thus,
“We usually give Amoxycillin. It is in the standing order”
“I usually give Cefuroxime”
“In our facility, we usually give Erythromycin or Azithromycin because they respond more to it than Amoxycillin”.
There was unanimity in their responses on the duration of treatment which was either 3 days or 5 days. Few gave for a longer duration and opined many did not return for follow-up or referral.
Overall, findings from their practices confirmed they were unaware of either primary (appropriate identification and treatment of bacterial pharyngitis) or secondary prevention (awareness and administration of benzathine penicillin injection) of RHD.
Discussion Among the health workers in this study, knowledge of GABHS as a cause of pharyngitis was limited in, as only 26.9% knew that Streptococcus was a bacterial causative agent of pharyngitis. This was low compared to the 60.6% obtained among primary health-care workers in a study in Tanzania.[16] This disparity could be accounted for by the presence of a higher cadre of officers in their study, however, inquiry to the specific name of the organism was not made in that study. Similarly, in a study from Zambia, among teachers who served as school health officers, the awareness of the bacterial cause was also low, implying the need for more engagement at the community and schools being a predominant problem of school-aged children.[25] Streptococcal organism is a specific cause of ARF and subsequent RHD and this needs to be known at all levels of the health workforce to encourage steps to ensure its elimination.
On the association between bacterial sore throat and heart disease, over half of the respondents were unaware of ARF (a major complication of bacterial pharyngitis); however, a larger proportion (79.7%) said they were aware of the association with heart disease which was higher than that reported by Manase where 73.1% of health workers were aware of this association.[16] However, more insight into this finding from this study was gotten from the FGD as all the health workers who participated admitted that they were not really aware of the complications of ARF and RHD but misconstrued “heart disease” to imply “chest infection” as pharyngitis being an upper respiratory infection can be followed by lower respiratory infection in its natural history.[26] This is an aspect on which they need specific training and possible curriculum reviews.
Majority selected amoxycillin which was confirmed to be the recommended first-line treatment stated in the National Standing Orders for CHOs and CHEWs.[27] This was stated during the FGD and confirmed by the researcher. However, penicillin which is the first-line recommended antibiotic, was selected by only 26.9% of them compared to over 90% of health workers in another study.[16] About 30% also selected drugs that were not actually recommended for pharyngitis, such as Gentamicin and Flagyl and this contributed to the low level of knowledge of treatment amongst the respondents.
The predictors of good knowledge of RHD prevention were years of practice and attendance at trainings. This was also evident in a similar study by Manase, where the older workers and higher cadre health workers had better knowledge of prevention compared to the lower cadre clinical assistants.[16] In this study, a similar pattern was seen as the higher cadre of nurses and CHOs accounted for a higher proportion of those with adequate knowledge than the CHEWs. They also had a longer duration of service. This finding is also corroborated by findings in Sudan by Osman on the improvement in knowledge after training the medical officers.[17] Ensuring continuous education postgraduation from school would also help the correlate lecture contents with practical reality on the job. It was seen in this study that most respondents got their source of information from their student lectures and colleagues.[28]
Attitude score for the respondents was mainly positive; however, more than a quarter of the respondents did not think their practice bordered on the prevention of heart disease in children, which is a significant proportion. Similarly, 17% did not see the need of referral of cases with fever and joint pains due to suspicion of ARF. This implies low awareness of assessing the risks of acquired heart disease in children. Corroborating this fact is a case report of an Fijian adolescent by Steer[29] who was being regularly seen for 2 years at a community health facility with a diagnosis of pneumonia and asthma till one of the staff nurses attended a training concerning RHD and diagnosed her with RHD when she presented very ill and died shortly after the correct diagnosis was made. In this study, those with better knowledge grades also had a better attitude toward the treatment of sore throat and prevention of heart disease.
