World Journal of Cardiovascular Diseases, 2020, 10, 363-378

https://www.scirp.org/journal/wjcd
ISSN Online: 2164-5337
ISSN Print: 2164-5329

Assessment of Knowledge, Attitudes and

Practices (KAP) on Rheumatic Heart Disease
among Senior Medical Students in Cameroon

David Chelo1,2*, Leslie Mbapah Tasha3, Anastase Dzudie Tamdja4, Clovis Nkoke3,
Denis Georges Tewafeu3, Nelson Njedock4, Samuel Kingue4
1
Mother and Child Center, Chantal BIYA Foundation, Yaoundé, Cameroon
2
Department of Pediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
3
Department of Internal Medicine, University of Buea, Buea, Cameroon
4
Department of Internal Medicine, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroun

How to cite this paper: Chelo, D., Tasha, Abstract

L.M., Tamdja, A.D., Nkoke, C., Tewafeu,
D.G., Njedock, N. and Kingue, S. (2020) Background: Rheumatic heart disease (RHD) is the commonest cause of val-
Assessment of Knowledge, Attitudes and vular heart disease in low and middle-income countries (LMICs). The low
Practices (KAP) on Rheumatic Heart Dis- cardiologist to patient ratio leaves a big challenge of RHD prevention and
ease among Senior Medical Students in
Cameroon. World Journal of Cardiovascu-
management to general practitioners in Cameroon. This makes it important
lar Diseases, 10, 363-378. to assess the aptitude of senior medical students who are doctors-to-be on
https://doi.org/10.4236/wjcd.2020.106035 RHD. This could thus give a base on which to increase awareness and de-
crease the burden of the disease. Therefore, we sort to evaluate the know-
Received: February 25, 2020
ledge, attitudes, and practices (KAP) of senior medical students on rheumatic
Accepted: June 25, 2020
Published: June 28, 2020 heart disease. General objective: To determine the level of knowledge, atti-
tudes on rheumatic heart disease, and assess practices towards RHD and its
Copyright © 2020 by author(s) and prevention. Methodology: A cross-sectional study was conducted in four
Scientific Research Publishing Inc.
medical schools in Cameroon for a period of 3 months (from January 1st to
This work is licensed under the Creative
Commons Attribution International April 1st, 2019). The senior medical students were recruited using a structured
License (CC BY 4.0). self-administered questionnaire and electronic forms. Data were entered into
http://creativecommons.org/licenses/by/4.0/ an excel spreadsheet and analysed with IBM SPSS version 25.0 for windows.
Open Access The knowledge level was divided into tertiles (poor, moderate and good)
while the attitudes and practices were divided into poor or good. Association
to KAP was evaluated and Statistical significance was set at P < 0.05. Results:
In total, 509 senior medical students (6th and 7th year) were recruited. The
mean age was 24.6 (SD ± 1.7) with 53.2% of students in the 19 to 24 years-old
range. There were more females (51.7%) and level 6 students (50.1%). Most of
the students had moderate knowledge (58.2%), with good attitudes and prac-
tices on rheumatic heart disease and its prevention. One-quarter of the stu-
dents had good knowledge, attitudes, and practices on rheumatic heart dis-

DOI: 10.4236/wjcd.2020.106035 Jun. 28, 2020 363 World Journal of Cardiovascular Diseases
D. Chelo et al.

ease. Lecture on RHD, history of sore throat and study in faculty of health
science (FHS) was associated with good knowledge, attitudes, and practices
on RHD. Conclusion: Despite having most of the senior medical students
(6th and 7th years) in Cameroon with moderate to good knowledge of RHD,
only a third has an above-average knowledge. There is a modest knowledge
of RHD that could be used as an important foundation upon which to build
RHD educational programs to expand awareness and understanding. Every 1
in 4 senior medical students have good knowledge, attitude and practice on
RHD.

Keywords
Senior Medical Students, Rheumatic Heart Disease, Cameroon, Attitude,
Knowledge, and Practice, General Practitioners

1. Introduction
Cardiovascular disease (CVD) is the leading cause of premature death world-
wide, with the highest occurrence reported in low and middle-income countries
(LMICs) [1]. Rheumatic heart disease (RHD) is one of the most preventable
causes of heart disease in children and young adults worldwide and the most
common cardiovascular disease in people under 25 years of age [2] [3]. Accord-
ing to the 2016 Global Burden of Diseases (GBD) study, there are 33 million
people with rheumatic heart disease(RHD) globally, causing more than 9 million
Disability-Adjusted Life Years (DALY) lost and 275,000 to 345,000 deaths each
year [4] [5] [6] [7]. RHD is thus a serious public health threat to the LMICs [6]
[8]. Amongst cardiovascular diseases (CVD) in children and young adults in Sub
Saharan Africa (SSA), RHD accounts for 17% - 43% with close to 400,000 deaths
annually [9] [10]. The prevalence of echocardiographically diagnosed RHD in
Cameroon ranges from 3.1% to 5.8% in hospital settings [11] [12].
The effective implementation of the ASAP (Awareness, Surveillance, Advoca-
cy and Prevention) program in Africa is limited by barriers such as limited
access to primary health care, the expense of microbiological diagnosis of sore
throat, low index of suspicion of ARF/RHD by physicians and poor community
awareness [13]. There is also limited data on knowledge, attitudes, and practices
(KAP) on RHD in Africa. A study in Zambia on school children with their par-
ents or guardians revealed that 26% received treatment of sore throat without
skilled assessment [14]. A similar study in Sudan on physicians revealed an av-
erage physicians’ knowledge of the prevention of ARF/RHD [15]. To the best of
our knowledge, only one study on RHD awareness has been done in Cameroon;
this revealed a low knowledge level on RHD among the general population at-
tending the Buea Regional Hospital [13]. The later study was hospital-based and
awoke the need for community and health personnel surveys to better under-
stand the level of awareness on this disease.

