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

Interviewer: Thanks for allowing to talk to us but before we start I just want to you to know that whatever answer you give there’s no wrong or right answer. We just want to determine how provide better to our RHD patients and then I want you to be frank and share your opinions the data we share is going to be confidential we will not link your identity to any of the comments you make so be free. Today is the 26th of March we are seated here in Buwambo health center. In which room?

Respondent: This office is for the in charge.

Interviewer: So we are seated in the in charge’s office with one of the health workers in Buwambo.

Respondent: Yes.

Interviewer: Now sir, tell me about yourself. How old are you?

Respondent: I am making twenty six.

Interviewer: What are your qualifications?

Respondent: I first qualified as a comprehensive nurse then I upgraded to clinical medicine.

Interviewer: How long have you been working here?

Respondent: I started in November; four months.

Interviewer: Okay and where did you train from?

Respondent: I Trained from Kabale School of Health Sciences for Nursing and Clinical medicine.

Interviewer: So you said you’ve been working here for?

Respondent: For four months.

Interviewer: Let’s look at the demographics of the patients you have seen in your practice. Tell me about them. Who are those people you have seen mainly? Age group, sex.

Respondent: According to the condition we are talking about?

Interviewer: Yes.

Respondent: Usually they are always adults; 16 years, 75 ... 50-75years.

Interviewer: Those are the commonest?

Respondent: Yes. Male or female.

Interviewer: And what are the commonest illnesses you see in this place?

Respondent: Common illnesses; diabetes, hypertension, arthritis.

Interviewer: And among the children?

Respondent: Most conditions; respiratory infections (Upper and lower,) common colds, skin diseases. Those are the common illnesses in children.

Interviewer: Okay. Do you ever see any children who come with sore throat?

Respondent: I’ve ever seen, not just once or twice.

Interviewer: Is it a common illness around here?

Respondent: Not common but it comes with a season then it disappears. It’s not so common.

Interviewer: Okay. Now let’s talk about your training in RHD that’s rheumatic heart disease. Have you ever heard about it?

Respondent: I’ve ever heard about it just that I’ve not got many patients to handle.

Interviewer: So did you get any specific or special training during school in RHD?

Respondent: No.

Interviewer: Did they introduce that topic during school?

Respondent: They did.

Interviewer: They did?

Respondent: Yes.

Interviewer: Okay. And after graduation have you had any CME or any talk on RHD?

Respondent: I have just graduated.

Interviewer: Okay, so you have not had any training in RHD?

Respondent: No, I have just graduated.

Interviewer: You have just graduated?

Respondent: Yes.

Interviewer: When?

Respondent: In November.

Interviewer: Okay. So since you started practicing have you seen any patient with rheumatic heart disease?

Respondent: Yes. I had a patient when I was still a student. So that patient had rheumatic heart disease so we had to refer to Mulago heart institute; it was late.

Interviewer: So you had to take the patient to Mulago?

Respondent: I had to escort the patient to Mulago.

Interviewer: So did you manage that patient at all here?

Respondent: I wasn’t here.

Interviewer: Where were you?

Respondent: I was in a different health Centre in Luweero.

Interviewer: So far have you seen any one?

Respondent: So far, no. The time I have been here, no.

Interviewer: You have not seen any one? Any RHD patient?

Respondent: No.

Interviewer: And then, so what is your understanding on the causes of rheumatic heart disease?

Respondent: The way I understand it originates from oral thrush (infection from oral thrush) then descends through blood to the heart valves.

Interviewer: Okay, and then are you aware of any link between sore throat and RHD?

Respondent: Yes.

Interviewer: And what’s the link between them?

Respondent: The link?

Interviewer: How are they related?

Respondent: The same infection that attacks the throat is the same infection that descends through blood, attacks the heart then the patient will develop rheumatic heart disease. That's my understanding.

Interviewer: And then what were you told can be done to prevent rheumatic heart disease.

Respondent: Preventive measures?

Interviewer: Yes. How can someone prevent getting RHD?

Respondent: Oral hygiene, I think that’s the first.

Interviewer: Okay. Anything else?

Respondent: And medical checkups can also help us.

Interviewer: okay. How do we treat RHD?

Respondent: In treatment?

Interviewer: Yes. How do they manage RHD?

Respondent: Of course for all patients with cardiac conditions we have to be in a specialized setting. Such a patient in place like Buwambo, we can’t give a lot of management. We always tend to refer those patients.

