Interviewer(s): Interviewer
Interviewee(s): Respondent

Interviewer: So we are at Kajjansi health Centre IV in the clinicians’ office and we want to know ... I am with a health worker here and we are having a discussion on building a case to invest in Rheumatic heart disease in a limited resource setting. Now tell me about yourself; how old are you?

Respondent: I am registered comprehensive nurse and I am 47 years old.

Interviewer: Okay, thank you. Tell me about your qualifications and where you trained from.

Respondent: As I have said, I am comprehensive nurse from Masaka School of Comprehensive Nursing.

Interviewer: That’s where you qualified from!

Respondent: Yes.

Interviewer: When did you qualify?

Respondent: In 1999.

Interviewer: Okay. So how long have you been qualified?

Respondent: Since 1999.

Interviewer: is that 20 or 30 years?

Respondent: it’s like 20 something years.

Interviewer: Okay. So how long have you been working here at Kajjansi Health Centre IV?

Respondent: Its 8 years.

Interviewer: And you are working in OPD?

Respondent: Yes.

Interviewer: How long have you been the in-charge here in the OPD?

Respondent: 8 years.

Interviewer: That’s good. As a nurse, tell me about the demographics of the patients you see here; the patients you see in your practice and the common illnesses you treat, their age group ...

Respondent: We treat the under 5s; they are many. Then the youths and elderly. We see all the age groups.

Interviewer: Okay, so what kind of common illnesses do you usually see?

Respondent: We normally have the respiratory tract infections, malaria, those with wounds, diabetes & hypertension, and those with skin diseases.

Interviewer: So in the age groups, do you usually see the young from 0-5 years, 10-18 and above? What kind of patients do you see? What is the age group that you mostly see?

Respondent: Most of them are children; the under 5s.

Interviewer: So tell me about your training in Rheumatic Heart Disease; have you received any specific training during school?

Respondent: No.

Interviewer: Even during school!

Respondent: No.

Interviewer: When you were in school they never taught anything about Rheumatic Heart Disease?

Respondent: I don’t remember.

Interviewer: Okay. What about after school; did you receive any training after graduation?

Respondent: No.

Interviewer: So you have no idea about Rheumatic Heart Disease?

Respondent: No.

Interviewer: Okay. How many patients of Rheumatic Heart Disease do you often see here in the OPD clinic, maybe in a week or a month?

Respondent: Since we don’t have the investigations, we can’t investigate and say that this one is having a Rheumatic Heart Disease.

Interviewer: So that means you don’t see them here?

Respondent: We don’t.

Interviewer: You don’t! So if a patient came here with Acute Rheumatic Fever which leads to Rheumatic Heart Disease, do you think you would be able to know?

Respondent: No, we can’t differentiate them from these other ... [coughs]

Interviewer: You can’t differentiate them from the other patients?

Respondent: Yes.

Interviewer: So what is your understanding of the causes of rheumatic disease?

Respondent: [Silence]

Interviewer: There are no wrong or right answers.

Respondent: [Giggles]

Interviewer: So just tell me what you know.

Respondent: Maybe one is having heart diseases.

Interviewer: So heart diseases causing Rheumatic Heart Disease?

Respondent: Yes.

Interviewer: Okay, anything else?

Respondent: No

Interviewer: Okay. Are you aware of a link between rheumatic heart disease and sore throat?

Respondent: No.

Interviewer: okay. So what were you taught can be done to prevent or treat Rheumatic Heart Disease?

Respondent: Nothing.

Interviewer: so are there any aspects of rheumatic heart disease management in which you think you need more training?

Respondent: [no response]

Interviewer: Okay like you said you have not received any training both at school and out of school (after graduation), but currently you are the in-charge of OPD and you see very many patients in a day. So do you think there’s any aspect of Rheumatic Heart Disease management in which you need more training?

Respondent: I need training in all; the signs and symptoms, management, how it presents and the prevention.

Interviewer: So you need training in all of it.

Respondent: Yes, I need training in all of the disease.

