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

Interviewer: Okay, like I told you it's about Rheumatic Heart Disease and Rheumatic fever. This is a study to determine how to provide better care for Rheumatic Heart Disease and there are no right or wrong answers. Please be frank and share your opinions. The data we gather is confidential, so we will not leak your identity or any of your comments in the reports we produce and basically the study is about building a case to invest in Rheumatic Heart Disease prevention and control in a limited resources setting. Like we told you that we have most patients who come in at the institute and yet they can easily access services in these hospitals here, but they leave here and come. So first of all we want to know the factors affecting them. So today, what is this office today? Is it a consultant room or?

Respondent: it's the clinical room.

Interviewer: at Wakiso Health Center IV. Tell me about yourself; age.

Respondent: I am..., a Clinical Officer, and am 30 years old.

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

Respondent: I trained from St Elizabeth School of Health Sciences, Mukono, where I attained a Diploma in Clinical Medicine and Public health.

Interviewer: when was that?

Respondent: 2016.

Interviewer: so how long have you been qualified?

Respondent: it's now two and half years.

Interviewer: and how long have you been working here at Wakiso Health Center IV?

Respondent: after I’ve been doing my internship for two and half years.

Interviewer: you have been doing internship, so which means you do internship beyond one year!

Respondent: Okay, it's upon you, but it's approximately six months. But for me I asked for an extension.

Interviewer: Okay, so which means you have been working here at Wakiso Health Center IV for two and a half years?

Respondent: yes.

Interviewer: so tell me about the demographics of the patients in your practice and what are the common illnesses you treat here at Wakiso?

Respondent: actually we receive a lot of patients; we receive around 200 patients, all children and adults with different conditions.

Interviewer: different conditions like?

Respondent: the upper respiratory tract infections, malaria, hypertension, diabetic patients, HIV, those ones of UTI's.

Interviewer: what are the common age groups of the patients?

Respondent: I will not say there are common age groups but we see almost all patients from 0 up to around 85+

Interviewer: is it like these elements cut across the age groups, or there are some elements which are more particular, for example those below five?

Respondent: For those below five, its most commonly with RTI's and malaria, and then from five years to thirty, UTI's and the malaria. Then 35+ you find them hypertensive, some are diabetic and some of them have heart problems especially the hypertensive patients.

Interviewer: Okay, so tell me about your training on Rheumatic Heart Disease; have you received any specific training during school about Rheumatic Heart Disease?

Respondent: Yes, just when I was in class but there was not any actual training that was done.

Interviewer: but in class, did they teach about RHD as a course or as one of those conditions that patients usually come with?

Respondent: um it was just a lecture about Rheumatic Heart Disease.

Interviewer: it was just a lecture, like a one off lecture?

Respondent: yes.

Interviewer: Okay, so have you received any training about Rheumatic Heart Disease since you qualified in 2016?

Respondent: no.

Interviewer: you have not received any training, since your graduation!

Respondent: Yes.

Interviewer: So how many patients of Rheumatic Heart Disease do you often see here, maybe in a day, week or a month?

Respondent: In a day we may not see any but patients we find hypertensive are like three. There are some we get and we refer. Others when their sugars are high, we basically send them to Mulago.

Interviewer: so how many do you often see sometime maybe in a week or in a month?

Respondent: in a month we can get like one.

Interviewer: so are these patients usually out-patients or in-patients?

Respondent: they are out-patients.

Interviewer: they are out-patients, do you have an in-patient unit here?

Respondent: yeah. So unless those ones who come and are in critical conditions, we admit. We can make them, give referral treatment.

Interviewer: so they come in here, you admit them give them and give the care they need, then after you refer them?

Respondent: Yes.

Interviewer: Okay. So now, you as an individual, tell me; what's your understanding of the causes of Rheumatic Heart Disease?