Interviewer: Where do you refer them?

Respondent: To clinics where we know they can be managed well.

Interviewer: Do you know some of those referral clinics?

Respondent: we have new Mulago Heart Institute

Interviewer: Apart from Mulago?

Respondent: And other big hospitals.

Interviewer: Okay. Are there any aspects of RHD management in which you need to be trained?

Respondent: Yes.

Interviewer: Like which area? If you were offered to be trained in any aspect of RHD management.

Respondent: l want them to train me how to identify a patient with RHD because we study but we don’t come out with that knowledge.

Interviewer: Okay. So in identifying patients!

Respondent: Identifying patients with Rheumatic Heart Disease and more training in management. Not just referring.

Interviewer: Okay. Any other area? So identification of symptoms and management!

Respondent: Yes.

Interviewer: Okay. And then so what is your understanding about the long-term prognosis of RHD?

Respondent: Long-term prognosis?

Interviewer: Yes.

Respondent: So long-term prognosis of RHD.

Interviewer: Yes.

Respondent: It can be due to other complications.

Interviewer: Any other?

Respondent: And maybe death as the final.

Interviewer: So you've told me that you have ever encountered an RHD patient.

Respondent: Yes.

Interviewer: So can you tell me; when did you last encounter an RHD patient?

Respondent: Last year.

Interviewer: Last year?

Respondent: No, October.

Interviewer: In October. So briefly summarize that visit. How did that patient present? How did you handle?

Respondent: The patient had a history of on and off fevers but had difficulties in breathing, and then he still had joint pains with swollen joints.

Interviewer: How was that patient managed? Did the patient come and present that I have RHD or came without.

Respondent: The patient came as an emergency, so we had to refer. We controlled the fevers but we had nothing much to do in that very moment so we had to refer the patient.

Interviewer: To where?

Respondent: Mulago.

Interviewer: So you said since you started practice how many patients have you encountered with RHD?

Respondent: I got one patient.

Interviewer: One patient!

Respondent: Yes.

Interviewer: Okay. And you said how old was that patient?

Respondent: Was 64 years.

Interviewer: Okay and then when you look at these patients do you think they know the link between sore throat and this Rheumatic Heart Disease?

Respondent: They don't know.

Interviewer: Okay. And then what sort of symptoms do they describe to you when they come? In their own description, what do they say?

Respondent: They will tell you they always have difficulties in breathing, that's the first symptom, and then with fevers.

Interviewer: Any other?

Respondent: No.

Interviewer: Okay and then when you look at their follow up or when you tell them to come back maybe for follow up do they come back?

Respondent: Excuse me. I have only encountered one patient so I didn't get a chance of meeting her again.

Interviewer: Okay. So in your opinion I know you have not encountered any but what do you think stops some people from going into care? Now that one came as an emergency, but why do you think people don't seek care?

Respondent: People don't seek care just because of their ignorance; they don't know what to do and those who have tried to go for health care meet a problem of health care provider attitude.

Interviewer: What is it about the attitude of the health care providers?

Respondent: Because if I refer a patient to your unit and you don't attend to him or her, of course tomorrow that patient won't come back. I think that’s the biggest problem.

Interviewer: Which other one? Why do you think you tell these RHD patients to come for treatment and they don’t?

Respondent: And we have units which are very deep. And people don't have access to the health facilities, lack transport and such issues.

Interviewer: Anything else? How about your health care, what barriers do you face?

Respondent: As in?

Interviewer: when you are providing care, like that RHD patient who came and you referred.

Respondent: yes.

Interviewer: What stopped you from handling that case?

Respondent: [laughs] okay, lack of medical supplies first, then having doctors but we don't have medical drugs, equipment of course, so you have to refer.

Interviewer: Okay. Which drugs in that case would you need, that if they were here you would have helped that lady?

Respondent: (sighs)

Interviewer: You don't know?

Respondent: Yeah.

Interviewer: You can't think of any. Okay and then let’s talk about the administration here. Is it working for you? Does it help you in any way when you are doing your work or makes your work better?

Respondent: The administration, though am learning it, in my view it doesn't help as I expect.

Interviewer: Where do you want them to improve?

Respondent: As Buwombo or from up?

Interviewer: Let's start from the district.