DOI: 10.4236/wjcd.2020.106035 364 World Journal of Cardiovascular Diseases

 D. Chelo et al.

We do not know whether primary healthcare providers trained in Cameroon

are adequately empowered to contribute to primordial, primary, secondary and
tertiary prevention of RHD in Cameroon to help eradicate the disease [13]. This
is evidenced by the paucity of data on studies done on the KAP of RHD among
physicians and senior medical students in the country [11] [12] [13].
The low cardiologist to patient ratio leaves the burden of rheumatic heart dis-
ease prevention and management to general practitioners in Cameroon. Empo-
wering senior medical students and general practitioners in sensitization, pre-
vention, early detection, and referral will help reduce the disease burden and
improve outcomes. Therefore, knowing the gaps in KAP towards RHD in doc-
tors-to-be will help the health and educational institutions to adjust the training
curriculum to fill these gaps, hence help to eradicate the disease from our setting.
This study had as objectives to assess the knowledge level of senior medical
students on RHD, describe their attitudes towards RHD and its prevention, as-
sess the practices of senior medical students in the prevention of RHD and iden-
tify determinants to the KAP on RHD in senior medical students in four medical
schools in Cameroon.

2. Materials and Methods

2.1. Study Design and Setting
This was a school-based cross-sectional study carried out in 6th and 7th-year
medical students in four medical schools in Cameroon from February to April
2019. These schools are; Faculty of Health Sciences University of Buea (FHS-UB)
in SouthWest region, Faculty of Medicine and Biomedical Sciences University of
Yaounde 1 (FMBS-UY1) in Centre region, Institut superieur de Technologie
Medicale (ISTM) in the Centre region and Institute of Health Sciences, Univer-
site des Montagnes (UdM) in the West region.

2.2. Variables
A self-administered structured questionnaire was used in this study (see Appen-
dix). Participants’ demographic information and information on their know-
ledge, attitudes and practices on Rheumatic heart disease. Using the aide of ei-
ther multiple-choice questions or a three-point categorical scale (Yes, No, Don’t
know), the level of knowledge on risk factors, aetiology, symptoms, complica-
tions, diagnosis, management, and prevention of RHD was tested for each student.
Their attitude towards the prevention of RHD was assessed using a five-point Li-
kert response scale (strongly disagree, disagree, no decision, agree, strongly agree).
Finally, their hypothetical practices on the management and prevention of RHD
and its risk factors were measured using the four-point Likert response scale
(very unlikely, unlikely, likely and very likely). The predictor variables consi-
dered were: Age, gender, grade level, medical school, lectures on RHD, history of
sore throat, history of RHD, seen case of ARF or RHD. The outcome variables
were: knowledge (poor, moderate, good), attitudes (poor or good), and practices

DOI: 10.4236/wjcd.2020.106035 365 World Journal of Cardiovascular Diseases

D. Chelo et al.

(poor or good) on RHD.

2.3. Sampling
A two-stage sampling process was done. Firstly, four out of six medical schools
with students in the clinical years of study were selected by a simple random
sampling technique (balloting). Secondly, a list of students 6th and 7th students
from the schools was established and they were met by convenience on their
school campuses and teaching hospitals during their breaks and free periods.
The students that could not be met physically were phoned and the Google elec-
tronic form was sent to their email addresses. Using Cochran’s formula, the
minimum sample size was estimated at 423 students. A structured questionnaire
adapted from both the standardized KAP questionnaire, from the KAP Manual
published in 2014 by the Food and Agricultural Organization [16] and that used
by Nkoke et al. in assessing the awareness of rheumatic heart disease in the
South-west region of Cameroon [13] was used in this study. The questionnaire
was pretested with 10 participants (five from each level) and necessary adjust-
ments were made. The questionnaire was self-administered and supervised by
three data collectors (7th-year medical students) who collected back the various
responses immediately upon completion by the participants at each study site.
The questionnaire was designed in both English and French. The students used
their first language for a better understanding.

