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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Glob Health . 2026 Apr 9;11(4):e018791. doi: 10.1136/bmjgh-2024-018791 Search in PMC Search in PubMed View in NLM Catalog Add to search Implementation and evaluation of a pragmatic community streptococcal treatment programme to improve rheumatic heart disease primary prevention in Uganda Emma Ndagire Emma Ndagire 1 Uganda Heart Institute, Kampala, Uganda Find articles by Emma Ndagire 1, ✉ , Joselyn Rwebembera Joselyn Rwebembera 1 Uganda Heart Institute, Kampala, Uganda Find articles by Joselyn Rwebembera 1 , Gloria Kaudha Gloria Kaudha 1 Uganda Heart Institute, Kampala, Uganda Find articles by Gloria Kaudha 1 , Jafesi Pulle Jafesi Pulle 1 Uganda Heart Institute, Kampala, Uganda Find articles by Jafesi Pulle 1 , Miriam Nakitto Miriam Nakitto 1 Uganda Heart Institute, Kampala, Uganda Find articles by Miriam Nakitto 1 , Juliet Alepere Juliet Alepere 1 Uganda Heart Institute, Kampala, Uganda Find articles by Juliet Alepere 1 , Jane-Liz Nambogo Jane-Liz Nambogo 1 Uganda Heart Institute, Kampala, Uganda Find articles by Jane-Liz Nambogo 1 , Ndate Fall Ndate Fall 2 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA Find articles by Ndate Fall 2 , Amy Scheel Amy Scheel 3 Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA Find articles by Amy Scheel 3 , Sarah de Loizaga Sarah de Loizaga 2 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA Find articles by Sarah de Loizaga 2 , McCall Miller McCall Miller 2 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA Find articles by McCall Miller 2 , Mucunguzi Atukunda Mucunguzi Atukunda 1 Uganda Heart Institute, Kampala, Uganda Find articles by Mucunguzi Atukunda 1 , Rachel Sarnacki Rachel Sarnacki 4 Children's National Hospital, Washington, DC, USA Find articles by Rachel Sarnacki 4 , Nanhua Zhang Nanhua Zhang 2 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA 5 University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Find articles by Nanhua Zhang 2, 5 , Nicholas J Ollberding Nicholas J Ollberding 2 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA 5 University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Find articles by Nicholas J Ollberding 2, 5 , Craig Sable Craig Sable 6 Ochsner Children’s Hospital, New Orleans, Louisiana, USA Find articles by Craig Sable 6 , Ganesan Karthikeyan Ganesan Karthikeyan 7 All India Institute of Medical Sciences, Delhi, India 8 Translational Health Science and Technology Institute, National Capital Region, Faridabad, Pali, Haryana, India Find articles by Ganesan Karthikeyan 7, 8 , Emmy Okello Emmy Okello 1 Uganda Heart Institute, Kampala, Uganda Find articles by Emmy Okello 1 , Andrea Beaton Andrea Beaton 2 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA 5 University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Find articles by Andrea Beaton 2, 5 Author information Article notes Copyright and License information 1 Uganda Heart Institute, Kampala, Uganda 2 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA 3 Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA 4 Children's National Hospital, Washington, DC, USA 5 University of Cincinnati College of Medicine, Cincinnati, Ohio, USA 6 Ochsner Children’s Hospital, New Orleans, Louisiana, USA 7 All India Institute of Medical Sciences, Delhi, India 8 Translational Health Science and Technology Institute, National Capital Region, Faridabad, Pali, Haryana, India Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. Additional supplemental material is published online only. To view, please visit the journal online ( https://doi.org/10.1136/bmjgh-2024-018791 ). EN, JR and JP are fellows on the Impact Program funded by Fogarty International Center and the National Heart, Lung and Blood Institute of the National Institutes of Health under Award Number D43 TW012255. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. All other authors declare no conflict of interest. ✉ Dr Emma Ndagire; [email protected] Received 2025 Jan 7; Accepted 2026 Feb 25; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084804 PMID: 41956705 Abstract Introduction Detection and treatment of streptococcal pharyngitis in children reduces acute rheumatic fever by 70–80%. However, investment in primary prevention is limited in rheumatic heart disease (RHD) endemic countries due to lack of diagnostic capacity. We conducted a pragmatic public health trial ( R heumatic Heart Diseas e Community Str e ptococcal T reatment Program (RESET)) to determine the effect of an integrated group A streptococcal (GAS) education and treatment programme on the echocardiographic burden of RHD among children aged 5–15 years in Uganda. Methods We implemented our interventions within the primary healthcare system of Tororo district, Eastern Uganda, over 2 years. The primary outcome was a reduction in RHD prevalence. Secondary outcomes included improved provider and community knowledge and increased health-seeking behaviour for sore throat. Interventions targeted three key barriers to primary prevention: limited provider expertise in diagnosing and treating GAS pharyngitis, poor uptake of guideline-based treatment and low public awareness of the link between sore throat and RHD. Results There was no significant change in RHD prevalence from baseline (0.66%, 95% CI 0.58% to 0.73%) to 2 years post-implementation (0.61%, 95% CI 0.51% to 0.71%). Primary training was completed by 101 healthcare workers with knowledge scores improving from 55% pre-training to 75% post-training. Secondary training reached 470 providers across 81 facilities. Facility assessments found only one-third met nearly all readiness metrics. Over 2000 community education events reached an estimated 380 000 people. Recognition of sore throat as a serious issue improved with 89% post-campaign identifying its link to heart disease. Health