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

Interviewer: OK thank you madam for allowing to be part of this interview. Today is 18th November 2018 and we are seated at nurses room at lira hospital and this is participant 001 and now like we said we are conversing and the conversation is going to be about how we take care of individuals with RHD, Factors that has enabled you take care of them and the difficulties you get in taking care of these patients and then let me first know a little about you

How old are you madam?

Respondent: Roughly I could say 47

Interviewer: Now tell me about your qualifications.

Respondent: My qualifications?

Interviewer: Yes.

Respondent: S.4

Interviewer: S.4 and then after that one, what did you train in?

Respondent: I just came straight to be a nursing Assistant, by that time, we were nursing aiders and then the ministry trained us to become nursing assistants

Interviewer: Nursing assistant? And how long have you been working here in lira regional referral hospital?

Respondent: Long time since 1986

Interviewer: 1986 up to now?

Respondent: Yes

Interviewer: Ok...that is wonderful and then when did you qualify for nursing assistant?

Respondent: That one was around 2001-2002

Interviewer: That’s is when you qualified?

Respondent: Yes

Interviewer: And then looking at the patients you get, are you aware, which ward are you working?

Respondent: Before I was in the Lab working at the blood transfusion unit but now after removing me from 2010, they first put me in the data DM ward for a year am now in Pead ward from 2010-2012 up to today

Interviewer: Ok...you are in Paed for RHD?

Respondent: It is a general ward.

Interviewer: Do you get RHD patients?

Respondent: Yes

Interviewer: Ok,

Respondent: When we get, ok we call people to do the test, they referred them to lacor or to Kampala.

Interviewer: Ok...do you handle any patient with RHD?

Respondent: Before?

Interviewer: Yes

Respondent: Ok we handle

Interviewer: Ok, looking at the demographics of these patient that you see commonly with the ... which categories of patients do you see, mainly those with RHD?

Respondent: Mainly the old ages

Interviewer: Old ages?

Respondent: Yes, like from 70’s and 80’s and among the kids/children rarely, some can be at birth, some can reach at even...but some can come at birth

Interviewer: At birth?

Respondent: Yes

Interviewer: Then on the ward, do you have other illness that you look at apart from RHD?

Respondent: Yes

Interviewer: Which are the common ones that you look at?

Respondent: They are many, like in the ward where I am working, we have those ones which comes with that ...diagnosis with malaria after doing the investigation, acute diarrhoea, hmm, some could come when they have already done local tonsillectomy, ok and other case

Interviewer: Ok...thank you, and then you are going to tell me about your little training on RHD, rheumatic heart disease, have you received any specific training on RHD?

Respondent: No

Interviewer: You are not ehh...during school time

Respondent: No

Interviewer: You didn’t? How about when you are in the ward, have you had any specific training in managing RHD?

Respondent: Ok, we only follow what the doctors prescribe then we keep on maintaining the patient

Interviewer: The patient? But you have never had any formal training?

Respondent: No

Interviewer: On RHD?

Respondent: No

Interviewer: Ok...and then how many patients do you see per day?

Respondent: Rarely...laughs

Interviewer: How about per week?

Respondent: Still rarely

Interviewer: How about in about per month, do you get?

Respondent: No

Interviewer: About per year, how many do you get?

Respondent: In a year, it can appear once, at times let me say once

Interviewer: One, one?

Respondent: I rarely see them

Interviewer: You rarely see them eh.., and so like in a year, you see like one?

Respondent: Let me talk like one.

Interviewer: Ok...thank you. And then and those patients, that person you usually see like in a year, usually are they inpatient or outpatient?

Respondent: Inpatients

Interviewer: Inpatients?

Respondent: Yes

Interviewer: Ok...and then, am interested in knowing what you have been taught about, the little you know about RHD? What are the causes of RHD or rheumatic heart disease? What are the causes?

Respondent: The causes... I can’t tell

Interviewer: But what is your guess?