2.4. Data Analysis

Data generated from the study were entered in an excel spreadsheet and ana-
lysed with IBM SPSS version 25 for Windows.
We assessed the knowledge level with a total of 22 questions. The answer YES
= 1, NO = 0, and DO NOT KNOW = 0 points respectively. For the MCQ, the
right answer = 1, and wrong = 0 respectively. The knowledge level score was di-
vided into tertiles, categorized as poor (0 - 8 points), moderate (9 - 13 points)
and good (14 - 22 points). Some questions were analysed individually.
We assessed attitudes using 12 questions with 5-points Likert scale responses.
Globally, attitude was rated as good if total response ≥ 6, poor if response < 6.
Some questions were analysed individually
We assessed practices using 10 questions. Overall, practice was rated as good
if total response ≥ 5 and poor if response < 5. Some questions were analysed in-
dividually
Finally, various determining factors were compared to knowledge, attitudes,
and practices for any statistical significance using the Chi-square test with Odd
ratio (OR) used to determine the strength of the association. A p-Value < 0.05
was considered statistically significant for the observed association.

2.5. Ethical Statement

This study was approved by the administrative authorities of the four medical

DOI: 10.4236/wjcd.2020.106035 366 World Journal of Cardiovascular Diseases

 D. Chelo et al.

schools. The study was explained to all eligible participants in their first language
(English or French) for better understanding. Participants who consented to our
study signed a written consent form. The students benefited from education on
RHD and its prevention after filling the questionnaire. The questionnaire was
anonymous to protect the identity of participants.

3. Results
3.1. Socio-Demographic Characteristics
In all, we reached out to 509 medical students, with a response rate of 90.1%.
The mean age of the students was 24.6 (SD ± 1.7) with 53.2% of students be-
tween the age group 19 to 24 years. There were 263 (51.7%) females and 255
(50.1%) 6th-year students. The distribution of participants per school was as fol-
lows; FHS-UB 169 (33.2%), FMBS-UY1 164 (32.2%), UdM 120 (23.6%) and
ISTM 56 (11.0%).
A prior history of sore throat was reported in 417 (81.9%) students, with 20
(3.9%) students who had been diagnosed with acute rheumatic fever and 3
(0.6%) diagnosed with Rheumatic heart disease.
Students who had had a formal lecture on RHD in either the 4th and or 5th year
made up 87.2% (444) of our study. Of the 444 students, 265 (59.7%) had one
lecture while 179 (40.3%) had two or more lectures. In this study, 238 (46.8%)
had seen at least one case of Acute rheumatic fever, while 171 (33.6%) had seen
at least one case of Rheumatic heart disease.

3.2. Knowledge of Medical Students on Rheumatic Heart Disease

Global knowledge level on rheumatic heart disease
The overall knowledge level of senior medical students on Rheumatic heart
disease was moderate 296 (58.2%), with 159 (31.2%) of students having a good
knowledge level. The mean knowledge score was 11.97 (SD ± 3.0) out of 22.
Knowledge on prevention of RHD
In our study, up to 30.1% of students thought that amoxicillin was the drug of
choice for secondary prophylaxis for acute rheumatic fever or rheumatic heart
disease. The minimum duration of secondary prophylaxis was known by 14.5%
of students, and 84.7% responded that Benzathine penicillin is the drug of choice
for the treatment of sore throat to prevent acute rheumatic fever.
Global attitudes level, and attitudes towards preventive measures on RHD
In this study, 456 (89.6%) students had good attitudes towards rheumatic
heart disease and its prevention. With a mean attitude score of 7.97 (SD ± 1.9)
out of 12.
Global practice level, and practices on RHD prevention
The majority of students had good practices (404, 79.4%) on the prevention of
RHD. With a mean practice score of 6.13 (SD ± 1.9) out of 10.
In this study, 72.7% of students were unlikely to suspect a diagnosis of ARF in
a patient with mono-arthritis and 65.5% were unlikely to admit a patient with

DOI: 10.4236/wjcd.2020.106035 367 World Journal of Cardiovascular Diseases

D. Chelo et al.

suspected ARF. More so, 18.9% of students were unlikely to recommend sec-
ondary prophylaxis with antibiotics in a patient with ARF/RHD and 21.4% were
unlikely to suspect RHD in a patient with a heart murmur. However, 78.6% of
the students were very likely to request echocardiography in patients with ARF.
Furthermore, 69% indicated the willingness to include RHD awareness in their
health campaign programs, and 71.9% indicated a willingness to advocate for
ARF/RHD registry in Cameroon.
Determinants to the Knowledge, Attitudes, and Practices Combined
In our study, 128 (25.1%) participants had good knowledge, attitudes, and
practice combined on RHD. The KAP on RHD was significantly associated with
being a student from FHS-UB [p < 0.001, OR: 3.0 (95% CI: 2.0 - 4.5)], having
had lecture on RHD [p = 0.004, OR: 3.1 (95% CI: 1.4 - 7.0)], and a history of
sore throat [p = 0.015, OR: 2.1 (95% CI: 1.1 - 3.9)] (Table 1).

Table 1. Determinants to good knowledge attitudes and practices of medical students on

rheumatic heart disease.