Interviewer: So what is your understanding about the long term prognosis of RHD?

Respondent: Long prognosis?

Interviewer: Long term prognosis.

Respondent: That it takes time to heal.

Interviewer: okay, it takes time to heal!

Respondent: Yes.

Interviewer: So do you think it heals quickly or it takes long to heal?

Respondent: It takes long.

Interviewer: it takes long to heal! Do you think it ever heals at all or it doesn’t?

Respondent: I think it doesn’t heal.

Interviewer: Okay. Thank you so much. So the next question; tell me about your encounters with a Rheumatic Heart Disease patient. You have you been an in-charge at OPD for 8 years, have you encountered any cases or patient with Rheumatic Heart Disease?

Respondent: I think there’s a patient whose father normally comes here; he comes for Benzathine. I wonder if that was Rheumatic Heart Disease!

Interviewer: How many times does the father come here?

Respondent: He doesn’t come with the patient but he normally comes for the Benzathine that they prescribed from Mulago. When they don’t have it, they come here and if we have them, we give them.

Interviewer: And you inject them?

Respondent: Yes.

Interviewer: What is the age of the patient? Because my next question would be; what is the average age of your Rheumatic Heart Disease patients? Are they working or not, are they in school or not?

Respondent: Personally, I have never seen that patient because the father usually comes and picks the drugs if we have them.

Interviewer: So who injects the patient?

Respondent: They have a special nurse to inject at a nearby place.

Interviewer: So the father comes here at the health Centre IV.

Respondent: Yes, with the prescription from Mulago (Hospital). He tells us “if you have these drugs, you can give me and if you don’t have, I go and buy.”

Interviewer: Then he takes it to the nearby clinic at home?

Respondent: Yes, that’s the only one I remember.

Interviewer: So you have not been in touch with a Rheumatic Heart Disease patient for all the time you have been here?

Respondent: No.

Interviewer: That patient whose father you have seen, are they aware of the link between sore throat, Acute Rheumatic Fever and Rheumatic Heart Disease?

Respondent: I don’t know.

Interviewer: You don’t know.

Respondent: Yes.

Interviewer: Okay. What sort of symptoms does that man describe that the patient presents?

Respondent: Hmm, he didn’t even describe.

Interviewer: He didn’t describe, he just only came for medicine only?

Respondent: Yes.

Interviewer: So which means you don’t know the kind of symptoms these patients present with?

Respondent: No.

Interviewer: Wow! So now you told me that’s the only case you know.

Respondent: Yes.

Interviewer: Then that’s the only case I am going to ask you about. About adherence and follow up, how often does that father come here to get the Benzathine?

Respondent: He can take a month without coming here. I think when he goes to Mulago and gets, he can take some time without coming here.

Interviewer: Okay. So what sort of barriers do those patients commonly state to getting the care they need?

Respondent: The barrier to get treatment?

Interviewer: Yes.

Respondent: Sometimes the drugs are out of stock.

Interviewer: That’s one of the major barriers, anything else?

Respondent: The transport.

Interviewer: Transport from where to where?

Respondent: To where to get the treatment.

Interviewer: Okay. Anything else?

Respondent: No.

Interviewer: So what sort of barriers do you perceive these patients commonly face? As a health worker what kind of barriers do you perceive these patients face in getting the care they need?

Respondent: They take long without being diagnosed and then the disease progresses.

Interviewer: Okay.

Respondent: Because the health workers lack information about those diseases.

Interviewer: So that’s the barrier; the health workers don’t have enough information about the disease, so it becomes barrier to these patients when they come in for care?

Respondent: Yeah.

Interviewer: Okay.

Respondent: Because if the patient comes here with this disease and I personally don’t know the signs and symptoms, I just continue giving antibiotics. Then it takes long to be diagnosed that he’s having a heart disease.

Interviewer: So I am going to ask you about the local health system barriers, administrative wise and leadership wise in the district.

Respondent: Administrative?