Respondent: My guess.., my guess, I have seen for all ages, it could be like you know old people, maybe they have stress, they are over stressed

Interviewer: And then do you know any association or the link between sore throat and RHD? Have you heard of that link, do you think it is there?

Respondent: The link of associating to getting sore throat?

Interviewer: Tensolite? Getting RHD, have you heard of the link between the two?

Respondent: No

Interviewer: Do you think it is there?

Respondent: Those things are there

Interviewer: Which things are those things? If someone came with sore throat, do you see any link between the possibilities of that person developing RHD at a later stage?

Respondent: No...not so much

Interviewer: Are the two related

Respondent: No, they are not related, according to me ...laughs...

Interviewer: So how do you think we can prevent RHD, how can we prevent our society from developing RHD?

Respondent: Ok...maybe we need to talk to our community, if we know into details, we teach them that maybe if you see any condition has started, don’t start from down because they have their local people, when they have the problem on oesophagus, they go direct to cutting those local things but when we sensitise them, they can come when any condition started,

Interviewer: They come direct to the hospital?

Respondent: Straight to the hospital

Interviewer: So, you said that they start with the local people?

Respondent: Yeah...outside

Interviewer: So it a common practice around the corner?

Respondent: It is the tradition whatever practiced

Interviewer: Wow! Tell me more about that if you have ...

Respondent: ‘’Anti’’ when the child is sick and the child is running temperature, they could come and tell you that ah.., that thing maybe you are having the problem with tonsil and that tonsil, we have to cut it, so they start from out there and cut the thing before and sometimes they say..., I don’t know how they call it, either worms or some germs in the body, they could come when they have cut, cut the body that they are removing the germs and the rest of the body, so by the time they come when they have septicaemia and with difficulties in breathing.

Interviewer: OK

Respondent: Yes

Interviewer: Ok...and then, how do you know about those things, laughs..., it looks like you have the ideas about the tonsillitis

Respondent: laughs...

Interviewer: Where do you get the ...?

Respondent: When they come and ask them, they will explain, they could explain to you all they have done

Interviewer: Ok

Respondent: Yeah...

Interviewer: And what were you taught about in treating RHD?

Respondent: Those ones, we only wait for what the doctor has prescribed and we follow

Interviewer: No one does, so that means that you have never gotten any idea?

Respondent: No,

Interviewer: About how to manage it

Respondent: So we only follow what doctors ordered in the file

Interviewer: Ok, so what do you understand by the long-term prognosis of RHD? What do you understand about the long term prognosis of RHD?

Respondent: That much I don’t know but that condition once the patient is having it hard now to handle because the patient could not move for a long distance

Interviewer: Usually these patients with RHD, when do they decide to come for treatment?

Respondent: Mostly, it’s the relative now to bring them,

Interviewer: They could not decide?

Respondent: Yes because once you have that condition, everything becomes difficult for you, moving is a problem, talking is a problem, hmm, everything is difficult

Interviewer: So it’s the relative to take actions on them

Respondent: Yes

Interviewer: From your experience, at what point do they come to the hospital, is it immediately they see the problem

Respondent: No, it’s difficult to understand immediately but now when they come and explain the signs to the doctor, that’s when the doctor will send you for further investigations and the diagnosis come

Interviewer: Ok...you tell me, you are going to talk to me about your encounter with these patients who have RHD ,can you recall the last person you worked on who had RHD, who had rheumatic heart disease

Respondent: The last patient was a child and that one was from Barr and we tried him but we lost him

Interviewer: You lost that patient?

Respondent: Yes

Interviewer: So how did they present?

Respondent: Ok the way they present, they look weak, generally weak and as far as you try to give what the doctor has ordered, you don’t see any proper improvement, that’s what I can answer

Interviewer: Ok, on that visit, what did they do for that..., you said it was a child?

Respondent: Yes

Interviewer: what was done for that child?

Respondent: The treatment?

Interviewer: Yes, what did they do when he came?

Respondent: Anti’’, you remains there while they are preparing you for the referrals, they maintain you on treatment and they tell you either they will take you out, either to be operated or not.