centre logs showed no increase in sore throat presentations over 22 months. Conclusion As the first large-scale integrated primary prevention programme for RHD in sub-Saharan Africa, RESET demonstrated both feasibility of scaling up patient and provider education and implementation challenges in translating education into action. Ongoing research aims to identify care-seeking barriers and co-design a sore throat treatment model tailored to the community’s cultural and contextual needs. Trial registration number NCT05276999 . Keywords: Public Health, Prevention strategies, Global Health WHAT IS ALREADY KNOWN ON THIS TOPIC There is evidence that primary prevention reduces rheumatic fever, but very limited contemporary data from primary prevention programmes in low-income countries, and none from sub-Saharan Africa. WHAT THIS STUDY ADDS This is the first study to implement a large-scale rheumatic heart disease (RHD) primary prevention programme in sub-Saharan Africa. The programme improved community education, awareness and healthcare provider training. However, this did not improve care seeking within the formal public health sector or the burden of RHD. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY Primary prevention is an important part of the toolkit needed to dramatically curb RHD morbidity and mortality globally. More research is needed to develop and test novel approaches, such as the one presented here, ultimately with implementation and dissemination research to understand scalability and adaptability of effective approaches to new contexts. This study has led to several ongoing follow-up studies using community-based participatory research approaches to understand the barriers and facilitators to seeking care within the formal healthcare system and to co-design a sore throat treatment model that culturally and contextually meets community needs. Introduction Rheumatic heart disease (RHD) starts with a superficial group A streptococcal (GAS) infection, most commonly a GAS pharyngitis. Left untreated, 0.3–3% of GAS pharyngitis infections trigger rheumatic fever (RF), a systemic inflammatory condition involving the joints, skin, brain and heart. 1 Between 50% and 80% of those with RF will develop RHD, a chronic valvular heart disease that can lead to heart failure, cardiac arrhythmias and premature death. 2 3 Although the initial attack of RF can lead to severe valvular disease, RHD is most often insidious in nature, with each recurrent RF episode causing further valvular damage. There are two main strategies for RHD prevention. Primary prevention involves the detection and treatment of symptomatic GAS infections in children and reduces the incidence of RF by 70–80%. 4 5 Secondary prevention relies on regular administration of antibiotic prophylaxis to individuals with RF/RHD to prevent recurrent RF. 6 7 In 2004, the WHO published an expert report on RF/RHD that promoted secondary prevention as the most cost and clinically effective global control strategy. 8 However, in RHD-endemic settings, most patients are diagnosed only after they have advanced valvular disease, when the benefit from secondary prevention has passed. 2 For example, in Uganda, data from the RHD registry shows that 75% of children diagnosed with RHD have advanced valvular heart disease at presentation and 30% will die within 9 months of diagnosis. 9 Given the high mortality and morbidity of advanced RHD, it is critical that we direct investment into interventions that target the disease process earlier, at the opportune time of primary prevention. RHD primary prevention can be effective. In the first half of the 20th century, initiation of an RHD primary prevention programme dramatically reduced the rate of acute rheumatic fever (ARF) in the US Army. 10 More contemporary evidence comes from the remarkable success of Costa Rica and Cuba in reducing ARF incidence from 18.6 to 2.5 per 100 000 in Costa Rica, and from 8.0 to 2.0 per 1000 school children in Cuba, by implementing comprehensive programmes incorporating primary prevention strategies emphasising early recognition and prompt treatment of GAS pharyngitis. 11 12 Further, a study reported from China among school children showed that active GAS diagnosis and treatment decreased community GAS carriage and lowered future incidence of GAS pharyngitis, showing potential for improved primary prevention to also confer population protection against GAS pharyngitis over time. 13 The main arguments against investment in primary prevention have been cost and low health-seeking behaviour for sore throat. However, cost is largely driven by the need for bacteriological diagnosis of GAS infection, 1 14 which can be overcome by using clinical decision rules to identify children at the highest risk. Health-seeking behaviour is also a modifiable barrier, with Uganda demonstrating that a school-based educational programme combined with a radio campaign was highly effective at increasing health-seeking among children with possible ARF. 15 There is a need to invest in the development and testing of pragmatic models that balance the concerns around primary prevention with the urgent need to prevent RHD. To test one potential model, we designed a prospective pragmatic public health trial “ R heumatic Heart Diseas e Community Str e ptococcal T reatment Programme” (RESET) to determine the effect of an integrated GAS education and treatment programme to reduce the echocardiographic burden of RHD among children aged 5–15 years in Uganda. We hypothesised that this RHD primary prevention programme would reduce the prevalence of RHD, detected through echocardiographic screening, among children aged 5–15 years, by at least 25% in 2 years. Secondary outcomes included improvement in healthcare worker knowledge around GAS pharyngitis diagnosis and treatment, adherence to guideline-based care, increased public