Variable Percentage (%) OR (95% CI) p-value

Age ≤ 24 years

Yes 23.2 0.8 (0.5 - 1.2) 0.292

No 27.3 1

Female

Yes 25.9 1.1 (0.7 - 1.6) 0.703

No 24.4 1

FHS-UB

Yes 36.6 3.0 (2.0 - 4.5) <0.001*

No 17.9 1

Level 7

Yes 26.8 1.2 (0.8 - 1.8) 0.399

No 23.5 1

Lecture on RHD

Yes 27.3 3.1 (1.4 - 7.0) 0.004*

No 10.8 1

≥2 lectures on RHD

Yes 30.2 1.0 ( 0.7 - 1.6) 0.855

No 24.8 1

History of sore throat

Yes 27.3 2.1 (1.1 - 3.9) 0.015*

No 15.2 1

History of ARF

Yes 15.0 0.5 (0.1 - 1.8) 0.286

No 25.6 1

DOI: 10.4236/wjcd.2020.106035 368 World Journal of Cardiovascular Diseases

 D. Chelo et al.

Continued

History of RHD

Yes 33.3 1.5 (0.1 - 16.6) 0.743

No 25.1 1

Seen case of ARF

Yes 23.9 0.9 (0.6 - 1.3) 0.559

No 26.2 1

Seen case of RHD

Yes 28.1 1.3 (0.8 - 1.9) 0.280

No 23.7 1

*Statistically significant. OR, Odd ratio; CI, Confidence interval; FHS-UB, Faculty of health sciences, Uni-
versity of Buea; ARF, Acute rheumatic fever; RHD, Rheumatic heart disease.

4. Discussion
This is a pioneer study assessing rheumatic heart disease awareness among
medical students in Africa. We report here that only 25% of medical students are
adequately equipped in a combination of knowledge, attitudes and practices to-
wards RHD in Cameroon by their sixth to the seventh year of studies.
Out of three main parameters assessed, knowledge had the lowest proportion
of students to be graded good, accounting for the low overall proportion of stu-
dents who were good in all three parameters.
In this study, less than a third (31.2%) of medical students had good know-
ledge of RHD and ARF. This result is superimposable to the report from Sudan
by Ali and co-workers who found that 30% of practicing physicians had good
knowledge of RHD [17]. Despite having a comparable report with this other
sub-Saharan African study, it still worrying to have only 1 in 3 senior medical
students with above-average knowledge on RHD. It is evident therefore that if
actions were taken to optimise the knowledge of medical students on RHD, this
could be translated in the field to knowledgeable practicing physicians as per
RHD.
Though most students (94.5%) were aware of the correlation between a sore
throat and ARF/RHD, only 14.5% were aware of the minimum duration of sec-
ondary prophylaxis which is 10 years [18]. Manase Maria had similar dispropor-
tionate findings in Tanzania, though a greater proportion of health care provid-
ers (67.8%) knew of the minimum duration of secondary prophylaxis.
Most of our participants (89.6%) portrayed good attitudes towards RHD and
its prevention. The direct and indirect cost of management of RHD and its com-
plications are very high especially in a resource-limited setting like ours [19]
[20]. Therefore, a focus on primordial, primary and secondary prevention is of
utmost importance making use of measures such as: raising disease awareness
through appropriate sensitisation on RHD and reporting of cases, improving so-
cio-economic status, avoiding ineffective locally made home remedies for sore

DOI: 10.4236/wjcd.2020.106035 369 World Journal of Cardiovascular Diseases

D. Chelo et al.

throat cases, consulting a skilled health care professional for appropriate assess-
ment and treatment with antibiotics if need be. Besides, screening school-aged
children for early detection of asymptomatic cases which constitute a high bur-
den of disease [21] and sending for cardiologist follow up and secondary proph-
ylaxis with Benzathine penicillin G should be envisaged.
In our study, close to 20% of participants disagreed on the necessity to treat a
sore throat with antibiotics to reduce the risk of ARF. This is lower compared to
what Tamader et al. in Saudi Arabia reported, where 68.2% of doctors did not
prescribe antibiotics for pharyngitis treatment [22]. This difference may be be-
cause the doctors used clinical decision rule to identify bacterial pharyngitis be-
fore antibiotics use and are more experienced with it. It is well known that most
sore throat is viral and may not require antibiotics. However, antibiotics are the
cornerstone of the prevention of ARF/RHD resulting from Group A streptococ-
cal (GAS) pharyngitis. Recent guidelines recommend the stratification of pa-
tients into high and low risk for ARF to guide the choice of the timing for anti-
biotics. Though the high prevalence of sore throat and ARF in our setting may
explain why most students will give antibiotics for sore throat, we must admit
that the answer to the question is ambiguous since it is patient-dependent and
not on the presence or absence of sore throat dependent.
Though the decision to use home remedies is unconventional and has no
scientific backing, close to half (44.1%) of the students still think that these re-
medies may be useful. Whether or not the students think they could be used
singly or in combination with conventional therapy cannot be answered by this
report and thus require further investigations as this may stem from their per-
sonal experience with these measures.
We found out that most students (79.4%) portrayed good practices towards
RHD prevention and were likely (81.1%) to recommend secondary prophylaxis
with antibiotics in patients with ARF/RHD to prevent ARF recurrence and slow
down RHD progression [23] [24]; suspect RHD (78.6%) in a patient with a heart
murmur; and request echocardiography (78.6%) in patients with ARF to identify
and grade any associated carditis [25] [26]. However, up to 72.1% were unlikely
to suspect a diagnosis of ARF in patients with mono-arthritis and over 65% were
unlikely to admit a patient with suspected ARF as recommended by scientific
societies. This is probably because most of the students had not been exposed to
ARF cases and had thus not considered mastering the management algorithm of
the disease.
Close to 70% of participants were likely to include ARF/RHD awareness in
their health campaign program and were equally likely to advocate for an ARF/
RHD registry in Cameroon-subjects which are in line with the ASAP (awareness,
surveillance, advocacy, and prevention) program of the Pan-African Society of
Cardiology [27]. It is thus deducible that if a continuous emphasis was laid on
this subject in medical schools and continuous medical education, many would
take the lead in projects that would contribute to eradicating the disease from

