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

Interviewer: Today is the 15th Dec 2018 interview being conducted in the female medicine ward lira regional referral hospital, doctors’ office room, and health care worker 004 Thank you very much for taking your time to participate in this interview, this is the study we are conducting to determine how to provide better health care for health workers, I mean better care for RHD patients, ah... feel free to respond in the best way possible, everything said here is confidential and there is no right or wrong answer, all answers are acceptable, Alright, tell me about yourself .thank you

How old are you?

Respondent: Am 25 years of age

Interviewer: Ok, your qualifications?

Respondent: Am a medical clinical officer

Interviewer: Alright, where did you train from?

Respondent: From Kampala school of health science

Interviewer: when was that?

Respondent: From 2013- 2016

Interviewer: Ok, so when did you qualify?

Respondent: I qualified in 2017 April

Interviewer: So, 2017, so how long have you been working hare in Lira regional referral hospital?

Respondent: 1 year and 6 months

Interviewer: Ok majorly which patients do you usually see during your time here in lira regional hospital?

Respondent: Patients like in age group from 5-19 years

Interviewer: Ok then, could you list a few common illnesses you usually see in your patients like in most programs in a typical day

Respondent: Yes, I normally see cases like pharyngitis, laminitis, UTI’s, malaria, osteomyelitis and others

Interviewer: Ok... like let’s say according to age groups being the lower ones, which are the common illnesses you see in them? Like in

Respondent: Children? Children below 5 years we have pneumonia

Interviewer: Ok

Respondent: We have bronchitis

Interviewer: Yes

Respondent: We have dysentery and people with sore throats

Interviewer: Ok then of these others, let’s say above 5 years, which common illness do you see in them?

Respondent: The common illness I normally see with those ones above 5 years, we see people with tonsillitis, people with laminitis, people with chronic illness like sickle cells, asthma, diabetes and many other

Interviewer: And then do you ever see people above 19 years in your practice?

Respondent: Yes

Interviewer: So, which are the common illness you see in those ones above 19 year?

Respondent: Above 19,

Interviewer: Yes

Respondent: I can majorly say as I said people majorly with chronic illness

Interviewer: Ok

Respondent: Like...we have diabetes, asthmatic patients

Interviewer: Ok

Respondent: People with recurrent tonsillitis

Interviewer: Yes

Respondent: Then UTI’s

Interviewer: Ok have you ever received any training on RHD?

Respondent: No

Interviewer: Not even in school?

Respondent: In school?

Interviewer: Yes

Respondent: Yes

Interviewer: What do you remember about what you were trained in school?

Respondent: So, if I could say what I was trained in school about RHD, when we were trained on the definitions and the signs and symptoms

Interviewer: Ok

Respondent: Yes, and how to manage them

Interviewer: Ok, what do you remember?

Respondent: I remember they told me that acute rheumatic fevers is an illness caused by an auto immune response to bacterial infections with groups streptococcus

Interviewer: Ok

Respondent: Yes

Interviewer: Alright, ever since graduation, have you received any training on RHD?

Respondent: No

Interviewer: Let’s say like on a typical day, how many patients do you come across with RHD during your clinic day?

Respondent: During my clinic day they can come, they can, so far they can be 3 in a day

Interviewer: 3 in a day? Ok... and these patients, do you see both the inpatients and the outpatients? Or you...

Respondent: Outpatient department?

Interviewer: You are based in outpatient?

Respondent: Yes

Interviewer: So are you based in that

Respondent: Yes

Interviewer: Ok...outpatient...ok and then just interested in what you are being taught, what is your understanding of what causes RHD?

Respondent: According to my understanding, rheumatic fever disease according to me, it’s caused by bacteria

Interviewer: Ok

Respondent: Yes

Interviewer: And then are you aware of the link between sore throat and RHD?

Respondent: Actually, not very

Interviewer: What do you mean by not very, so like do you have an idea?

Respondent: So, I have the idea that I was just with it from school

Interviewer: Ok

Respondent: Yes

Interviewer: So, what do you remember?

Respondent: So, what I can remember from what I was taught from school about sore throat with rheumatic fever is the way I understand, it is there, if someone is presented with sore throat what to do is...

Interviewer: Ok

Respondent: You need to take some investigations and you find of majorly what could have been the cause of this sore throat and you go deeper and deeper to understanding what could be the major cause of this sore throat. If you have found out what caused it, by like we have many groups of bacteria so you try to relate it to what could be the target place in the heart

Interviewer: Yes

Respondent: That is what I know

Interviewer: Ok, am going back to our previous question on understanding the causes of RHD, you talked of bacteria do you know these bacteria exactly?

Respondent: No but I can say it’s in a group of streptococcal A, group A

Interviewer: Ok..., alright...ah... were you taught about what can be done to prevent RHD?

Respondent: Yes, a little bit, I was given how to treatment of rheumatic fever disease

Interviewer: What else under prevention?

Respondent: Under prevention I was also taught...under prevention ...early diagnosis and treatment

Interviewer: Ok...anything else?

Respondent: Others, I was taught about management of or prevention of rheumatic fever disease, so like I said earlier, like... early diagnosis and treatment

Interviewer: Ok

Respondent: After you have given treatment, you need to make follow up, yes

Interviewer: Alright, and then what were you taught about the treatment option for RHD?

Respondent: Treatment option?

Interviewer: Yes

Respondent: So, I can remember what I was taught with it that once you see someone with rheumatic fever disease, you can put that person on strong anti-biotic like penicillin, benzathine penicillin

Interviewer: Ok, anything else concerning treatment?