health awareness about the importance of childhood sore throat, increased health-seeking behaviour for childhood sore throat measured by number of sore throat evaluations at public health facilities, and increased general community knowledge of GAS, RF and RHD. Methods Study design This study was a prospective, pragmatic public health trial to determine the effect of a GAS education and treatment programme integrated into the Ugandan public primary care system. Ethics statement The study was conducted in accordance with Good Clinical Practice guidelines. A six-member advisory board was involved in the design and oversight during the conduct of the trial. The trial was registered on ClinicalTrials.gov, NCT05276999 . Health workers and community members who participated in the knowledge surveys gave informed consent. Trial population Following the principles of a ‘pragmatic trial’ the interventions were overlaid on the background of routine clinical practice with minimal protocol-related constraints. 16 The study was conducted within the infrastructure of the existing health system in Tororo district, which included 101 health facilities at the time of study launch. Tororo district lies approximately 200 km east of the capital city, Kampala. The district has 609 117 residents based on the 2024 census with more than half younger than 15 years. 17 Tororo was selected because the district had no existing RHD control programmes, limiting contamination of our primary study outcome, had a relatively stationary population (compared with a transient urban population) and had long-standing research and community relationships with the Uganda Heart Institute. The non-contiguous but geographically and demographically similar Iganga district (population approximately 500 000) was planned to be used as a control district for this project. Interventions + evaluation Our intervention was designed as a service-oriented plan to be implemented through the primary healthcare structure including the national (public) health and private system. Additional support came from the education system, with participation from schools, teachers, patients and their families, as well as the public. Our intervention focused on three of the more easily rectified impediments to primary prevention, namely, limited expertise of healthcare providers in diagnosing and treating GAS pharyngitis, poor uptake of guideline-based treatments for GAS pharyngitis and low level of public awareness of the importance of treating sore throat and its link to RHD. Healthcare provider trainin g In partnership with the Ministry of Health and the District Health Office of Tororo district, we implemented a mix of training and educational activities within the pre-existing district continuing medical educational system. Education targeted community health workers and frontline providers (nursing assistants, nurses, clinical officers) at all levels of the district healthcare system. Education focused on three main messages: (1) sore throat is important and can lead to RHD, (2) clinical guidelines, namely the Cape Town Clinical Decision Rule, which is the most contextually appropriate clinical decision rule for GAS pharyngitis 18 ( table 1 ), should be used to differentiate those at high and low risk of GAS pharyngitis and (3) providers should follow guideline-based treatment for those suspected of streptococcal pharyngitis, specifically the WHO best practices, also adopted in the Uganda Clinical Guidelines, for primary RHD prevention 19 ( table 2 ). We aimed to communicate these critical messages to all providers in the district within the first 3 months of the intervention period and provided continuing education. Table 1. The Cape Town Clinical Decision Rule for group A streptococcal pharyngitis 18 . Feature Point score Absence of cough 1 Absence of rhinorrhoea 1 Presence of tonsillar swelling 2 Presence of tonsillar exudate 1 Open in a new tab * Treat if score is 2 or higher, published sensitivity 96.6% and specificity 12.4% . Table 2. WHO guidelines for treatment of children at high risk of group A streptococcal pharyngitis 19 . <30 kg ≥30 kg Intramuscular benzathine penicillin G 1 intramuscular injection of 600 000 IU 1 intramuscular injection of 1 200 000 IU Oral penicillin 250 mg by mouth two times a day for 10 days 500 mg by mouth two times a day for 10 days Erythromycin (penicillin allergy) 10 mg/kg by mouth three times a day for 10 days (max 500 mg/dose) 500 mg by mouth three times a day for 10 days Open in a new tab Scheduled trainings included primary educational workshops, with one provider from each of the 101 healthcare facilities sent to a centralised training. An immediate post-training assessment was conducted to assess knowledge gain of primary trainees. These primary trainees were given a training packet with an instructional flipchart and clinical reference posters ( onlinesupplemental files 1 2 ) to take back to their healthcare centre to disseminate learnings through on-site continuing medical education for other providers, including the community healthcare workers that were linked to each facility. This training was to take place within 1 month of the initial training. Additionally, trainees at all stages could ‘opt in’ to receive motivational and educational text messaging that was sent out biweekly to reinforce content and enthusiasm for improving sore throat diagnosis and treatment. These messages were customised after the primary training to focus on re-education of content with the lowest mean scores in the post-assessment. Basic demographic and practice information was collected in an anonymised fashion from primary and secondary trainees. All trainees provided consent. A standardised 20-point knowledge assessment (multiple choice, true/false) was developed to reflect critical knowledge needed to diagnose and treat sore throat. This assessment was