DOI: 10.4236/wjcd.2020.106035 370 World Journal of Cardiovascular Diseases

 D. Chelo et al.

Sub-Saharan Africa.
Good knowledge was significantly associated with being a student from
FHS-UB. More students from FHS-UB have good knowledge (50.3%) than those
not from FHS-UB with good knowledge (21.8%). This may be because students
from FHS-UB were exposed to at least two formal lectures on RHD in paedia-
trics and internal medicine in their 4th and 5th year respectively while students
from the other schools had only one lecture either in paediatrics or internal
medicine, in 4th or 5th year. In addition, having a formal lecture on RHD was also
significantly associated with good knowledge.
There was a significant association between having a history of sore throat and
a good knowledge of RHD. More students with a history of sore throat had a
good knowledge level (33.3%) than those without a history of sore throat with
good knowledge (21.7%). This could be because students with such exposure are
motivated to study extensively about the disease. Having a formal lecture on
RHD was the only factor significantly associated with good attitudes towards
RHD.
A quarter of the students were graded “good” on combined Knowledge, Atti-
tudes, and Practices assessment on RHD. This was significantly associated with
having a formal lecture on RHD, a history of sore throat and schooling at FHS-
UB.
We provide here one of the first KAP on RHD among medical students in
Cameroon. Nevertheless, our results may have a few limitations. A nonresponse
bias—resulting from the 10% of students who did participate in the study—as
well as reporting and recall bias despite all the measures that were taken to pre-
vent this; including confidentiality, pre-test evaluation of the questionnaire and
sufficient time was given for each responder. Though the students were reas-
sured that it was a simple survey and that valid response were needed, we can
not prove that those who took the online questionnaire all answered without
checking other sources.

5. Conclusion
Attitudes and practices towards rheumatic heart disease can easily be interpo-
lated from the attitude and practice of similar conditions, but adequate know-
ledge may require specific training. Despite having most of the senior medical
students in Cameroon with moderate to good knowledge on RHD, only a third
had an above-average knowledge. Thus, there is a modest knowledge base on
RHD that could be used as an important foundation upon which to build RHD
educational programs to expand awareness and understanding.

Recommendations
The ministry of public health of Cameroon should take steps to establish na-
tionwide awareness programs on RHD by using outlets like media houses, bill-
boards, health campaign programs, etc.

DOI: 10.4236/wjcd.2020.106035 371 World Journal of Cardiovascular Diseases

D. Chelo et al.

The ministry of higher education of Cameroon should emphasize RHD in

the harmonised national curriculum for medical schools like it’s done with other
diseases like HIV/AIDS.
Researchers should conduct further studies to determine if increasing know-
ledge leads to behavioural changes that could help decrease the burden of RHD
in our setting. And to also conduct a KAP on RHD among physicians in Came-
roon.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this pa-
per.

References
[1] Palafox, B., Mocumbi, A.O., Kumar, R.K., Ali, S.K.M., Kennedy, E., Haileamlak, A.,
et al. (2017) The WHF Roadmap for Reducing CV Morbidity and Mortality through
Prevention and Control of RHD. Global Heart, 12, 47-62.
https://linkinghub.elsevier.com/retrieve/pii/S221181601630789X
https://doi.org/10.1016/j.gheart.2016.12.001
[2] Ali, S., Awadallah, H., Al Hamim, A., Al Hussein, H., Al Amin Al Sunni, M.,
Bushari, T., et al. (2018) Handheld Echocardiography for Screening and Control of
Rheumatic Heart Disease Study in Gezira State, Sudan: A Double Approach Model.
Cardiovascular Diagnosis and Therapy, 8, 500-507.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129838
https://doi.org/10.21037/cdt.2018.07.04
[3] Dougherty, S., Khorsandi, M. and Herbst, P. (2017) Rheumatic Heart Disease Screen-
ing: Current Concepts and Challenges. Annals of Pediatric Cardiology, 10, 39-49.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241843
https://doi.org/10.4103/0974-2069.197051
[4] Carapetis, J.R., Beaton, A., Cunningham, M.W., Guilherme, L., Karthikeyan, G.,
Mayosi, B.M., et al. (2016) Acute Rheumatic Fever and Rheumatic Heart Disease.
Nature Reviews Disease Primers, 2, Article No. 15084.
http://www.nature.com/articles/nrdp201584
[5] Sika-Paotonu, D., Beaton, A. and Carapetis, J. (2019) Epidemiology and Global Bur-
den of Rheumatic Heart Disease. Oxford University Press, Oxford.
http://oxfordmedicine.com/view/10.1093/med/9780198784906.001.0001/med-97801
98784906-chapter-65
https://doi.org/10.1093/med/9780198784906.003.0065
[6] Zühlke, L., Karthikeyan, G., Engel, M.E., Rangarajan, S., Mackie, P., Cupido-Katya
Mauff, B., et al. (2016) Clinical Outcomes in 3343 Children and Adults with Rheu-
matic Heart Disease from 14 Low- and Middle-Income Countries: Two-Year Fol-
low-Up of the Global Rheumatic Heart Disease Registry (the REMEDY Study). Cir-
culation, 134, 1456-1466.
[7] Saxena, A. (2016) Task Shifting Rheumatic Heart Disease Screening to Non-Experts.
The Lancet Global Health, 4, e349-50.
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30077-8/abstract
https://doi.org/10.1016/S2214-109X(16)30077-8
[8] Watkins, D.A., Johnson, C.O., Colquhoun, S.M., Karthikeyan, G., Beaton, A., Bukh-
man, G., et al. (2017) Global, Regional, and National Burden of Rheumatic Heart