Respondent: To me it is basically patients who have uncontrolled blood pressures, actually they poorly take their medications and their BPs have failed to be controlled, and those ones who are diabetic. They irregularly take their drugs or miss and sometimes when they come to the facility, by the time you check their sugar levels they are high. So you put them on treatments and when they feel better, they go back and relax.

Interviewer: what kind of treatment do you usually put them on?

Respondent: probably, for the DM patients, their sugars are high and they have been on oral treatments and if the orals have not worked, we subject with insulin. And if the sugars have failed to stabilize, then we can refer them.

Interviewer: Okay. Um, as a health worker, are you aware of the link between a sore throat and Rheumatic Heart Disease?

Respondent: sorry?

Interviewer: As a health worker, are you aware of the link between a sore throat and Rheumatic heart disease?

Respondent: A sore throat to my understanding, it could be maybe an ulcer in the throat and the Rheumatic disease could be possibly because of high blood pressure, or then failure of blood vessels where they actually become narrow and the failure to supply blood to the delicate organs.

Interviewer: Okay. So according to you, the link between a sore throat, it's an ulcer, and then RHD is where the hypertension comes in!

Respondent: yes.

Interviewer: But do you think there is a link between the two?

Respondent: there is.

Interviewer: and what do you think that link is?

Respondent: Okay, maybe she can tell you.

Interviewer: Okay I will tell you later. Now for example in class you had one unit about Rheumatic heart disease, so what were you taught can be done to prevent rheumatic heart disease?

Respondent: possibly caring for those hypertensive patients to avoid other causes like heart failures.

Interviewer: so we are talking about the treatment of hypertension!

Respondent: yes

Interviewer: So that is prevention, how were you taught to treat RHD?

Respondent: treating!

Interviewer: so we were talking about the treatment; what do you think is the treatment for RHD?

Respondent: Um, to me the treatment for RHD could be when you treat the cause then you are trying to stop RHD, probably the hypertensive urgencies; when you treat them, then you are preventing RHD.

Interviewer: so, are there any aspects of RHD management in which you think you need more training?

Respondent: yes, possibly the whole course.

Interviewer: the whole course! Be specific, like?

Respondent: managing those conditions especially Rheumatic.

Interviewer: so what aspects?

Respondent: for the hypertensive, that I can manage, but when it comes to the chronic, I don't.

Interviewer: so according to you, you feel that you need to study about the whole course and not just RHD management!

Respondent: yes.

Interviewer: so as a health worker what is your understanding about the long term prognosis of RHD?

Respondent: the prognosis is that they are put on late treatment and the care that those patients are given, the prognosis may be good but if the care is not good and the treatments, then the prognosis is poor.

Interviewer: so which means that the long term prognosis will be depending on?

Respondent: the treatment and the care.

Interviewer: Okay, thank you so much. So tell me about your encounters with patients of RHD; tell me how the last time you saw a patient with rheumatic heart disease was? Who was the last patient you saw of RHD and how do they present themselves? How was that visit?

Respondent: actually I have ever seen one patient and, it was HT clinic. It was in 2017 and he was having difficulty in breathing, tachypnea and tachycardia. He was over-sweating and his BP was high.

Interviewer: his BP were high!

Respondent: yes.

Interviewer: Okay.

Respondent: actually they could just refer that patient.

Interviewer: you just referred the patient! Was the patient an out-patient or in-patient?

Respondent: was an out-patient. Actually we were treating the patient before but it was an on and off treatment.

Interviewer: so what were you treating before?

Respondent: hypertension.

Interviewer: you were treating hypertension!

Respondent: yes.

Interviewer: not RHD as such?

Respondent: no.

Interviewer: Okay, so what is the average age of the RHD patients that you see here?

Respondent: 65+

Interviewer: 65 and above! Are they either working or not? Are they in school or not?

Respondent: not working.

Interviewer: they are not working! Okay, so which means they are 65 and above and not working!

Respondent: yes.

Interviewer: why is it that they are not working? Is it the disease process? Is it because of the age?

Respondent: some are saying age and others don't have work.