Interviewer: So what treatment was that baby on?

Respondent: The one I was handling was on ceftriaxone and genta

Interviewer: On genta?

Respondent: Yes Ok. .and when the baby is becoming weak, they put on de-ten

Interviewer: Ok and then so you told me that you get to see one patient.

Respondent: Yes it’s rare and one

Interviewer: Are they old or young?

Respondent: Ok I last saw the young one, ok, I started seeing the old and then the last young one but i don’t put my mind so much

Interviewer: But looking like 10 years back, on average which patients were you seeing? What was the age?

Respondent: Ok, you see I told you I was in the lab for some time back but from 2011, I was in adyebo and that is mainly surgical ehh and those cases don’t appear there, then I was brought here, that is when I started seeing them Interviewer And so far you have seen them?

Those ones were kids and if they discovered they refer you

Interviewer: Ok kids in school or kids out of school?

Respondent: Kids...no, young ones under breast feeding, ages of breast feeding,2 years below there

Interviewer: Do you think our patients are aware about the association between RHD and sore throat, do you think they know any link?

Respondent: That maybe like if a child has sore throat, the problem can also come in where the attenders or the mothers don’t know

Interviewer: They don’t know?

Respondent: Yes, they don’t know

Interviewer: So if they come to you, what symptoms do they present to you, those patients with RHD? What do they complain about when they come?

Respondent: At times they could come when they have already gone somewhere and they have already told them, then they just come with the real diagnosis and maybe you can just push them to say some symptoms but for them, they say that my patient has problem of the heart conditions but you as you, what symptoms do you see?

Ok those symptoms, you just see when a child is having difficulties in breathing and generally weak and could not feed well

Interviewer: And not feeding well?

Respondent: Yes

Interviewer: Ok

Respondent: And not active, he is not active, they didn’t become active

Interviewer: They are not active? So what sort of barriers do they commonly state to getting care that they need, why, what stops them from coming to get the care when they get this disease ,the RHD?

Respondent: Ok they have this local belief that maybe somebody has charmed the child, they maybe when they fall into the hands of somebody who knows that this condition you need to come to the hospital, then that is when they could come to the hospital.

Interviewer: Ok...One of them is belief in charms, what other reasons, what else prevents them from coming?

Respondent: Sometimes, there is maybe they don’t have transport for coming

Interviewer: So sometimes its transport? So poverty, belief in charms, what else?

Respondent: Sometime when there are couples hmm, the mother can have maybe the idea of coming and the father may not have that idea of bringing the child to the hospital when the heart is divided

Interviewer: So who usually decides on in a home usually around?

Respondent: It’s the father

Interviewer: It’s the father?

Respondent: Because it’s the father to pull the transport

Interviewer: Those are three, which other reasons?

Respondent: I think that is all that I can say

Interviewer: And then for those that you give treatment, why are some not taking it?

Respondent: when you give them treatment?

Interviewer: Yes

Respondent: But for the kids, they take, then the adults, it’s the attendants to be keen on doing, if they are not keen, then...

Interviewer: To be keen on what?

Respondent: On giving drugs, when the drugs is not here, they will tell the attendants to go and buy this and they will say that there is no money and if the drug is there, then it’s the attendants to give

Interviewer: To give? So for the drugs for RHD, are they given for free of charge here?

Respondent: Ok.., is it’s there, they give free of charge because this is a government hospital

Interviewer: But for you from your work assessment, are the drugs always around?

Respondent: That drug is there

Interviewer: It’s there?

Respondent: Yes, when they are ordered, they collect immediately

Interviewer: Ok good to hear, and then how are they treated in your own assessment? When they come for treatment, how are they treated by the health workers?

Respondent: You know these people, they need counselling, when it’s a child you need to counsel the mother, if it’s the adult you talk to them

Interviewer: And do you get time to talk to them?

Respondent: Yes

Interviewer: when you look at your schedules

Respondent: Yes you have to talk to them usually

Interviewer: And when you look at the time they spend at the facility, how is it

Respondent: It’s long

Interviewer: It’s long? On average, how much time on one patient?