Interviewer: Yes, in relation to management and treatment of rheumatic heart disease. Do you think everything is working in accordance to what would be needed to provide health care to these patients at this health Centre? Administrative wise and leadership wise; does the district provide the necessary things to provide health care to those Rheumatic Heart Disease patients?

Respondent: No.

Interviewer: So according to you, what is the health system barrier according to the leadership and administration at the district?

Respondent: Lack of diagnostic equipment like the x-ray; we don’t have them. Most of the health units don’t have those diagnostic equipment.

Interviewer: What about health care funding in general and particularly in RHD? Are you aware of the funding in this unit?

Respondent: No, I am not.

Interviewer: So tell me about the health care workers you have here; their numbers, qualifications, are they able to wait for the patients and provide the proper quality of care?

Respondent: They can provide but most of the time, sometimes the drugs are out of stock and we don’t have them.

Interviewer: Anything else?

Respondent: They lack information.

Interviewer: The health workers lack information.

Respondent: They lack adequate information about those RHD diseases.

Interviewer: Okay. What about medication; when the patients come here, for example, you have talked about that man. Do you have medications like Benzathine penicillin, anti-coagulants and heart failure drugs?

Respondent: No, we don’t have them. We don’t have most of them.

Interviewer: You don’t have them! What about the diagnostics?

Respondent: No.

Interviewer: You don’t have?

Respondent: Yes.

Interviewer: Okay, so tell me about health information or medical records systems; how do you keep your information? How is your health keeping at the unit?

Respondent: We have the Health Information Officer who keeps the out-patients books. He is the one who keeps them.

Interviewer: What about integration between all units; do you have an in- patient unit around here?

Respondent: In maternity.

Interviewer: Only maternity?

Respondent: Yes. At OPD we don’t have in-patients.

Interviewer: Okay. So the record keeping at maternity is different from all the other units?

Respondent: Yes.

Interviewer: Do you have specific registers for specific conditions for example, a register for Acute Rheumatic Fever?

Respondent: No, we don’t have. They are combined.

Interviewer: So how has the local health system enabled your work to become easier to management of patient care?

Respondent: hmm, now how?

Interviewer: Now like in this health system, what motivates you to leave home and come to work? What has the health system made easier for you to be able to provide patients with care?

Respondent: salary.

Interviewer: Only salary?

Respondent: When the drugs are there, I am comfortable.

Interviewer: Okay.

Respondent: But when the drugs are not there, I say, “Go and buy! Go and buy” for everything. It is demotivating.

Interviewer: So if the drugs are there, it motivates you to do your work and when you are paid on time, it also enables you to do your work.

Respondent: Yes.

Interviewer: Okay. So perception of patient outcomes; generally, do you think these patients get the care they need or not?

Respondent: Sometimes, but when things are out of stock, they don’t.

Interviewer: How often do you have stock outs?

Respondent: We can even take a month or three weeks.

Interviewer: About patient safety and quality of care concerns, have you had preventable deaths here at the hospital? A situation where by this patient came here sick but you feel as health worker if you did what you were needed to do, you would have prevented this patient from dying. Have you ever had that scenario?

Respondent: No.

Interviewer: You have not! Do you think patients are dying in the community without presenting to the hospital?

Respondent: They die.

Interviewer: Why?

Respondent: Some can stay in those traditional healers, some may not be having transport to take them to hospitals. So they die in the community.

Interviewer: So in your opinion, what are the most important things Ministry Of Health should do to improve patient outcomes?

Respondent: Providing enough drugs to the hospitals, providing those diagnostic equipment.

Interviewer: Okay. Just that ...

Respondent: And improving referrals like providing ambulances to health units.

Interviewer: Okay. What about training of health workers?

Respondent: And training of health workers.

Interviewer: Okay. Anything else?

Respondent: We talked about drugs?

Interviewer: Yes.

Respondent: Only those.

Interviewer: So we talked about the drugs, ambulances, diagnostic equipment and you also talked about referrals.

Respondent: Yes.

Interviewer: Okay. Thank you so much nurse for your time.

Respondent: you are welcome.