given to all primary trainees before and after the initial training session, as well as at one additional follow-up, with one-third of the trainees randomly assigned to either 1 week, 3 months or 6 months post training (approximately 33 per survey point). A research staff member visited each participating healthcare centre to confirm the completion of secondary trainings and to obtain the number of participants to determine uptake. Additional facility-based assessments were conducted at 3 months and 6 months post-training with 32 health facilities randomly selected for inclusion, half at each time point. These visits used a standardised checklist to assess facility readiness to handle cases of childhood sore throat (clinical decision rule and treatment recommendations posted, sore throat log in place, appropriate antibiotics in stock) and staff assessment (two randomly selected clinical staff underwent case-based staff interviews to assess if they knew when to use the clinical decision rule, could apply the clinical decision rule to a case, could identify the link between GAS and RHD and could prescribe appropriate antibiotics for clinical scenario). Finally, with District Health Office approval, all facilities were provided with and asked to keep a sore throat evaluation log. This included data on date of evaluation, child age, sex, score on Cape Town Clinical Decision Rule and treatment given. Quarterly outreach by research staff was conducted to collect data on the number of children 5–15 years who were evaluated for sore throat at each facility, and to compare a child’s score on the decision rule to the prescribed treatment. Unfortunately, uptake of these logs was poor. At month 6, these logs were abandoned due to lack of uptake, and instead four facilities were randomly selected for quarterly review of the Ministry of Health Management Information Systems log, which captures data on every person seen at the facility and their diagnosis. A retrospective and prospective count was used to assess trends in a widely defined group of diseases that could include sore throat, including pharyngitis/sore throat, upper respiratory tract infection or difficulty swallowing. Public health awareness An intensive district-wide public health campaign was implemented in months 3–6 to ensure healthcare worker training was complete and facilities were ready for increased volume of cases. A community advisory board helped to develop the message, campaign logo and slogan ( online supplemental figure A ) and inform the outreach strategies to achieve maximal community penetration. Campaigns continued during months 6–24 but with lower intensity. Strategies for community awareness and outreach included school-based education (integrated into health curriculum, student ambassadors, performance troops), engagement with church leadership (educational workshops, leader messaging), education of parents and patients (educational pamphlets sent out to the community), radio messaging (public health announcements, radio talk shows), community outreach events (health-educators in markets and other populated areas) and wall painting (prominent buildings painted with health messaging). Prior to the campaign, we conducted an anonymous survey of 300 community members at large, through simple random sampling of adults ≥18 years at three geographically diverse community markets. The survey, which we developed for this purpose, contained 20 items, a combination of multiple choice and open-ended questions on sore throat. Some questions were formatted around a 4-point Likert scale, with 1=strongly disagree to 4=strongly agree. Interviewees were asked how likely they would be to recommend different treatment options (home remedy, traditional medicine, formal health evaluation) for a child with 1 of 10 common paediatric conditions in the community (ie, rash, headache, runny nose, fever). The survey also contained five questions assessing if participants have seen or participated in any training around sore throat in children over the past 1 year. This survey was repeated using the same methodology in month 12 of the study to assess post-campaign change in knowledge, awareness and practice. Additional infrastructure investments Additionally, in consultation with the Tororo District Health Office, we also provided support for planning of antibiotic supply, to support the anticipated increased demand secondary to the project. This included providing a buffer stock of medication to the central district stores that could be dynamically redistributed as needed to ensure those seeking care for childhood sore throat were not met with medication stockouts. Patient and public involvement The community was involved with the design of the awareness and educational campaign through a community advisory board and through volunteers who spread the campaign messages to peers at community outreach events and disseminated findings to the community. The community was not directly involved in developing the research question or the intervention. Primary outcome The primary outcome was prevalence of definite RHD, detected through school-based echocardiographic screening at 2 years as compared with baseline. In brief, echocardiographic screening was planned and conducted under the National RHD Registry community outreach programme. Permission for school-based screening was obtained from the District Education Office and from individual school headmasters. A pre-study consultation with the District Education Office in Tororo identified 230 primary schools, across 21 subcounties, serving children between primary one to primary seven. Schools had a mean of 500 students/school, with approximately 115 000 school-aged children in the district. The school register was used to generate a covariate constrained randomisation that sought to achieve balance on school location (eg, subcounty), ownership (eg, public vs private) and size (eg, total enrolment) when randomising schools to undergo screening at either baseline or follow-up. Weights of 100, 10 and 10 were assigned to school location, ownership and size, respectively, to improve balance on the small number of subcounties. A total of 50 000 randomisations were generated with a random scheme selected from the top 10% of optimal randomisations as determined by the balance score. The randomisation was carried out using the cvrall function provided in the cvcrand package (V.0.1.0) in R. Pictorial RHD information pamphlets were used to raise parent and community awareness of RHD screening. Screening teams were staffed to include echo-trained nurses, cardiology trainees, cardiologists and support staff to help manage the registration and flow of students and organise and disseminate results. Screening was planned to average 2750 children per week, or 550 children per day. The screening teams used a handheld Philips (Best, Netherlands) Lumify probe and Android tablets and a standardised echo protocol 20 including black and white and colour parasternal long and apical 4/5 chamber views of the mitral and aortic valve and those with positive screening examinations (mitral regurgitation ≥2.0 cm or aortic regurgitation ≥1.0 cm) were referred for a comprehensive echocardiogram. The parents/guardians of children with positive confirmatory evaluations were invited to a cardiology follow-up clinic, held weekly during the screening period at the district hospital and staffed by a cardiologist from the Ugandan Heart Institute. Comprehensive echocardiograms were conducted on a fully functional echocardiography machine (ie, GE Vivid I/Q). Children who were confirmed to have RHD were enrolled in the national RHD registry, while those with other heart diseases were linked to appropriate care. Sample size and power Our primary outcome was to determine the difference in the echocardiographic prevalence of RHD among children aged 5–15 years in Tororo district measured prior to and 2 years after deployment of our interventional package. We used a two-sample z-test to calculate the difference in the proportion of RHD diagnoses between time points. A 25% reduction in prevalence was chosen to reflect a clinically meaningful reduction in RHD burden and as an assumed conservative estimate of impact based on data from successful programmes in Cuba and the Caribbean demonstrating 50–75% reduction in cases over 5–10 years. 11 12 We assumed a baseline rate of 1% RHD prevalence. For alpha=0.05 (two-sided), we determined that a total of 21 784 children would need to be screened at each time point to achieve 80% power to detect a difference of 25% at follow-up. Since baseline estimates of the prevalence of RHD were not available for the Tororo district, an interim analysis was planned to obtain an estimate of RHD prevalence after 4 weeks of screening. If the prevalence was <1%, the decision would be to forgo screening in the control district (Iganga) and double the number of children screened at baseline in Tororo to improve the statistical power for the primary outcome assessment. Statistical analysis plan Primary outcome Our primary goal was to see whether the rate of RHD in children aged 5–15 years in Tororo District changed 2 years after we introduced our intervention. We measured RHD prevalence at each time point using the proportion of children who screened positive, along with 95% CIs. Because different children were screened at baseline and follow-up, we used a two-sample z-test to compare the proportions and test for any significant difference over time. Secondary outcomes We examined changes in healthcare worker knowledge, readiness to deliver primary prevention and public health knowledge. Data were analysed using descriptive statistics and are presented as medians or means for continuous variables and frequencies with percentages for categorical variables. Results Primary outcome There was no change in RHD prevalence in the district between programme start and at 2 years post implementation. Prior to programme launch, 44 223 children (district prevalence <1% so control district abandoned as planned to double primary district screening), aged 5–15 years, across 120 schools underwent screening between January and March of 2022. Of these, 22 779 (51.5%) were female, median age 11 years (IQR 8–13). An abnormal screen occurred in 653 cases (1.5%) and 598 (91%) attended confirmatory clinic (349 female, 58.5%) for comprehensive echocardiogram. Of these, 291 were confirmed to have RHD (0.66%, 95% CI 0.58 to 0.73%) with 129 definite RHD (0.3%) and 162 borderline RHD (0.4%). At the end of 2 years, 21 818 children, aged 5–15 years, across 43 schools underwent screening between February and March of 2024. Of these, 10 255 (47%) were female, median age 11 years (IQR 8–13). An abnormal screen occurred in 416 cases (1.9%) and 397 (95%) attended confirmatory clinic (161 female, 50.6%) for comprehensive echocardiography. Of these, 133 were confirmed to have RHD (0.61%, 95% CI 0.51 to 0.71%) with 78 definite RHD (0.36%) and 55 borderline RHD (0.24%). Secondary outcomes Healthcare provider training Over 50% (571/1060) of healthcare providers received training. Primary training was attended by 101 healthcare workers, with at least one representative from each of the public health centre facilities (main target of the intervention). Nearly all trainees (94, 93%) completed a pre-workshop evaluation with a median knowledge score of 11 out of 20 (55%, IQR 10–12). Providers initially rated their comfort in diagnosing and treating GAS pharyngitis at 6 of 10 (10 being highest comfort level). An anticipated sharp increase in knowledge was seen post-training, peaking at 1 week. Although there was a decline in the knowledge gained from 1 week to 3–6 months, the median score remained higher than