Respondent: That case if they are not referred, it’s a long term, and it’s a long term stay in the hospital.

Interviewer: And how do they take this time, how do they take it?

Respondent: Ok, at time the condition can worsen and somebody just pass on

Interviewer: Ok... how about for those outpatients, how much time do they usually spend here?

Respondent: The outpatients but mainly they refer them

Interviewer: They refer them?

Respondent: Out patients they push to the wards

Interviewer: To the wards?

Respondent: For the doctors to manage

Interviewer: To manage? So you dint get a patient well?

Respondent: Ok outpatient there I have never worked there but once they discover your problem, they push you in the wards to be attended to at least where the doctor can handle you carefully

Interviewer: And when you tell them, when you give them dates to come back for appointments, from the time you have been on the wards, what is your general opinion about their appointment?

Respondent: Ok, they are good at keeping their appointments

Interviewer: They keep them?

Respondent: They keep

Interviewer: Ok, so what do you think encourages them to keep these appointments? Come back next week, come back this month?

Respondent: ’’Anti when they come and they get the proper services and they feel that there is some improvement, they keep on coming back, they keep on coming and even they keep on telling their friends from out that, let’s go there, we are getting proper services from there, this is how I was referred and this is how I am now, yes, they make a difference

Interviewer: Ok, what are proper services when you say proper services, expand more on that

Respondent: ‘’Anti ‘’when they come, that day will be a special day for them

Interviewer: They have a special day?

Respondent: Yes

Interviewer: which day is that?

Respondent: This here I don’t know but once they come on appointments, doctors will make sure they have seen those patients because they will see them if they are fair and they will be adding them treatment and then they go back and then they keep on to give them another return date like that

Interviewer: For those that don’t come back, what do you think hinder them?

Respondent: The what?

Interviewer: Those who don’t come back, who don’t get appointments?

Respondent: I don’t think they can refuse to come back

Interviewer: They cannot?

Respondent: Unless they have changed their mind of going to another hospital

Interviewer: So usually they come back!

Respondent: They come back and if they want to cross to another hospital, eh...they ask for referral reports

Interviewer: Referral reports? So how about you, now when you are doing your work, helping those RHD patients, what are the barriers or the difficulties that you face as you do your work?

Respondent: ok... The difficulties like from my side I don’t get any difficulties, if the doctor is there or my colleagues are there, we can discuss and we handle the patients fairly.

Interviewer: So, as you do your work, you have not had any barrier that you wish would be better as you manage these RHD patients

Respondent: Because when the doctor is there and other cadres, we discuss together, things becomes easier

Interviewer: Ok.., are the doctors there, because you said when the doctor is there, are there times when the doctor is not there?

Respondent: They are always there, in case when they have gone maybe for lunch or around evening there because they cannot keep full time on the wards so they leave behind their numbers and then their contacts

Interviewer: Ok and then, let’s look at the local health system barriers, those ones within the respective setting within the health Center, what is not working for you in your system, here as you work, here do you see a gap and you need improvements?

Respondent: A gap?

Interviewer: Yes

Respondent: On those patients who are coming?

Interviewer: In your work, as you do your work here, what do you want to be improved in your general hospital so that you can manage the RHD patients better, so that you can manage them better?

Respondent: Ok, maybe they could have their specialists, that is what I can say because this issue of referring means people from here could not handle, they need to be taken to another level where specialists are

Interviewer: Ok do you have any training needs as you via this area of managing RHD patients?

Respondent: I can have that training

Interviewer: what training would suit you?

Respondent: Maybe to know more about the condition and how to manage them, what treatment can we give to them and their stages?

Interviewer: Ok and the stages, ok and then, any other thing in case they gave you a chance, so before you manage the RHD patient, what are the things you need to know to do?

Respondent: Since I have not yet known more about it, I cannot even know things to have on the ground...laughs...maybe after that study, I will now say ohh...! They need this and that

Interviewer: Ok and then if you look at the leadership, the administration here and the district as a whole, what are some of the gaps

Respondent: The gaps?