Interviewer: so do you think those patients are generally aware of a link between a sore throat, Acute Rheumatic Fever and Rheumatic Heart Disease?

Respondent: I don't know.

Interviewer: Okay, why do you think that they are not aware?

Respondent: because they have not been informed and not educated about it.

Interviewer: about the disease?

Respondent: yes.

Interviewer: so according to you, you feel that the patients are not aware!

Respondent: I think.

Interviewer: Okay.

Respondent: at least unless they can get CMEs, health talks and education and other health studies.

Interviewer: so what sort of symptoms do those patients of RHD describe?

Respondent: fatigue, then the palpitations, swelling of the lower and upper limbs and the varicose veins.

Interviewer: anything else?

Respondent: no.

Interviewer: so are those patients usually good about follow-ups and adherence to treatment or not?

Respondent: sorry?

Interviewer: are those patients, now like for example that one who came to the clinic, do they usually come for follow- up and do they adhere to their treatment?

Respondent: no. When they get better or when they feel fine, they don't come back. So they only come back when they get problems. That’s when they come back.

Interviewer: so you are trying to say that the when the symptoms re-surface that's when they come back!

Respondent: yes.

Interviewer: anything else why they don't come back for follow-ups?

Respondent: I am not sure but to me that's what I think, because we only see them when they have a problem, but if they don’t ...

Interviewer: they don't come! So as a health worker, what sort of barriers do those patients commonly face or state to get the care they need?

Respondent: the distances they travel; the health facility is far from their homes, but then when they come, there are no drugs. So you prescribe and they go and buy. So drugs become a problem because what they stock is not enough.

Interviewer: so you are saying that some of them have issues of transport! You said that they stay very far from the health facility!

Respondent: yes.

Interviewer: and then the issue of drugs!

Respondent: yes. Someone says that I will go and then they write for me but I don't have money to buy the drugs, then they come here when the condition is worse.

Interviewer: Okay, so what sort of barriers do you perceive they face in getting the care they need?

Respondent: I beg your pardon.

Interviewer: according to you as a health worker, what do you perceive these patients face in getting the care they need, as a health worker?

Respondent: to me, I think the inadequacy of drugs that they stock.

Interviewer: anything else?

Respondent: that is what I think, maybe even the health workers to see the patients are not enough because you might find that one clinician or doctor sits here from morning to around evening and yet the patients are many. So you find yourself tired, and the patients over-wait, then they get tired and then someone goes away.

Interviewer: so the patients over-wait to see the clinician and the doctors!

Respondent: yes.

Interviewer: so they get tired and go!

Respondent: some are sent to the lab and they delay there; they spend a lot of time there because not only one patient is worked on. So someone gets tired from the lab and then just goes.

Interviewer: so when they tired from the lab, they don't come back to you?

Respondent: yes.

Interviewer: Okay, so let's look at the local system barriers. For example, now we are talking about Wakiso district, right from the district then to the hospital. So when we talk about administration and leadership to the district, what are the kinds of barriers that affect your work as a health worker, administration-wise and leadership-wise at the district?

Respondent: with communication, there is a gap.

Interviewer: how?

Respondent: at times there are things that happen, or they say that there will be a meeting and then they inform you that there is a meeting tomorrow, so they inform you today or you just see when they have lined up with the staff an urgent staff meeting,. So some may be off and then they will just miss. Possibly me I think there is a communication gap.

Interviewer: administration-wise; what are some of the barriers that hinder you? Because now we want to find out the enablers, and barriers that hinder a health worker to do your work Administration-wise and leadership-wise. Do you think communication is only the issue?

Respondent: and possibly the supplies of drugs, because when they come to the district it takes long; they may take like a week or weeks when they have not supplied the facility and yet when these patients see that the vehicle has gone to the district, they think drugs are supplied. So you will see them in big numbers and when you don't give them drugs, they say that you take them.

Interviewer: they say that you take the drugs?