DOI: 10.4236/wjcd.2020.106035 372 World Journal of Cardiovascular Diseases

 D. Chelo et al.

Disease, 1990-2015. New England Journal of Medicine, 377, 713-722.

https://doi.org/10.1056/NEJMoa1603693
[9] Anthony, J., Osman, A. and Sani, M.U. (2016) Valvular Heart Disease in Pregnancy.
Cardiovascular Journal of Africa, 27, 111-118.
https://doi.org/10.5830/CVJA-2016-052
[10] Sliwa, K., Carrington, M., Mayosi, B.M., Zigiriadis, E., Mvungi, R. and Stewart, S.
(2010) Incidence and Characteristics of Newly Diagnosed Rheumatic Heart Disease
in Urban African Adults: Insights from the Heart of Soweto Study. European Heart
Journal, 31, 719-727. https://doi.org/10.1093/eurheartj/ehp530
[11] Nkoke, C., Lekoubou, A., Dzudie, A., Jingi, A.M., Kingue, S., Menanga, A., et al.
(2016) Echocardiographic Pattern of Rheumatic Valvular Disease in a Contempo-
rary Sub-Saharan African Pediatric Population: An Audit of a Major Cardiac Ul-
trasound Unit in Yaounde, Cameroon. BMC Pediatrics, 16, 43.
https://doi.org/10.1186/s12887-016-0584-z
[12] Nkoke, C., Dzudie, A., Makoge, C., Luchuo, E.B., Jingi, A.M. and Kingue, S. (2018)
Rheumatic Heart Disease in the South West Region of Cameroon: A Hospital Based
Echocardiographic Study. BMC Research Notes, 11, Article No. 221.
https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-018-3341-6
https://doi.org/10.1186/s13104-018-3341-6
[13] Nkoke, C., Luchuo, E.B., Jingi, A.M. and Makoge, C. (2018) Rheumatic Heart Dis-
ease Awareness in the South West Region of Cameroon: A Hospital Based Survey in
a Sub-Saharan African Setting. PLoS ONE, 13, e0203864.
[14] Musuku, J., Lungu, J.C., Machila, E., Jones, C., Colin, L., Schwaninger, S., et al.
(2017) Epidemiology of Pharyngitis as Reported by Zambian School Children and
Their Families: Implications for Demand-Side Interventions to Prevent Rheumatic
Heart Disease. BMC Infectious Diseases, 17, 473.
https://doi.org/10.1186/s12879-017-2563-x
[15] Osman, G.M., Abdelrahman, S.M.K. and Ali, S.K.M. (2015) Evaluation of Physi-
cians’ Knowledge about Prevention of Rheumatic Fever and Rheumatic Heart Dis-
ease before and after a Teaching Session. Sudanese Journal of Paediatrics, 15, 37-42.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958660
[16] Fautsch Macías, Y. and Glasauer, P. (2014) Guidelines for Assessing Nutrition-Re-
lated Knowledge, Attitudes and Practices. Food and Agriculture Organization of the
United Nations. http://www.fao.org/family-farming/detail/fr/c/284518
[17] Ali, S., et al. (2018) Handheld Echocardiography for Screening and Control of
Rheumatic Heart Disease Study in Gezira State, Sudan: A Double Approach Model.
Cardiovascular Diagnosis and Therapy, 8, 500-507.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129838/pdf/cdt-08-04-500.pdf
[18] Carapetis, J., et al. (2012) The Australian Guideline for Prevention, Diagnosis and
Management of Acute Rheumatic Fever and Rheumatic Heart Disease (2nd Edi-
tion).
[19] North, D.A., Heynes, R.A., Lennon, D.R. and Neutze, J. (1993) Analysis of Costs of
Acute Rheumatic Fever and Rheumatic Heart Disease in Auckland. New Zealand
Medical Journal, 106, 400-403. http://europepmc.org/abstract/med/8377955
[20] Watkins, D.A., Mvundura, M., Nordet, P. and Mayosi, B.M. (2015) A Cost-Effec-
tiveness Analysis of a Program to Control Rheumatic Fever and Rheumatic Heart
Disease in Pinar del Rio, Cuba. PLoS ONE, 10, e0121363.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0121363
https://doi.org/10.1371/journal.pone.0121363