Interviewer: What do you think can be done better?

Respondent: I think because here we don’t have that unit of intensive care, maybe they can open, but they could not open without the specialist

Interviewer: And then, how is the administration? How are they managing you the health workers, what are the problems you face as you do things here?

Respondent: Here we are fair because we have the area managers, if there is any hardship, you contact them but here I rarely get those challenges

Interviewer: You don’t get the challenges?

Respondent: Yes

Interviewer: And then when you look at the funding for health care in general, how is it?

Respondent: The funding? , what? According to the salary or what?

Interviewer: One, ok...let’s begin from that, are you comfortable the way you are being paid, ok basing on the work you are doing?

Respondent: ’’Anti’’salary is there, but small, small motivations

Interviewer: What would motivate you to work better?

Respondent: Ok you know here, there are some people who go for the workshops but not all people

Interviewer: So they select some few?

Respondent: Like me since I came in Paed, I have never gone for the workshop but during that time when I was in the Lab, I could go for the workshop and I was well equipped with the knowledge

Interviewer: Ok,I understand, then if you look at the funding for RHD in particular, are there any barriers, are there things that needs to be brought?

Respondent: That much have not been in the ground, specifically, now, I could not tell

Interviewer: You can’t tell? Respondent...laughs...

And then if you look at the number of health workers who are working on RHD patients, how are the numbers?

Respondent: You see here, like when the patient fall in our wards, ok we work as a team, yeah... So I don’t see any difficulties unless if the units were separate, that’s when I could say that the staffs are few, but since we work as a team, I don’t see any challenge

Interviewer: So do you have any health workers who has been trained on managing RHD patients?

Respondent: From here?

Interviewer: Yes

Respondent: That much I don’t know

Interviewer: You don’t know? So you don’t know anyone who has been trained?

Respondent: No

Interviewer: Ok and then do you think it’s important?

Respondent: Yes, it’s important

Interviewer: It’s important? How do you think it is important to train some health workers in management of RHD?

Respondent: At least if somebody trained is there, when the patient comes, you just call him to handle that person because he will handle better than somebody who is not trained

Interviewer: and if you look at the number of patient that you see in a day. How are the numbers?

Respondent: Like from my unit, we could range from 30 to 30 something

Interviewer: 30 something?

Respondent: Yes

Interviewer: How many each day can health workers handle?

Respondent: Ok...we have on shifts

Interviewer: Ok you have shifts?

Respondent: Like day, evening, and night, like day they could be 2-3 people, then evening you work alone and if staffs are many, they could put like 2 of you then night at least one person

Interviewer: One person?

Respondent: Yes

Interviewer: Then how do you find the work load now like on night, one person works?

Respondent: Work like on night when you are alone without student, you can really work until morning without resting

Interviewer: How about during the day?

Respondent: They but at least 2-3 staffs plus students but at night always you are alone

Interviewer: Alone?

Respondent: Evening time also they can put students but with different cadre, it can be like those in second years, you can have diploma nurses and sometimes even degree people can be there, maybe at night the work load can be, at night there are no students but during day and evening, it is fair

Interviewer: Are there at times when you can fail to cover the whole ward?

Respondent: When you are alone?

Interviewer: Yes

Respondent: Then you run day, evening and night, maybe at that shift patients are not there

Interviewer: Now when you are there, you cover?

Respondent: You cover

Interviewer: You must cover?

Respondent: Yes

Interviewer: And then let’s look at the medications, especially like the heart failure drugs, the anticoagulation drugs, the BPG drugs and the diagnostic eh... Like for echo-cardiography, is that done here, do they do echo here

Respondent: Yes, they do

Interviewer: What do you have to say about the medication and the distribution of these drugs?