Respondent: yes.

Interviewer: so which means that you’re saying that when they see that truck, is it a truck?

Respondent: yes, the truck

Interviewer: the truck of ...

Respondent: the medicines, because they offload first at the district and then the district supplies, so the supplies take time from the district.

Interviewer: to reach here?

Respondent: yes.

Interviewer: so which means that when the patients see those, like you said earlier, they presume medicines have come!

Respondent: and then you will see them in big numbers, so when they come and someone goes without drugs, they say that you haven't given them.

Interviewer: so here at Wakiso Health Center IV, what are some of the local health system barriers to funding for health care in general or RHD in particular? Are you aware of any?

Respondent: no.

Interviewer: do you know anything about funding for the Health Center IV.

Respondent: no.

Interviewer: you don't?

Respondent: actually the funding, what I know is about PHC.

Interviewer: about?

Respondent: PHC, that one the in charge.

Interviewer: that is PHC. What is PHC?

Respondent: those are the funds that are for the facility, like cleaning, preparing.

Interviewer: Okay tell me about the health workers; how are the numbers? What are the numbers of the health workers and their qualifications, and the barriers, as in; waiting time and the quality of care?

Respondent: possibly we have the nursing assistants or the nursing officers, the midwives, we have the clinical officers, and the theatre assistant, and the nurse but we don't have a psychiatric personnel.

Interviewer: Okay, what about the doctors?

Respondent: they are around.

Interviewer: like how many?

Respondent: they are two.

Interviewer: so according to you, are the health worker numbers enough?

Respondent: they are not depending on the patients we receive because you may find on duty, there is one clinical officer and one nurse, so the nurse is supposed to be here at OPD, then the in-patient and even at the in-patient wards.

Interviewer: you’re saying that the nurse, on a shift you can have one clinical officer and one nurse!

Respondent: yes.

Interviewer: and the nurse is attending to OPD and in-patients and theatre!

Respondent: no, in the theatre there is a theatre assistant and the nurse. So what happens, those midwives sometimes help out in the theatre? When it comes to OPD and in-patient, you find one nurse on duty?

Interviewer: so according to you, are those numbers enough or not?

Respondent: they are not enough.

Interviewer: so what about the wait times, how long does a patient wait?

the waiting is not much, so it is dependent; if you have gone to the laboratory, it depends on the tests requested because there are some patients we see clinically, then they go to the table outside. After getting the number, they go to the dispensary and get drugs and then go. So it's dependent on the request you have made in the laboratory and how you see the patient.

what about quality of care.

Respondent: it is not bad.

Interviewer: why is it not bad? How do you quantify that it has not been bad?

Respondent: because you may see a patient and he or she tells you what, her problem is and then you treat accordingly. So I may say it's good and then you ask the patient and he says that it's bad.

Interviewer: so the health workers; are they all qualified to provide care in this healthy facility?

Respondent: yes they are.

Interviewer: so tell me about the medications in regards to RHD; do you have enough drugs for example Benzathine Penicillins, anti-coagulant drugs and heart failure drugs? Do you have all those drugs around?

Respondent: the Penicillins are there.

Interviewer: like which Penicillins specifically?

Respondent: Amoxicillin, Penicillins, Ampicillins.

Interviewer: what about Benzathine?

Respondent: it's there, but when they bring, they are few.

Interviewer: they bring few! Like how many and for which duration?

Respondent: because they bring every quarter, in a quarter they supply around 6000.

Interviewer: 6000 vials!

Respondent: and the patients we receive actually in a month are 1000 plus.

Interviewer: the patients you receive in a month?

Respondent: yes.

Interviewer: So you are telling me about the medications; you are telling me that for a quarter, they need like how many vials?

Respondent: 6000 and yet the numbers we receive are many.

Interviewer: the numbers of?

Respondent: as in the numbers of patients. And those ones we put on Penicillins are especially the children. So you may find that the ratio of drugs to patients is less.