Respondent: From the district, for the better of our patients they don't do close supervision and then sometimes we have a lot of patients but we have few staff and even medical supplies we don't have. We don't have drugs.

Interviewer: Like which drugs are scarce here? Which are some of the essential drugs that you don't really have here?

Respondent: We don’t have most of the drugs like, we don’t have Hypertensives.

Interviewer: Okay. And do you have any drugs that treat heart disease?

Respondent: No.

Interviewer: Do you have any drug like Benzathine in stock here?

Respondent: I haven't heard but for the moment we don't have.

Interviewer: And you’ve said there's no supervision, supervision is lacking! How would you want your health center to be supervised?

Respondent: Of course if you come to ground as a head, you have to discover the problems; our issues, but those people may take a long time to come to the ground yet some of us have our issues so, it is such things.

Interviewer: Okay. How about the leadership here, if you need supplies and things to use do you get them?

Respondent: They do supply.

Interviewer: Anything lacking in the administration?

Respondent: [no response]

Interviewer: silence means nothing?

Respondent: Let's leave that.

Interviewer: How about funding in health care, is it working for you as you are doing your work as a health worker?

Respondent: It's working for me on side but not much for the patients.

Interviewer: Okay. Explain more.

Respondent: Maybe we get funding but maybe we may not be knowing because I see we don’t get most of the things we need. You find that one who has a BP machine moves with it; it's personalized. That means it's his and the health center doesn't have any.

Interviewer: So when you request what happens?

Respondent: Of course they keep on promising we shall get.

Interviewer: So what do you do when you get a hypertensive patient or people whom you need to check with that machine? In such instances how do you handle?

Respondent: But we always have our own equipments.

Interviewer: So you move with your own BP machine.

Respondent: [laughs] and when I am not around they won't take any blood pressure and I cannot leave it behind.

Interviewer: Umm, when you look at the number of health workers, how are they here? Are they working in number?

Respondent: We have a number of health care providers but I can say to an extent they are not enough. You know they may be enough but they don't want to provide services.

Interviewer: So how are the numbers of patients here?

Respondent: For the patients they know the time when we get drugs and when they are out of stock. When they know we have drugs they come in big numbers. Like in this season, we have a big number of patients not like the previous months.

Interviewer: They get to know there are drugs?

Respondent: Yes, that's when they come.

Interviewer: And then if you look at the qualifications of the health workers here are they working for you or there are Cadres where you feel like they need to be boosted.

Respondent: So things of Cadres, as you have seen we have doctors, nursing officers, clinical officers but you find a doctor doesn't work and it's the nursing assistant who works meaning those cardiac patients have to be attended by a clinical officer or a doctor or nursing officer but when you find a nursing officer attending to cardiac patients, that means doctors and clinical officers don't know what they are supposed to be doing.

Interviewer: When you look at the medicine you said you usually have stock outs. You don’t have most of the medicine.

Respondent: Yes.

Interviewer: And for the heart medicine you don't have any. Is that what you are saying? Okay let me mention some; do you have some of the heart failure drugs here in your health center? Have you seen any?

Respondent: Am not sure.

Interviewer: How about the BPG?

Respondent: Am not sure.

Interviewer: Do you have Anti coagulation drugs in stock here?

Respondent: May be.

Interviewer: Maybe? Have you seen any?

Respondent: But I can't tell because I haven't seen any.

Interviewer: Okay. And how about diagnostics, tell me about them. How are they in this Buwambo health center? Are they working for you?

Respondent: The?

Interviewer: The diagnostics. For instance, do you have echo-cardiography here?

Respondent: No we don't have.

Interviewer: And where is the nearest health center to get one?

Respondent: Maybe in town or Bombo.

Interviewer: Okay. So let's look at the record keeping system and the health information flow here. Is it working here?

Respondent: As in what?

Let's look at how you keep records in case you need to look up a patient who has come in for follow up. Is it easy to access the file if you want to know who worked on that person?

On my side it's working very well in the HAART clinic but this side I don't think it’s flowing very well.

Interviewer: How can we improve the way information flows between you?

Respondent: Maybe installing a system where we can track all those patients.

Interviewer: What kind of system?

Respondent: It can computerized.

Interviewer: Have you had any RF patients? Patients who come with acute rheumatic failure?

Respondent: I haven’t had any.

Interviewer: So you don't have any kind of registers for those kind of patients.

Respondent: No. I know we don't have any registers.

