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

Interviewer: Thank you for allowing to speak to us. Just to remind you, there are no right or wrong answers; we just want your opinion and we just want to see how we can improve care for our RHD patients. I will just request you to be frank and share your opinions because the data we are collecting is confidential, and then I will just request you to be a little bit loud. Sometimes we fail to hear people on the ... I have a big voice so I usually hear myself but sometimes I don’t hear ...

Respondent: the voice of the respondent?

Interviewer: Yeah, and mine is not as important as the voice of the respondent in the study.

Respondent: Okay.

Interviewer: So please tell me a little bit about yourself; how old are you sir?

Respondent: I am 50 years old.

Interviewer: Maybe before we do that, let me just mention where we are. Okay. Today is the 8th of November 2019. We are here in the Cardiology room, Mbarara hospital. Please tell a little bit about yourself; how old are you sir?

Respondent: I am 50 years old.

Interviewer: Okay, and then when did you qualify and where?

Respondent: I qualified as a clinical officer in 1997 and I was in service until 2009 when I went back for Medicine which I completed in 2015, then in 2016 I completed my internship and came back to my station and started working later on.

Interviewer: Okay, nice. And then um, so you have been qualified as a clinical officer?

Respondent: Yes.

Interviewer: How many years were those?

Respondent: Before I went for studies, it was 12 years.

Interviewer: 12 years, now as a medical?

Respondent: It’s coming to three and a half years.

Interviewer: And how long have you been working here?

Respondent: For all that period.

Interviewer: all that period you have been working in Mbarara hospital!

Respondent: Yeah.

Interviewer: Okay. When you look at the demographics of the patients practice, what are the common illnesses you usually see by age group? You can say that between this, among the pediatrics ...

Respondent: Okay, um, the commonest mostly in adult patients above 18 years, we commonly have the GI conditions, we have of course ... we have the communicable conditions like the malaria, respiratory tract infections and then in the non-communicable we have Hypertension and Diabetes.

Interviewer: Okay, thank you so much, and then um, tell me about your training in RHD, have you received any specific training on RHD maybe during school.

Respondent: During school of course we study it as one of the conditions but after that I have not had any other additional training specifically.

Interviewer: For RHD!

Respondent: Yeah.

Interviewer: Have you had any CMEs about RHD?

Respondent: CMEs, not really.

Interviewer: Do you think they are important?

Respondent: Yes of course they are important because whatever training you undertake, you get the knowledge and this knowledge is usually applied in the management of patients

Interviewer: so um, have you seen um, in the recent past, have you seen any RHD patients here? Have you worked on any?

Respondent: I have not worked on any in the recent past although I encountered one. It was quite some time back.

Interviewer: When was that? Like how long was the period?

Respondent: It was around 2, 3 years.

Interviewer: 2, 3 years ago? But in the recent years?

Respondent: In the recent years I have not interacted with any.

Interviewer: Those ones that you saw three years ago, how do you describe them? Typically, who are these patients, and were they out patients or in patients? Were they young or old?

Respondent: This one was a middle aged person who had been on care for some time and, of course he presented with an exhibition of the symptoms but he was on care except that he was not regular on his medications and I think that’s why he was getting exaptation of the cardiac symptoms.

Interviewer: okay, so you said by middle age, which age is that?

Respondent: He was around 35years.

Interviewer: And was he an outpatient or inpatient?

Respondent: He came in as an outpatient.

Interviewer: Okay, and um, I am interested in knowing what is your understanding of the causes of RHD?

Respondent: Okay the causes, those that I know of are ...

Interviewer: Or what you were taught.

Respondent: Auto-immune condition which affects the joints and then, because the tissues of the joints are similar to those of the heart, then the heart ends up getting affected also.

Interviewer: Okay, thank you. And then um, are you aware of a link between sore throat and RHD? Are those two related; sore throat and rheumatic heart disease?

Respondent: Yes, because when someone gets a sore throat um, okay of course in most cases the cause is bacterial and being bacterial, the body creates a defense mechanism and those antibodies that are produced as a means of fighting off the infection also affect the heart muscle.

Interviewer: Thank you. And then what were you taught in school that can be done to prevent RHD?

Respondent: Of course when someone gets signs, he has to get um, to seek medical attention in terms of getting treatment quick treatment because when it stays for long, that's when he gets cardiac problems and complications.

Interviewer: okay, and then what were you taught as some treatment options for RHD?

Respondent: Umm, in terms of bacterial infections we give antibiotics which are Penicillins, then because of the inflammation, we can also give steroids and if there are signs of heart failure, then we can give also heart failure drugs.