DOI: 10.4236/wjcd.2020.106035 373 World Journal of Cardiovascular Diseases

D. Chelo et al.

[21] Yadeta, D., et al. (2016) Prevalence of Rheumatic Heart Disease among School
Children in Ethiopia: A Multisite Echocardiography-Based Screening. International
Journal of Cardiology, 221, 260-263.
https://www.internationaljournalofcardiology.com/article/S0167-5273(16)31242-6/a
bstract
[22] Aloofy, T.A., et al. (2017) Public Knowledge and Practice of Sore Throat Manage-
ment among Visitors of Primary Care Clinic in Riyadh, Saudi Arabia. Journal of
Advances in Health and Medical Sciences, 3, 1-8.
https://doi.org/10.20474/jahms3.1.1
http://www.tafpublications.com/platform/Articles/full-jahms3.1.1.php
[23] Kevat, P.M., et al. (2017) Adherence to Secondary Prophylaxis for Acute Rheumatic
Fever and Rheumatic Heart Disease: A Systematic Review. Current Cardiology Re-
views, 13, 155-166. https://europepmc.org/articles/pmc5452151?pdf=render
https://doi.org/10.2174/1573403X13666170116120828
[24] Ralph, A.P., et al. (2016) Improving Delivery of Secondary Prophylaxis for Rheu-
matic Heart Disease in Remote Indigenous Communities: Study Protocol for a
Stepped-Wedge Randomised Trial. Trials, 17, 51.
https://trialsjournal.biomedcentral.com/track/pdf/10.1186/s13063-016-1166-y
[25] Rémond, M., Atkinson, D., White, A., Brown, A., Carapetis, J., Remenyi, B., et al.
(2015) Are Minor Echocardiographic Changes Associated with an Increased Risk of
Acute Rheumatic Fever or Progression to Rheumatic Heart Disease? International
Journal of Cardiology, 198, 117-122. https://doi.org/10.1016/j.ijcard.2015.07.005
[26] Beaton, et al. (2012) Echocardiography Screening for Rheumatic Heart Disease in
Ugandan Schoolchildren. Circulation, 125, 3127-3132.
https://doi.org/10.1161/CIRCULATIONAHA.112.147538
[27] Mayosi, B.M. (2016) National Rheumatic Fever Week: The Status of Rheumatic
Heart Disease in South Africa. South African Medical Journal, 106, 740-741.
http://www.samj.org.za/index.php/samj/article/download/11253/7512

DOI: 10.4236/wjcd.2020.106035 374 World Journal of Cardiovascular Diseases

 D. Chelo et al.

Appendix: Data Collection Questionnaire

SECTION 1: DEMOGRAPHIC INFORMATION
1) Last two digits of phone number_____
2) Age_____
3) Gender: a) male b) female
4) Grade level: a) level 4 b) level 5 c) level 6 d) level 7
5) Faculty: a) FHS-UB b) FMBS-UY1 d) ISTM e) UDM
6) Marital status: a) single b) married c) divorced d) widowed
7) Nationality: a) Cameroonian b) Foreign (specify)___________
SECTION 2: PAST MEDICAL HISTORY
8) Have you ever had a sore throat? a) yes b) no c) don’t know
9) Have you ever been diagnosed with acute rheumatic fever: a) yes b) no c)
don’t know
10) Have you been diagnosed with rheumatic heart disease? a) yes b) no c)
don’t know
11) Have you had formal lectures on Rheumatic heart disease? a) Yes b) no c)
don’t know.
If no, skip question 12
12) For how many semesters? a) 1 b) 2 c) 3 d) more than 3
13) Have you ever seen a patient with acute rheumatic fever? a) yes b) no c)
don’t know
14) Have you ever seen a patient with rheumatic heart disease? a) Yes b) no. c)
don’t know
SECTION 3: KNOWLEDGE ON RHEUMATIC HEART DISEASE (answer
by yes, no, I don’t know, or mark the right answer).
15) What causes rheumatic heart disease?
a) Age b) scarlet fever b) acute rheumatic fever d) virus e) don’t know
16) What is the clinical syndrome of acute rheumatic fever?
a) Sydenham chorea, carditis, erythema nodosum, arthritis, subcutaneous
nodules.
b) Sydenham chorea, carditis, erythema marginatum, arthritis, subcutaneous
nodules.
c) Sydenham chorea, carditis, erythema nodosum, arthralgia, subcutaneous
nodule
e) Don’t know
17) Can a sore throat cause heart disease? a) yes b) no c) don’t know.
18) If yes, which germ is responsible? a) virus b) staphylococcus c) strepto-
coccus d) group A streptococcus e) don’t know
19) Which strain of the germ is implicated? a) L protein b) N protein c) M
protein d) P protein e) don’t know
20) What is the duration from a sore throat to the onset of acute rheu-
matic fever?
a) 5 days b) 1 to 2 weeks c) 1 month d) 2 months e) don’t know