Interviewer: so does that still work for Benzathine penicillin?

Respondent: yes, what they stock is not enough.

Interviewer: so what about the anti-coagulants drugs, the warfarin and heart failure drugs?

Respondent: they don't stock.

Interviewer: they don't stick them!

Respondent: the anti-coagulants.

Interviewer: but do you get patients who need them?

Respondent: yes, especially those ones who are on DVTs.

Interviewer: about diagnostics; what kind of diagnostics do you have here in the health facility or what kind of diagnostics do you do?

Respondent: we have the chemistry tests, the RFDs.

Interviewer: any others? Like ecocardiography, do you do them here?

Respondent: no, we don’t. It’s only chemistry.

Interviewer: only labs that you do!

Respondent: yes.

Interviewer: so the other diagnosis like X-ray, ecocardiography, those ones?

Respondent: we send them out.

Interviewer: you send the patients to be done from out.

Respondent: yes.

Interviewer: Okay, so tell me about health care information in the health facility.

Respondent: the what?

Interviewer: health information and medical records systems here; how are your medical records? Tell me about the registrars and how you store your patients' information here at the facility.

Respondent: we have HMIS book registers especially at the OPD and the dispensary. Actually every department has registers.

Interviewer: what is HMIS?

Respondent: they are registers where we find the out-patients and in-patients maybe in the lab ... I was saying that maybe in the lab it is a computerized system but here it is in-patient and out-patients.

Interviewer: we were talking about health information, how is the integration of health information between the OPD the in-patients? How do you integrate your medical records?

Respondent: we have the medical records personnel

Interviewer: what does that person do?

Respondent: he collects data weekly and monthly and then he issues a report. We also have meetings, data implementation meetings done every month.

Interviewer: data implementation meetings?

Respondent: Yes

Interviewer: so do you have any in-patients and out-patients’ registers?

Respondent: yes, they are there. The out-patients' are outside there, then the in-patients' is at the ...

Interviewer: Okay, so do you have specific registers for specific conditions? For example, a register for Rheumatic fever, RHD, or a register for those other conditions?

Respondent: actually we have one register for all conditions; we don't specify registers or for UTI's or RTI's.

Interviewer: what about for hypertensives?

Respondent: those ones are there at the hypertension clinic.

Interviewer: so you are saying that the patients for hypertension also have their own register?

Respondent: yes, but the screening is done from OPD. So when you screen them, you put them on treatment for one week and then you send them to the hypertension clinic, but the screening is done here.

Interviewer: so you are saying that you have a general register of the OPD but you don't have specific register for example other treatments like hypertension and RHD!

Respondent: yes, apart from TB cases.

Interviewer: any guidelines and protocols for RHD care here?

Respondent: no, we don't.

Interviewer: do you have any referral pathways in receiving patients of RHD here?

Respondent: actually we have been referring them to Mulago.

Interviewer: so what is your referral pathways? When you receive them, what do you do before you send then to Mulago?

Respondent: in general, we just write a referral to Mulago (Hospital).

Interviewer: so tell me about the local health system enablers here; what motivates you as regards to administration and leadership? What motivates you to do your work as a health worker?

Respondent: Okay, the motivation may not be there so much, but me personally, I love what I do.

Interviewer: so, structure of the health system here enables you to do your work?

Respondent: yes.

Interviewer: Okay, it makes you to love what you do! Okay, so the funding of this health facility does, it enable you to do your work as a health worker, funding in general, and that of RHD?

Respondent: I reserve that question to the in-charge because I don't know how much they receive, and despite that, I am not a qualified or I am not paid, so I may not know.

Interviewer: so we are talking about enablers do the health workers. Do the numbers enable you to be able to do your work.

Respondent: the what?

Interviewer: the enablers as health workers; are your numbers enough to do your work?

Respondent: the health workers are not enough.

Interviewer: so which means they don't enable you to do your work!