Interviewer: okay, thank you. Then what is your understanding of the long term prognosis of RHD?

Respondent: um, prognosis, depending on how someone is a compliant to the drugs; if he doesn't adhere to the treatment usually the prognosis is not so good because they usually tend to go into failure and when they go into failure, then it makes there life not pleasurable.

Interviewer: So tell me about your encounters with the patients of RHD? You told me there is one you saw three years ago!

Respondent: Yes.

Interviewer: and um, that was that the last one you saw?

Respondent: Yes.

Interviewer: And you said he was around 35?

Respondent: Around 35 years.

Interviewer: around 35 years old. Okay, did he look like a person who was working? Was he in school, was he not working, typically how was he?

Respondent: okay, he was working but the nature of his work wouldn't be comprised by his condition except when he has exacerbations.

Interviewer: What kind of work was that, if you recall?

Respondent: yeah, he told me that he had undertaken a course in tailoring and he was working as a tailor.

Interviewer: okay. When you look at those patients, do they know that there’s a link between a sore throat Acute Rheumatic Fever and RHD? Do you think they have a clue?

Respondent: No, they don't have a clue.

Interviewer: What sort of symptoms do they describe to you when they come? What do they present?

Respondent: when they are presenting, they usually would present with joint pains and subsequently they would develop features of heart failure where they have easy fatigability, they have edema, the swelling of the limbs. Those are the most clinical whatever, symptoms they present.

Interviewer: okay. When you look at follow up and adherence, how are they adhering? Do they come when you call them for follow up?

Respondent: Yeah, because there are few that I have attended to, the one that I attended to of course came because he had issues but initially he was given treatment which I cannot say he was adhering to because if he had adhered to, he wouldn't have come with the symptoms.

Interviewer: Why do you think they are not adhering?

Respondent: why they are not adhering, I think, and this my personal opinion; it is because when they take medication and they get some bit of relief, it makes them think that maybe they won't get the problem anymore and get relaxed in taking the medications.

Interviewer: And when you give them appointments to come back, why do you think some people don't come back?

Respondent: I think it's because um, they lack the knowledge of their disease condition, of course not knowing that they need to adhere to the medication. So they end up getting the complications.

Interviewer: So where is the gap in the ... what can be done?

Respondent: I think what can be done is to educate them on their conditions, what they are supposed to do and what can be done to adhere to the medications.

Interviewer: Currently is the healthy system not catering for their education in your own opinion?

Respondent: For sure it's not catering enough for giving information regarding RHD.

Interviewer: Where could be the problem?

Respondent: The problem could be in um, of course it starts with the health workers because we are the ones to give information to the population.

Interviewer: but what could be stopping the health workers from doing that?

Respondent: Of course now this one is much factorial. One; the staffing levels within the hospitals. Then two; although we study these conditions in school, we also a need for a continuing medical education on those conditions so that the health workers themselves also have the information which Information they can to pass on to the population.

Interviewer: okay. You have talked about staffing; what is it about staffing?

Respondent: The staffing levels are low I may say, because like now when you consider, of course there are many cadres. When you go to the nurses, they will tell you they are not enough. When you consider the clinicians, the staffing is also not adequate in most cases.

Interviewer: Okay, thank you very much. We have talked about some of the things that are stopping them from coming and you said when they feel better, they can relax.

Respondent: Yes.

Interviewer: Which other reasons apart from ignoring the fact that when they get better they relax? What else do they say when you tell them to come back this month they don’t come back.

Respondent: Of course also their social-economic status can limit them because if someone is coming from far, at times they will give excuses that I didn't come because I didn't have transport, such things.

Interviewer: So transport is the problem?

Respondent: Yeah.

Interviewer: Any other that you can think of?

Respondent: Yes, and even the cost of the medications because in most cases, some of the medications that can be prescribed for them might not be available in the hospital. It can also be a limitation.

Interviewer: So does that mean that probably there are some drugs that are not available in the hospital for these patients?

Respondent: yeah. I am not saying that they are not available, okay they are available but there is some duration of stock outs.

Interviewer: It is okay. Okay, good. And then um, I am going to ask you about the barriers you face as health workers later. But let's now concentrate on the local health system barriers. I want to see which pieces that am going to mention are working for you and why you think they are working for you? Let's first look at the administration here and the leadership in the district; is it working for you when you're caring for these patients? Are there issues or you feel it is working fine, you don't have problems with the administration when you are doing with the patients?