pretraining levels ( figure 1 ). Overall provider comfort in diagnosing and treating GAS pharyngitis increased to 9 of 10 Figure 1. Median scores of healthcare worker primary trainees in assessment of sore throat, guideline-based care and linkage between sore throat and rheumatic heart disease. Although there was a decline in the knowledge gained from 1 week to 3–6 months, the median score remained higher than pretraining levels. Open in a new tab Secondary trainings were completed with 470 providers, 56% female, median age 37 (IQR 30–48), across 81 facilities (100% facility capture for secondary trainings). Of those attending secondary training, 12 were medical officers, 209 nurses, 67 community health workers and the rest clinical and non-clinical facility staff. Median years in practice of clinical staff was 9 years (IQR 4–15 years). Healthcare centre readiness assessments Assessments of health centre readiness for implementation of guideline-based care for sore throats were completed in 32 healthcare centres (30% of all participating) including 24 public facilities (10 Health Center IIs (HC II), 10 Health Center IIIs (HC III), 3 Health Center IVs (HC IV) and 1 district hospital) and 8 private clinics. Facility preparedness metrics were variable. While the clinical decision rule, sore throat log and antibiotic recommendations were locatable in most facilities, very few had these posted in key paediatric clinical areas. Stock-outs of critical primary prevention medications and supplies were also common, with only one-third of facilities having 0–1 readiness metrics missing at time of survey ( table 3 ) Table 3. Measures of healthcare centre readiness (32 health centre assessments). Metric Achieving Cape Town Clinical Decision Rule available 28 (88%) Cape Town Clinical Decision Rule posted in paediatric consultation area 19 (59%) Sore throat log available at the healthcare centre 31 (97%) Sore throat log in a place where children are evaluated 25 (78%) Antibiotic recommendations available to clinicians 27 (84%) Antibiotic recommendations posted in paediatric clinical area 20 (63%) Stock assessment BPG Dilutant 10 mL syringes Penicillin Amoxicillin Erythromycin 50% 59% 63% 53% 38% 53% Facilities with 0–1 stockouts 12 (38%) Facilities with 2–3 stockouts 14 (44%) Facilities with 4+ stockouts 6 (19%) Open in a new tab BPG, benzathine penicillin G. 122 theoretical case-based provider assessments were completed across 29 different facilities (15 of these occurred between months 2 and 4 and 14 occurred between months 12 and 14). Those assessed were 69% female with a median age of 35 years (IQR 25–44 years), and most were nurses (73%). Of these, 91 (75%) correctly identified the Cape Town Clinical Decision Rule as the right tool for assessment of childhood sore throat, 89 (73%) of vignettes were properly identified as either GAS sore throat or non-GAS sore throat and 96 (79%) identified a correct course of treatment. When the diagnosis or diagnostic work-up was incorrect, testing and treatment for malaria were most often cited. Community awareness In total, over 2000 education and awareness events were completed in the community, spread across the 40 subcounties within Tororo district. Approaches included mobile announcements (n=87), work-place events (n=522), radio advertisements and talk shows (n=12), community meetings in trading centres and daily and weekly markets (n=1043), wall-branding (n=22), door-to-door campaigns (n=209) and school-based education (n=190). During outreach events, our team relied on brochures, posters and t-shirt giveaways to increase engagement and retention of knowledge. We estimated that in total, the direct reach (directly attending an event or listening in to a radio programme) of these events was at least 380 000 community members, with indirect reach (someone hearing the message and telling a friend/neighbour/family member) even greater. Community survey on knowledge and attitudes on childhood sore throat included 300 participants prior to community awareness campaigns (median age 33 years (IQR 26–45 years), 39% female), and 300 participants 6 months after campaigns had started (median age 35 years (IQR 27–48 years), 44% female) ( table 4 ). From baseline, there was increased recognition about sore throat being an important problem for children in the community (3.11 vs 3.90 out of 4). Report of passive education (hearing or seeing information on childhood sore throat) increased from 40% to 99% and for active education (taking part in a learning session around childhood sore throat) increased from 25% to 99%. Additionally, post-sensitisation responses to the open-ended response question, “Education on childhood sore throat taught me that…”, identified that childhood sore throat was important (72% of respondents) and that childhood sore throat could lead to heart damage (89% of respondents). Table 4. Community survey results at baseline and 6 months after awareness campaign. 4-point Likert scale questions on childhood sore throat Baseline * (n=300) 6 months after awareness campaign * (n=300) 1. Sore throat is an important problem for children in my community. 3.11 3.90 2. Children who have sore throat should be seen by a traditional medicine provider. 1.46 1.31 3. I know what causes sore throat in children. 1.98 2.51 4. I can take care of a child with sore throat myself at home. 1.66 1.47 5. Untreated sore throat can lead to dangerous complications in children. 3.64 3.78 6. Children should never miss school because of a sore throat. 2.29 2.30 7. Children who have sore throat should be seen by a healthcare worker. 3.79 3.93 8. I am confident that the health centre is prepared to take care of children with sore throat. 3.55 3.87 9. Herbal medications are the most important treatment for sore throat in children. 