Interviewer: Have you looked at any guidelines for RHD management?

Respondent: No.

Interviewer: Okay. Have you ever attended any CME on heart disease or RHD?

Respondent: I have never attended any CME.

Interviewer: Do you hold CMEs here?

Respondent: We have.

Interviewer: How many? How often?

Respondent: We always have. Of course for CMEs it always depends on staff cooperation; when you call someone to come and have a CME they say, "are you paying me? If you're not paying me, then I am not coming”. Because some people are not cooperative so we can’t have a CME of 2 or 3 people. With two people you can have it but of course it's better if you are more than 3.

Interviewer: Okay how often do you hold them?

Respondent: We always have CMEs twice a month.

Interviewer: And then could you be knowing a referral path for RHD patients; that this is where you take them. Do you know any of those facilities?

Respondent: Am not very sure.

Interviewer: So among the things we've have mentioned administration, funding, health records system, guidelines what has worked for you? What has motivated you to do your work? What do you think is working for you in Buwambo?

Respondent: Okay funding, administration, record keeping; actually everything is down.

Interviewer: Nothing has worked for you! Okay, and then let's look at the perception of patient outcome. Generally do you think these patients like the RHD patients get the care they need here?

Respondent: For those who find positive health care providers, they get the care.

Interviewer: Okay. And can your health center handle surgeries for RHD patients?

Respondent: Maybe you ask the doctor.

Interviewer: Okay. Do you have anyone who can handle such cases?

Respondent: I don't think.

Interviewer: You don't think?

Respondent: Yes.

Interviewer: Okay. When you look at your patients and their safety; is it put into consideration when you are working on them here in Buwambo?

Respondent: Safety?

Interviewer: Yes, for patients.

Respondent: Usually that's the first thing but in Buwambo I don't think it's considered. Somewhere somehow it's not considered.

Interviewer: Why do you think so?

Respondent: This is a center where you find the VHTs prescribing in the absence of staffs. So you can never know that they might prescribe a dangerous drug. So anything can happen.

Interviewer: Why does it happen? What makes that happen?

Respondent: I can't say that we don't have qualified staff because we have qualified staff, but people don't know how to perform their roles or when to perform their duties.

Interviewer: When you look at the quality of care being given to your patients here how is it?

Respondent: I think it's at 50

Interviewer: What’s stopping it from being 100%? Where are the gaps?

Respondent: Those people will prescribe a drug, the patient goes to the register but doesn’t have drugs that means the chain is not complete. Some come to the laboratory but from there they are not seen by the medical staff.

Interviewer: Okay, anything else?

Respondent: no

Interviewer: Okay, have you seen any preventable death which occurred but wouldn't have occurred? You know there are those deaths that happen and you are like um no.

Respondent: It might have happened?

Interviewer: Yes.

Respondent: For The time I’ve been here I've seen only death that was at theater.

Interviewer: Where do you think went wrong?

Respondent: There I wont go deep.

Interviewer: I had to do with what? You don't have to mention people's names but what could have happened to her?

Respondent: Let's leave that.

Interviewer: We Leave that?

Respondent: yes.

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

Respondent: Of course.

Interviewer: Why?

Respondent: There are far away from the basic health care settings or they don't know what they are supposed to be doing.

Interviewer: They don't know what they are supposed to be doing, in what ways?

Respondent: In that when you are sick you have to go to the hospital where you can get help.

Interviewer: Which other reason? Why are they dying? Apart from distance and not knowing.

Respondent: (silence)

Interviewer: Okay. So in your opinion which are the two most important things Ministry of health should do to improve patient outcomes? Let's begin from general patients then we will narrow it down to RHD patients.

Respondent: Ministry of health! What I know they are funding but they don't follow the accountability for their funds. That's what they are supposed to do so that such a health care unit cannot lack even a thermometer and yet we are getting a lot of funds.

Interviewer: So accountability needs to be improved.

Respondent: Yes.

Interviewer: Okay anything else?

Respondent: And regional supervision for health workers.

Interviewer: What can be done for our RHD patients?

Respondent: Firstly by recruiting qualified staffs for future conditions.

Interviewer: Okay. Anything else before we finish? Okay. Thank you so much for your time and contribution towards this study, we shall your ideas to provide better services to RHD patients.

Respondent: You are welcome.

Interviewer: And we going to give you your money to pay for the time you spent away from your duties.