Respondent: No, when I am doing my work, I think the leadership is doing what is possible to see that we give good care to our patients. I don't have any problem on that.

Interviewer: How about the administration here in the hospital.

Respondent: I think it's the same; they are doing everything possible so that we give quality care.

Interviewer: Why do you feel that way?

Respondent: Yeah, because one; of course as the staffs, the staffs are mostly motivated when they get their payments on time. Then two; um, although I said that there may be a stock outs at some time, they do what is possible to make sure that the drugs are available and of course the health worker also gets motivated when you, like, prescribe treatment and the patient gets the prescribed treatment.

Interviewer: How about the funding in general, is it working for you?

Respondent: In general?

Interviewer: Yes, before I go to the funding of RHD, let's first look at funding for health care in general for all the diseases that you take care of; how do you find the funding? Any issues you have there?

Respondent: I don't have any issues.

Interviewer: You are happy with the funding that is given?

Respondent: At least.

Interviewer: okay um, Of course you have talked about the health worker numbers and you have said.

Respondent: Yes the numbers are low.

Interviewer: How about the qualifications, do you have enough people with different cadres and different qualifications around?

Respondent: Well that's what I meant that when you go to the side of the nurses, the staffing is not adequate although the ones who are there are qualified, but the numbers are not ... I think they are fewer than expected even when you go to the clinicians.

Interviewer: okay. Now let's look at the waiting time for our patients, how is it here?

Respondent: The waiting time, I am not so sure about how much they should be waiting but to me, initially the waiting time was okay because we would receive patients, the patients are triaged and then after the triage, we attended to the patients. But recently, they brought in a system whereby we have to enter the patients into the computer; that one has sort of increased on the patients’ waiting time because you know it's a slow process. It increases on the time because they have to be triaged, entered into the computer and then seeing them on the computer also is a problem because the system is not fully functional, so there are some things which have not been put in place to make it fully functional and it ends up increasing on the patients’ waiting time.

Interviewer: okay, so on average how much time does a patient have to take?

Respondent: From the time the patient enters into the hospital to the time he sits um, roughly, what can I say? Anyway that one varies depending on whether the patient has been sent for investigations or not, but if the patient has not been sent for investigation, he can spend like three to four hours.

Interviewer: 3 to 4 hours. Then with investigations?

Respondent: With investigations, it can go up to, it can go to five to six hours.

Interviewer: Okay and If you look at the quality of care, if you look at it in the perspective of numbers of health workers, what do you have to comment about the quality of care you give to the patients?

Respondent: The quality of care versus the number of patients, I feel if the staffing is improved by providing more staffs, then I think the quality will improve more.

Interviewer: But how is it right now?

Respondent: um, what it is now is that because of the fewer patients it doesn't compromise the quality but maybe as you said it increases on the patients’ waiting time and of course when the patients wait for long, they tend to get discouraged.

Interviewer: Let's look at the medication; um, before I move on I forgot something which is important; how do you look at the funding for RHD in particular for this hospital or the country entirely? How is it? Are you happy? Is it working for you?

Respondent: For RHD, I cannot say for the nation specifically because usually when they are procuring drugs and things they use, they do them generally. But generally, I think with the care, there has been some gaps there and just like I told you, most especially the drugs, there are some times when there are stock outs and the drugs are not there. So generally I think even with RHD, it's the same thing.

Interviewer: Ok, because my next question was s about the medication and we are interested in the heart failure drugs, how are the stocks, anti-coagulation drugs, the BPG drugs. How are they in the hospital? For insistence you had that patient you had at that time and probably you prescribed something, did the person get it?

Respondent: Well the person was lucky that time because by the time he came, the stocks were available and he got some medications. However, there are some instances when there are stock outs.

Interviewer: okay, and then when you look at the diagnostics like ECHO-Cardiograph, do you have it in place? Can it be done here?

Respondent: Yeah, it can be done here but the problem that we have is that the ECG and ECHO here are private, so we consider that for a person who has come from the village and doesn't have much may not afford to have those investigations done. It would be okay if they are made to be free so that whether someone has the money or not, they can access the services.

Interviewer: How much do they pay?

Respondent: They pay, I am not quite sure; is it around 10,000shs?

Interviewer: around 10,000shs!

Respondent: Yeah, around 10,000ushs I think

Interviewer: Let's look at the way records are handled here, the medical records, do you have a system? You told me that now you do the recording on the computer.

Respondent: Yeah

Interviewer: Is that across all departments?

Respondent: That's why I told you that it's not fully functioning because it's not on all departments. They have started it with outpatients where I work now, but all departments have not been connected to the system.