Respondent: You see, if you have that case in your wards, that’s when you can have those medications but if you don’t have them since they get drugs per file, there is no way you can bring in those drugs at store

Interviewer: Ok now you said that at least per year you get a patient

Respondent: Yes

Interviewer: Of RHD patients, are the drugs there of the RHD

Respondent: If the doctor orders, you go to the pharmacy and collect

Interviewer: And when you go there, do you find the drugs there

Respondent: Yes

Interviewer: And then for the echo, is it available for these patients?

Respondent: ’’Anti’’we call them

Interviewer: You call them?

Respondent: If we see or if the doctor is suspecting a case, they send for them and they go and do them

Interviewer: You do it here or you...

Respondent: Yes

Interviewer: You do here and the services?

Respondent: Yes

Interviewer: Ok and then when you look at the health information and the medical record system, inpatient that register from RHD patients, how is it, what do you have to say about the health system?

Respondent: The medical records?

Interviewer: Yes, how do you manage the information about these RHD patients

Respondent: Because after the discharge, they take back to the boards, I think they’re doing well

Interviewer: Ok, so if the patient came back after one year and they needed to retrieve their records, do you get it?

Respondent: Yes, they go for the same file

Interviewer: Is it easy to get that file?

Respondent: yes

Interviewer: So you feel that the records are kept

Respondent: Yes, it’s well-kept because they give them the discharge forms, in that discharge form, it will be carrying their numbers from the file, so when they came back, you present your numbers and they give you the file immediately

Interviewer: Ok... on your wards, do you have any guidelines or protocols’ for RHD patients? Do you have posters... do you have guidelines on how to manage RHD patients?

Respondent: Maybe it is there, I have not gone there, we have charts anyway on our wall

Interviewer: Is there any chart which is talking about RHD?

Respondent: I think it’s there

Interviewer: You have seen it?

Respondent: Maybe, I have not taken my time to read it but we have a lot

Interviewer: You have a lot on the wall. But you personally, you have not read any chart?

Respondent: I have not picked any interest on

Interviewer: Ok... Have you had any chance to look at the guidelines for management of RHD patients?

Respondent: No

Interviewer: No and then, do you think they are important?

Respondent: They are...

Interviewer: How important?

Respondent: ‘’Anti’’ supposed it comes at night, you are alone and your colleagues are not there, so if you have that knowledge, you just apply it to the patient

Interviewer: Ok...do then as a health worker, what is working, which is that thing that is working for you and why do you think it is working for you, what is making your work tick

Respondent: The thing which is making me active?

Interviewer: which is working for you, let me say, what is that advantage you are seeing in this system, in your health system that is working for you or that is making you do your work well

Respondent: In the first place

Interviewer: Yes

Respondent: Before you come, you pick some interest that I want to become a health worker ,secondly ,we are here for life saving then thirdly it’s that work which is also helping us to even pay our children school, now if they suck you out, how will you manage your family

Interviewer: What do you like about this region of the hospital?

Respondent: Here?

Interviewer: Yes

Respondent: I like this place in so many ways, in the first place if you are sick, you are already, the doctors are there for you and your family, then secondly, salary, they pay us in time, we have love, they love us also, they can appreciate us ah...you are hardworking and you feel so happy, laughs...that is what I can say

Interviewer: Who are those people who appreciate you at least?

Respondent: Especially the..., our authority, if you go down there to them, they are like how are you and they introduce you in a very big way...laughs

Interviewer: They can give you names

Respondent: Yes, like for me when I come and they find certain veins, they call me like professor, consultant and the what...laughs

Interviewer: Consultant comes in and...

Respondent: ...laughs...

Interviewer: Ok...and what has made you work this here?

Respondent: I work easily, ok, in the first place, they have accommodated me here

Interviewer: As you treat these patients, what has made it easy for you to treat them?

Respondent: Ok, we have things like ok what we need in place is there

Interviewer: Like what?

Respondent: Like the gloves, the syringes, the leads

Interviewer: All those things are there?

Respondent: Yes

Interviewer: And then let me see, so for you, you get your money, the leadership at least they appreciate you and then you have enough health workers, that is what you said here except t night, you always have to work alone

Respondent: yes

Interviewer: But they add on you the students?