Respondent: it's because you may find only one person as you may see, and they are calling me mostly. Especially we have these students here; they always want to consultant and you find that you are alone.

Interviewer: Okay, so which means that even the quality of care ... tell me about the quality of care, as in regards to the numbers. Because now, you are alone; does it enable you to provide proper quality of care?

Respondent: Yes, for the patient we receive, you have to manage and give care to that patient because what is in your hands is the one you use.

Interviewer: so the drugs or the medications that are sent to the health facility, do you enable them or enable you to do your work so far?

Respondent: Actually, like I said, they are not enough. You may find yourself sending a patient to go and buy because they are not around.

Interviewer: so it is not enabling?

Respondent: yeah.

Interviewer: so what about the medical records system! Are they enabling for you to provide your care?

Respondent: there is no problem with the records system.

Interviewer: and you are able to access information in case you need records on the in patients!

Respondent: yes.

Interviewer: or for example, are you able to obtain that information from all the different departments?

Respondent: yes.

Interviewer: so you told me that you don't have guidelines and protocols for RHD, right?

Respondent: we don't.

Interviewer: Okay, this is my last question; perception of patient outcomes. Generally, do you think the patients get the care they need or not?

Respondent: me I thin they do.

Interviewer: you think they do! Why do you think they do?

Respondent: because we at least try our best so that we give what they need.

Interviewer: Okay, so you feel that you give them what they need!

Respondent: yes.

Interviewer: what about surgery?

Respondent: surgeries, they do.

Interviewer: what kind of surgeries do you do?

Respondent: C-section, hernia

Interviewer: Okay, tell me about patients’ safety and quality of care concern.

Respondent: as in security?

Interviewer: safety, as in, as you provide your care as a health worker, are the patients safe and do you provide quality care or do you have any concerns with that?

Respondent: As we said, they have; we have out stocks, for example you may be giving service but you don't have gloves and yet you see that the patient needs service from the health worker.

Interviewer: so do you think the patients are safe?

Respondent: actually the patients are not safe.

Interviewer: Okay, and what about the quality of care?

Respondent: I think the quality is fine.

Interviewer: have you had any preventable deaths here at the health facility?

Respondent: the?

Interviewer: preventable deaths, have you had any here?

Respondent: as regarding?

Interviewer: preventable deaths, for example, we have patients who die or patients you lose but then the health worker would have prevented that death.

Respondent: yes, they are there.

Interviewer: why do you think?

Respondent: lack of what to use.

Interviewer: lack of what to use, as in?

Respondent: now for example, you might get asthmatic and you don't have oxygen, and you have the skill but you end up losing the patient.

Interviewer: any other scenario you have had around here?

Respondent: now for the accident patients, you have the knowledge of what to do but you will see the patient dying because you don't have what to use.

Interviewer: so do you think patients are dying in the community without presenting to the hospital for care?

Respondent: yes they are there.

Interviewer: why do you think patients should be dying?

Respondent: first; they don't have what to bring them here, as in regards to transport. Then two; someone thinks I will go to the hospital and be told to buy this and that because it is not there, so as a result they stay at home.

Interviewer: anything else?

Respondent: there are some who don't have caretakers! I So you think; when I go to the hospital, they will ask me that you are admitted but do you have anyone to look after you? So he stays home because of that.

Interviewer: Okay, thank you so much. So what in your opinion the one or two most important things ministry of health could do to improve patient outcomes?

Respondent: one; stocking enough drugs; and then supervising health workers.

Interviewer: supervising health workers, anything else?

Respondent: and motivating.

Interviewer: what kind of motivation are we talking about?

Respondent: in terms of support, or it can be quarterly. They can say we are giving sugar or say that we shall take or give lunch to the health workers.

Interviewer: Okay, anything else about motivation?

Respondent: then the payments and calling health workers for training because sometimes they do organize workshops but as I said, the communication is poor. You find that one health worker goes for a workshop over and over again and others are not gaining.

Interviewer: Okay, thank you much for your time.