1.45 1.29 10. It is important to know what caused a child’s sore throat to know how to treat it. 3.71 3.62 Questions on childhood sore throat awareness I have heard or seen messaging about childhood sore throat 119 (40%) 297 (99%) Radio 84 (28%) 223 (74%) Posters 3 (1%) 231 (77%) Billboards/wall painting 0 (0%) 27 (9%) I have received education on childhood sore throat 74 (25%) 297 (99%) Community health workers 19 (6%) 191 (63%) School 16 (5%) 11 (4%) Community forum 12 (4%) 89 (30%) Religious service 6 (2%) 197 (65%) Healthcare centre 32 (11%) 56 (19%) Education on childhood sore throat taught me that (open ended): Formal evaluation of children with sore throat is important 46 (15%) 217 (72%) Sore throat can lead to heart damage 91 (30%) 267 (89%) Open in a new tab * Mean score of a 1–4 Likert scale (1: Strongly Disagree, 2: Disagree, 3: Agree, 4: Strongly Agree). Sore throat presentation Between January 2022 and October 2023 (22 months), review of the Health Information Management System Logbooks from 10 health facilities (4 HCII, 4 HCIII, 2 HCIV) included 72 351 paediatric cases between the ages of 5 and 15 years. Of these, 1498 (2% of all paediatric cases in this age range) included presenting concerns of sore throat or difficulty swallowing, or diagnoses of pharyngitis, tonsillitis or laryngitis. Expanding this to include upper respiratory infections, there were 14 486 presentations (20% of paediatric cases in this age range). There was no significant increase in the number of possible sore throat or upper respiratory tract presentations over the 22 months of community education and awareness campaigns ( online supplemental figure B ). Discussion There is a significant global knowledge gap both for health consumers and health providers on the importance of timely diagnosis and appropriate treatment of streptococcal sore throat for the prevention of RHD. Further, implementation studies to understand how to effectively deliver primary prevention in the lowest resourced contexts are limited, with few countries having established primary prevention programmes. RESET tested one pragmatic model, with notable success in education and awareness but poor translation of knowledge into action and no measurable decrease in RHD prevalence in 2 years. The primary objective of this study, a reduction in the prevalence of RHD detected through echocardiographic screening, was not achieved. Here, it is important to note that the RESET programme was implemented over a relatively short period of time and on the heels of the COVID-19 pandemic that disrupted school attendance and community life for nearly 2 years. It is possible that the lower initial prevalence of RHD, as compared with prior studies in Uganda, 21 22 was partially driven by reduced social interactions in crowded places (schools, etc), with strong global data suggesting decreased streptococcal infections during this period. 23 Further, the time for implementation may not have been long enough to impact RHD prevalence, which was reduced in other successful primary prevention programmes, such as those in Cuba, 11 Guadeloupe and Martinique, over decades. 11 24 These programmes suggest that longer-term investments in primary prevention may be needed, as suggested by a recent modelling study of RHD prevention in the African Union, which also pointed to the use of community health workers, rather than health facilities, as the most cost-effective implementation strategy with potentially also the highest coverage. 24 However, these are middle or high-income countries with less competing infectious diseases, and different strategies may be needed in RHD endemic countries to address these challenges successfully. Community awareness, which reached nearly full saturation, was driven largely by a health literacy campaign designed by the community, through a community advisory board, a strategy that has been successful in Australia and New Zealand. 25 , 27 We also had prior success with this approach around raising awareness and encouraging health-seeking for ARF in Uganda. 15 While this study was not designed to formally assess this difference in outcomes, we can offer some hypotheses based on our experience. ARF is not a diagnosis commonly made within the community, making it less familiar and more likely to be perceived as a serious condition. In contrast, sore throat is widely recognised as a common and relatively minor illness, often managed with self-prescribed treatment. Thus, the barrier to change of health-seeking behaviour may have been greater. Before we conclude that improving health literacy around childhood sore throat did not change behaviour, we must also consider that the community could have acted on this knowledge differently than expected. In fact, while the education and awareness campaign was community-driven, the community was not part of the interventional design. It is quite possible that seeking care at a government healthcare centre for childhood sore throat was not the access point most appropriate and acceptable for the community. For example, the community could have increased care seeking for childhood sore throat but relied on more traditional methods or self-prescribed antibiotics. We are conducting further qualitative research in this community to understand approaches to childhood sore throat and community-based participatory research is ongoing to co-design an RHD primary care intervention that may be more culturally and contextually appropriate for these Ugandan communities. Health provider education and health centre readiness to treat childhood sore throat are important issues in low-resource settings. A prior study in Uganda found that across 402 facilities only 1.5–14% of Ugandan public health staff had received training in management of childhood sore throat. 