Interviewer: Okay, I understand that. But now if I wanted a record of someone who came maybe four years ago, if you want to look at that patient’s records, is it easy to get that information?

Respondent: Yes it can still be got because when we see patients, we record them in the registers and those registers are kept. Even when the patient is admitted, on discharge they give the patients the discharge letter and then the file is kept for records.

Interviewer: okay. Do you have any registers for ARF and RHD patients here?

Respondent: I think they are not specific; we have general registers.

Interviewer: um, are they integrated between inpatient and outpatient? Is there a clean flow like in case you need access?

Respondent: Yeah when you need access, I think it can be got but except that now the registers, the ones for outpatients are specific for outpatients and then those for inpatients also have their own registers for admitted patients.

Interviewer: Do you have any guidelines and protocols for RHD Care in this hospital?

Respondent: no, I have not come across those guidelines.

Interviewer: you don’t have them, and do you have a clear referral pathway for RHD patients here?

Respondent: Yeah, the procedure is that when we see those patients, usually when they are in a state where they need to be attended to in the cardiology clinic, then we refer them in the cardiology clinic. But if their symptoms are mild, we prescribe treatment and then they go.

Interviewer: okay, would you think that guidelines and protocols for RHD patients would be useful?

Respondent: Yes, I think they would be very much useful because they would guide us on how to manage these patients.

Interviewer: As we are about to wind up, so the pieces that are working for you are; administration is satisfying

Respondent: yeah

Interviewer: Funding is you are okay with you

Respondent: Yeah

Interviewer: and health information?

Respondent: Yes.

Interviewer: If I say something that is not right you tell me.

Respondent: Yes.

Interviewer: And what is not working for you at least is that most times there are stock outs and the health workers.

Respondent: Yes.

Interviewer: Okay, any other health system barrier that you feel that it needs to be addressed?

Respondent: I don't remember any.

Interviewer: okay, there’s none! Now let's look at perceptions about patient outcomes; generally do you think patients get the care that they need?

Respondent: Yeah, of course now for the patient’s expectations is to be attended to by a clinician and then two; to get the necessary investigations, and three; to get the medications. For the clinicians, I told you that there is that staffing gaps. And then on investigation, okay the major investigations that would be done here are all paid for investigations. And then on the medications, when someone is lucky and comes during the time when there are no stock outs, then they will get medication. However, when the stock is out, then it means that the medication will not be got also.

Interviewer: In case like for the RHD patient who needs surgery can they access it?

Respondent: They can't get it here?

Interviewer: So what do you do for those who need it?

Respondent: Those ones, usually at my level, we refer them to the cardiologist but what I know is that they are usually referred to Mulago.

Interviewer: they are referred! Okay. Do you have any patient safety and quality of care concerns, as you?

Respondent: concerns! I can't think of any?

Interviewer: Do you think you have had some preventable deaths occurring in the hospital? You just look surely and say “that patient shouldn’t have died. We could have prevented that but it occurred”

Respondent: But because I don't work on the wards and I am in OPD, I usually see the patients who are relatively stable. I think that could be the reason.

Interviewer: So you have not seen any preventable deaths?

Respondent: No, I have not seen any preventable deaths.

Interviewer: Do you think our patients dying in communities without presenting themselves to hospitals for care?

Respondent: Yes.

Interviewer: Why?

Respondent: one; um, because maybe they may be lacking information regarding their conditions, and then two; social-economic status when they can't afford to pay for whatever has to be done in terms of care. As I told you, in terms of investigations and medications when they are out of stock.

Interviewer: okay, thank you very. So in your opinion, give me one or two most important things Ministry of Health should do to improve the outcome of our patients?

Respondent: one; to improve on the staffing levels within the health facilities and then two; um, to provide um, I have failed how to term it; to make sure that drugs are available all the time so that there are no stock outs. And then three; to plan so that maybe the investigation are all affordable or can be accessed by all patients because if they are payable and someone can't afford them, they will lose out. And then three; maybe also to improve the motivation of the staffs.

Interviewer: In what ways?

Respondent: Because the staffs, although the salaries come on time but it's a prayer that when the salaries are increased, they will be more motivated to do their work.

Interviewer: Any think else before we stop?

Respondent: I don't have anything to add on.

Interviewer: Thank you so very much for giving us this opportunity to talk to you and we appreciate your feedback we shall use it with the views of others to improve care for our RHD patients.

Respondent: You are welcome.

Interviewer: Now I will hand you over to Rosemary.