Appropriate practices in diagnosing bacterial pharyngitis and appropriate treatment start with a high index of suspicion in enquiring about symptoms of pharyngitis in a febrile child, of which a large proportion (91%) admitted they do. About 77% examine the pharynx of suspected cases; however, this was done infrequently in more than half of the cases. Findings from the FGD also confirmed poor practice and a lack of requisite knowledge and tools to perform this appropriately. A large proportion prescribed antibiotics for cases of pharyngitis without differentiating clinical features of viral or bacterial pharyngitis. An abysmally low proportion prescribed the drug of choice, oral penicillin V, for the treatment of pharyngitis, which was only in 41.4%, while 79.6% and 21.6% of the respondents prescribed the extended-spectrum aminopenicillins as amoxycillin and amoxyclavulinic acid.[30] The reason could be due to a lack of awareness and exposure to continuing medical education during their practice, as analysis of the determinants of good practice revealed that those who admitted to receiving a training had better practice grading though not significant. In a similar study conducted in Tanzania, about 90% were aware of the drug of choice, but their practice was not assessed.[16] It was also seen that negative attitude was significantly associated with poor practice among the respondents, even though it did not attain statistical significance on logistic regression. This exposes the need to bolster health workers' confidence in the system and their practice for better output on the health of the community. This was typified in the study from Uganda, where the health workers admitted that there was not much attention given to RHD when compared to HIV. They also lamented on lack of requisite skills and materials, which made them feel they see the cases but miss them due to the lack of diagnosis.[31]
The only significant predictor of good practice was the male gender and this was also evident during the conduct of the FGD as they responded more positively to the prompts given. In a study in Uganda by Musoke where an analysis of the gendered division of labor among community health workers was done, the males were involved in manual work and responded faster in patient care during emergencies both within and outside the hospital compared to females.[32] Given the larger number of female health workers, more support and mentoring may be required for them.
Conclusions The knowledge on the prevention of RHD was inadequate in two-thirds of the respondents; this was more pertaining to the complications of bacterial pharyngitis and its relation to RHD. Length of the practice of more than 10 years and attending training were predictors of good knowledge of preventive practices. The attitude of the respondents was positive in the majority.
The practice of the respondents was mainly inadequate and overall; more insight was deducted from the findings on the qualitative survey (FGD). Majority did not examine the pharynx of affected children and lacked the requisite knowledge to distinguish bacterial and viral pharyngitis. The materials to examine the pharynx and expertise in this regard were lacking. Less than half of them prescribed the recommended first line of treatment and they were totally unaware of secondary prophylaxis. The predictor of good practice was the male gender.
Recommendations Due to the inadequacies in the knowledge of primary health care workers on the prevention of RHD, it is recommended that the stakeholders of Primary Health Care in the Federal Ministry of Health, National Primary Health Care Development Agency and Community Health Practitioners Registration Board should delegate members to review their training curriculum in respect with knowledge of pharyngitis, ARF and RHD and regular on the job training in line with the tertiary hospital or relevant specialists (consultants) within the zones can also be organized.
The national standing orders should also be reviewed to include steps to differentiate bacterial and viral pharyngitis and symptoms and signs of ARF as well as their explicit treatment, referral modes, and documentation. Local protocols can also be drawn up at the health facilities urgently in line with other specialists before that of the National level is actualized. Health workers should be provided with appropriate materials like visual aids to assist in the diagnosis of pharyngitis, rapid diagnostic kits and facilities for gram staining. Drugs such aspenicillin V and injectable benzathine penicillin should be made available for high index cases due to poor follow up.
Acknowledgment
We acknowledge the staff of the Sokoto State Ministry of Health and Sokoto Primary Health care development agency for their support.
Authors contributions
Isezuo Khadijat-conceptualized the topic, wrote the initial draft, and collected the data. Awosan KJ and Ango UM contributed to the concept, and critically reviewed the manuscript, methodology and data collection. Mohammed Y, Sani UM, Waziri UM, Garba BI, Adamu A and Jiya FB also reviewed the manuscript and contributed to the literature searches and analysis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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