28 The RESET approach, which used a train-the-trainer model showed modest success in increasing knowledge. Primary trainees who received education directly from expert trainers gained substantial knowledge and confidence and were able to train an average of four additional healthcare providers in the community. Loss of knowledge is common over time, as also demonstrated by Namuyonga et al who reported a similar decline in health workers knowledge of ARF/RHD 6 months post-training in the same district. 29 This finding is also similar to a study by Draiko et al who demonstrated a marked decline in knowledge of health workers 1 year following training on Helping Babies Breathe protocols in South Sudan. 30 Future research and educational approaches should develop and test more innovative educational methods, such as e-learning, mobile health decision tools and educational-bots, as suggested in the recent National Institutes of Health article on research priorities for primary prevention of RHD. 31 Finally, even with the study providing a supplemental supply, and even without the expected increase in demand, many facilities had stock outs of critical antibiotics for RHD primary prevention. This is consistent with a prior study in Uganda which showed that stock of oral amoxicillin and injectable benzathine penicillin, the two first-line drugs for streptococcal sore throat, ranged from 36% to 100% stock across 402 facilities. 28 Solving these supply chain challenges will require diverse stakeholder engagement, as shifting these costs to out-of-pocket expenditures is not affordable for most community members in Uganda. It is already known that current RHD care in Uganda, which should be covered under the public health programme, commonly leads to catastrophic personal expenditure. 32 This study has several limitations. First, we only have administrative data on health-seeking behaviour from a handful of public health facilities. As mentioned, further qualitative work is underway to broaden our understanding of the behavioural impact of the community-based knowledge and awareness programme. Second, the intervention, while based on current scope of practice in Uganda, may not have been acceptable to our target population. This points out the importance of multidisciplinary, community-engaged research to develop health programmes within RHD-affected communities, work that is currently underway in Uganda. Third, as with all studies that occurred during or immediately after the SARS-CoV-2 pandemic, it is impossible to separate out the potential impact of changes in socialisation, exposure to crowding, improved hand hygiene and sanitation, and masking that could have impacted RHD prevalence in the region. In conclusion, delivery of primary prevention in low-income, RHD-endemic settings has proven to be a global challenge. Developing, testing and evaluating novel approaches, such as the pragmatic programme described here, has been identified as a global priority. As the first at-scale, integrated primary prevention programme in sub-Saharan Africa, RESET has both successes and challenges. Ongoing research is focused on understanding health-seeking behaviour for childhood sore throat and on deeper community engagement in co-design, adaptation and innovation in training and continuing education, and multistakeholder engagement to improve the flexibility in the supply chain to ensure essential medication availability. Ultimately, primary prevention is an important part of the toolkit needed to dramatically curb RHD morbidity and mortality globally, and continued research is needed to optimise its potential. Supplementary material online supplemental file 1 bmjgh-11-4-s001.docx (1.7MB, docx) DOI: 10.1136/bmjgh-2024-018791 online supplemental file 2 bmjgh-11-4-s002.docx (196.4KB, docx) DOI: 10.1136/bmjgh-2024-018791 online supplemental file 3 bmjgh-11-4-s003.docx (94.8KB, docx) DOI: 10.1136/bmjgh-2024-018791 online supplemental file 4 bmjgh-11-4-s004.pdf (45.1MB, pdf) DOI: 10.1136/bmjgh-2024-018791 online supplemental file 5 bmjgh-11-4-s005.pdf (11.9MB, pdf) DOI: 10.1136/bmjgh-2024-018791 Acknowledgements We would like to thank all study participants, the research study team and all Tororo district authorities who rendered us support during this study. Footnotes Funding: This research was supported by a grant from Thrasher Research Fund. Provenance and peer review: Not commissioned; externally peer reviewed. Handling editor: Mark G Shrime Patient consent for publication: Not applicable. Ethics approval: This study involves human participants and was approved by (1) Makerere University School of Medicine (Mak-SOMREC-2021-66), (2) Uganda National Council of Science and Technology (HS1580ES2) and (3) Cincinnati Children’s Hospital Medical Center (2021-0026). Participants gave informed consent to participate in the study before taking part. Data availability free text: De-identified participant data will be made available upon reasonable request. Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details. Author note: The reflexivity statement for this paper is linked as an online supplemental file 1. Data availability statement Data are available upon reasonable request. References 1. Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. The Lancet. 2005;366:155–68. doi: 10.1016/S0140-6736(05)66874-2. 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[ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials online supplemental file 1 bmjgh-11-4-s001.docx (1.7MB, docx) DOI: 10.1136/bmjgh-2024-018791 online supplemental file 2 bmjgh-11-4-s002.docx (196.4KB, docx) DOI: 10.1136/bmjgh-2024-018791 online supplemental file 3 bmjgh-11-4-s003.docx (94.8KB, docx) DOI: 10.1136/bmjgh-2024-018791 online supplemental file 4 bmjgh-11-4-s004.pdf (45.1MB, pdf) DOI: 10.1136/bmjgh-2024-018791 online supplemental file 5 bmjgh-11-4-s005.pdf (11.9MB, pdf) DOI: 10.1136/bmjgh-2024-018791 Data Availability Statement Data are available upon reasonable request. 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