DOI: 10.4236/wjcd.2020.106035 375 World Journal of Cardiovascular Diseases

D. Chelo et al.

21) Within which time range does the treatment of sore throat have to be
initiated to reduce the risk of acute rheumatic fever?
a) 14 days b) 21 days c) 9 days d) 30 days e) don’t know
22) Which treatment is appropriate for a sore throat to prevent acute
rheumatic fever and rheumatic heart disease?
a) Benzathine penicillin G b) vancomycin c) azithromycin d) acyclovir e)
don’t know
23) Carditis in acute rheumatic fever most often persists with the resolu-
tion of other symptoms. a) yes b) no c) don’t know
24) Rheumatic heart disease can occur without prior evident acute rheu-
matic fever.
a) Yes b) no c) don’t know
25) Which lesion is always associated with carditis in a patient with acute
rheumatic fever? a) erythema marginatum b) subcutaneous nodules c) con-
junctivitis d) don’t know 1
26) Can indolent carditis alone fit the criteria for the diagnosis of acute
rheumatic fever?
a) Yes b) no c) don’t know
27) Patients with acute rheumatic fever or rheumatic heart disease should
be placed on secondary prophylactic antibiotics. a) yes b) no c) don’t know
If no or don’t know, move to question 31
28) Which is the drug of choice for prophylaxis?
a) Amoxicillin b) penicillin v c) benzathine penicillin d) ceftriaxone e) Don’t
know
29) What is the frequency of prophylactic antibiotics?
a) 2 weekly b) 4 weekly c) 3 monthly d) 6 monthly e) Don’t know
30) A patient should take the prophylaxis for a minimum of?
a) 5 years b) 10 years c) 20 years d) 30 years e) Don’t know
31) What are the complications of rheumatic heart disease?
a) Stroke, atrial fibrillation, heart failure b) deep venous thrombosis, infective
endocarditis, renal failure c) pulmonary hypertension, pneumonia, heart failure,
d) Don’t know
32) Carditis in acute rheumatic fever is treated with?
a) NSAID b) paracetamol c) corticosteroid d) don’t know
33) Which valve is most commonly involved in rheumatic heart disease?
a) Tricuspid b) aortic c) mitral d) pulmonic e) Don’t know
34) The disease presentation in developing countries is most commonly
characterised by?
a) Regurgitation b) stenosis c) don’t know
35) Should some patients with rheumatic heart disease be placed on an-
ticoagulants?
a) Yes b) no c) don’t know
36) One of the management of rheumatic heart disease involves surgery.
a) Yes b) no c) don’t know

DOI: 10.4236/wjcd.2020.106035 376 World Journal of Cardiovascular Diseases

 D. Chelo et al.

SECTION 4: ATTITUDES TOWARDS RHEUMATIC HEART DISEASE

AND ITS PREVENTION
37) Do you think it’s necessary to treat a sore throat with antibiotics?
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
38) Will you recommend everyone with a sore throat to consult a doctor?
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
39) Other home measures appropriate for the management of sore throat.
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
40) Rheumatic heart disease is associated with low-socioeconomic status
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
41) Reducing overcrowding reduces the risk of sore throat
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
42) Acute rheumatic fever and rheumatic heart disease are underreported
in Cameroon.
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
43) Sensitization on rheumatic heart disease is appropriate in Cameroon
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
44) Rheumatic heart disease is well taught in medical schools in Camer-
oon.
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
45) Will you recommend echocardiography in a patient with acute rheu-
matic fever?
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
46) Acute rheumatic fever can present as mono-arthritis.
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
47) Do you recommend screening for rheumatic heart disease in all
medical students?
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
48) Will you recommend cardiologist consultation in all patients with
rheumatic heart disease?
1-Strongly disagree 2-Disagree 3-No decision 4-Agree 5-Strongly agree
SECTION 5: PRACTICES TOWARDS RHEUMATIC HEART DISEASE
AND ITS PREVENTION (answer; answer very unlikely, unlikely, likely, or
very likely)
49) How likely will you consult a doctor when you have a sore throat?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely
50) How likely will you ask someone with a sore throat to seek healthcare?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely
51) How likely will you ask a patient with a sore throat to take a home
prescription?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely
52) How likely will you consider the diagnosis of acute rheumatic fever in
a patient with monoarthritis?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely

DOI: 10.4236/wjcd.2020.106035 377 World Journal of Cardiovascular Diseases

D. Chelo et al.

53) How likely are you not to admit a patient with suspected acute rheu-
matic fever?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely
54) How likely are you to request an echocardiogram in a patient with
acute rheumatic fever?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely
55) How likely are you to suspect rheumatic heart disease in a patient
with a heart murmur?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely
56) How likely are you to recommend for secondary prophylaxis in a pa-
tient with acute rheumatic fever or rheumatic heart disease?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely
57) How likely are you to include the awareness of rheumatic heart dis-
ease in your health campaign programs?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely
58) How likely are you to advocate for the establishment of a rheumatic
heart disease registry in Cameroon?
1-Very Unlikely 2-Unlikely 3-Likely 4-Very Likely

DOI: 10.4236/wjcd.2020.106035 378 World Journal of Cardiovascular Diseases