Respondent: Yes

Interviewer: Ok, night is always alone?

Respondent: Yes

Interviewer: So the missing link is that you didn’t have the guideline for RHD management or you have not just looked at them?

Respondent: I have not checked on all those charts, but I think it is up there

Interviewer: And then you get your salary on time, those are the things that is working for you, the administration is ok,you have the things that you need to do your work like the gloves and then you said the way your files ate kept, you can easily get it, its ok, so and then generally do you think that your patients like the RHD patients, because it’s like now, it is where we have an interest, do they get the care they need here?

Respondent: The care that they need?

Interviewer: Yes

Respondent: They get

Interviewer: They get?

Respondent: Yes

Interviewer: How about for surgery like for those RHD patients who need surgery, do they get here?

Respondent: Sometimes they send them outside the country, that is what I always hear and they tell them to raise some good money to manage

Interviewer: So basically, surgeries are not done here?

Respondent: No, I have never seen it

Interviewer: Ok and then you have told me that many of them are referred

Respondent: Yes

Interviewer: Who are referred? Which RHD patients are referred?

Respondent: Ok... like when you have it, they just tell you we could not manage here especially children, they refer them

Interviewer: They refer them to? Usually, where do they refer them to?

Respondent: They refer them mainly to Mulago

Interviewer: To Mulago and then when they refer them to Mulago, in your view, do you think they continue to Mulago?

Respondent: Yes because at times they could say there are some other machines which are not here to go for those further serious illness issues that is why they always refer them

Interviewer: like which machines are lacking here?

Respondent: I don’t know their names

Interviewer: You don’t know their names? Laughs...and then do you have any concerns regarding patients safety and the quality of care that is given to your patients, any concerns where you feel the government needs to improve there, the way you handle patients?

Respondent: But from there, I always see, once they have that condition, they really take proper care of you and every time somebody has worked on and is leaving, he could report down, you have to write down, day person can report, evening person reports, night reports, they keep on courage

Interviewer: Ok

Respondent: Yes

Interviewer: Looking at your motives and other people you work with, how do you feel when they are handling patients?

Respondent: I think they are handling them well

Interviewer: They are handling them well?

Respondent: Yes

Interviewer: Ok, good to hear that, how about...have you ever witnessed any death that occurred here that could have been prevented, have the patient been cared for well?

Respondent: I have not

Interviewer: You have not seen any case that you felt like that maybe this case surely was neglected or was not managed well? Respondent...laughs..., I have not seen

You have not seen that?

Respondent: Yes

Interviewer: Ok, and do you think that there are some RHD patients that are dying from the villages when they have not come for care here?

Respondent: Ok... I don’t think they can just die when they have not been taken to any hospital, so they could go and then, time for review come, hmm, maybe poverty can leave them there alone to suffer

Interviewer: So there are some who don’t come because

Respondent: Yes, they don’t have money

Interviewer: Ok, what else? What else would stop them from coming?

Respondent: I think that is all

Interviewer: Its money?

Respondent: Yes

Interviewer: Ok

Respondent: Because they always try, they try even to beg people

Interviewer: Ok and then in your opinions, what are the two most important things ministry of health should do to ...to improve on the outcome

Respondent: Laughs

Interviewer: Of RHD patients?

Respondent: They should open the unit

Interviewer: units?

Respondent: And let those doctors who are really concerned to be available, so that this means of transport to long distance, going out of the country may not be there because they could not afford like in our country

Interviewer: Anything else that you want to share concerning RHD care that I have not mentioned but you feel that it’s important

Respondent: The ones...ok...what I feel, you know those people outside there, ok...their mind is in their family and doing other things but in their health, they wait until when they are really down and they start maybe from the health centers, then health centres start referring them like that and that. So if there was any way health worker who can go out there and talk to them at least

Interviewer: Thank you very, very much for this information that you have shared with us, surely we shall put these things together, what you have told us and what other health workers are going to tell us to come up with the strategies of improving RHD management and prevention, thank you.