Respondent: So, things which I can add about the treatment, it’s just time, its long treatment time

Interviewer: what do you understand about the long-term prognosis of RHD?

Respondent: A long term prognosis of rheumatic fever, I can say the long term is the way I understand it, long term prognosis can be what could be the cause after the treatment

Interviewer: No, the prognosis is like the outcome

Respondent: Yes. The long-term outcome of rheumatic fever disease?

Interviewer: Yes ,

Respondent: Yes, I can say some patient or in some age group, you will find some people within that age group will start to be traumatized with what has been taking place since their understanding is still about the disease or what is affecting them

Interviewer: Yes

Respondent: Since they know about it, so they will keep on asking themselves why am i, they are doing this on me, others they are not doing this, so in the long term, they will be traumatised

Interviewer: Ok, anything else concerning that?

Respondent: That is the information

Interviewer: Ok, when do you recall the last patient, when was the last time you saw a patient with RHD?

Respondent: The last time I saw a patient with acute rheumatic fever was in sept...was in July

Interviewer: July eh?

Respondent: Yes

Interviewer: Ok, could you tell me about, like summarise the visit like the description, the presentations

Respondent: Actually, the patient was referred from the health center within their locality where they were coming from.

Interviewer: Ok

Respondent: And he was referred to lira regional referral hospital for further management and investigation, so on arrival, the patient had a form which he was referred from a health Center where they were so on reaching on my desk, so they explained to me what was taking place until when they were given a referral form, so I did some investigations, clinical investigation

Interviewer: Ok

Respondent: and what they told me was the child had recurring tonsillitis, like it can take like 2 weeks, it comes back, two weeks, it comes back like that, so they went to a nearby facility and they were referred to the regional referral hospital and I had a clinical assessment like looking through the oral cavities and found out that there was sore throat and pain when swallowing and the patient was complaining of like she feels pain on the knee like I can say that the digits all over.

Interviewer: Ok

Respondent: And slight increase in temperature, sometimes it increases and drops drastically, it increases and drops drastically

Interviewer: Ok... other than that what else?

Respondent: so even she also told me that she has like headache which is sometimes on and off, it comes like in 2 days and it disappears, then it comes the next day like that, like that

Interviewer: Ok, so what was your management plan for them?

Respondent: the management plan for them?

Interviewer: Yes

Respondent: As per outpatient

Interviewer: Yes

Respondent: As per outpatient, after me looking at those signs and symptoms

Interviewer: Ok

Respondent: So, I had to send them to a clinic where they are supposed to be seen

Interviewer: OK

Respondent: According to the information we were given, the person presenting the complaints of the signs and symptoms of rheumatic fever disease, so there is a special clinic they normally go and attend the services for further investigation and management but from outpatient, we also put our diagnosis but we query

Interviewer: So, for you, you only suspect

Respondent: Yes

Interviewer: Ok. And then what is the average age of the patients you see with RHD, those that come to you

Respondent: According to the age groups?

Interviewer: Yes, on average, the age

Respondent: The age? It’s majorly from the age, you can say from 8-12 majorly

Interviewer: From 8-12?

Respondent: Yes

Interviewer: Ok are most of them in school or...l?

Respondent: Yes, most of them, most of them are in school, some clients who come, most of them are primary pupils, and others are secondary students

Interviewer: Ok, so you don’t have any who come and they are not in school?

Respondent: Others come and tell you that am no longer in school

Interviewer: Ok, so they give reasons why they are no longer in school?

Respondent: Yes

Interviewer: And what reasons do they give?

Respondent: The major reasons they normally give is the disturbance from their step mothers, they have abandoned them, others the fees problems, others the distant from home to school is quite long, so that’s the problem they normally give me why they are not in school but the majorly is because of the family issues

Interviewer: But not because of the disease?

Respondent: Yes

Interviewer: Ok, when you try to ask them, are they generally aware of the link between sore throat, ARF and RHD?

Respondent: Some others when you have asked, they say they have heard of this over the radio stations and village health teams about the relationships between sore throat and ARF

Interviewer: Ok

Respondent: So, others come when they have already heard that information, we heard over the talk shows, over the radio, those ones whose parents are educated and other over the village health team

Interviewer: Ok, whenever they come to you, what sorts of symptoms do they describe to you, most of your patients?

Respondent: The symptoms, they normally tell us about what they have gone through, majorly others can say I have been having this long thing for a long time, I don’t know what could be this, so I have come to the hospital to seek what could be the problem with me

Interviewer: Like do you mind listing the symptoms, what they come with or what would be presenting complains always when they come?

Respondent: So, when they come, we normally record it in our medical record forms what they are telling us about what they are experiencing

Interviewer: Ok what am trying to ask is ,can you list them, the symptoms that they always describe just like you talked of joint pains, do you know any other symptoms that they...

Respondent: So, when they come with joint pains, they normally say that they feel like something is just scooping inside the bones, that’s what they normally tell us, there is something like they are scooping my bones like roughing on a roughing, so they feel much more pain when those things are happening

Interviewer: Any other thing other than that they come and explain to you?

Respondent: Yes, others, they come like they feel like fever, when the temperature is high like they feel is associated with chills, even if during hot conditions

Interviewer: Ok

Respondent: Yes

Interviewer: Anything else

Respondent: Like others say they muscular pains

Interviewer: Ok, is that all

Respondent: That is what I can recall

Interviewer: Can recall?

Respondent: Yes

Interviewer: Ok, so generally about the follow up and adherence, is it good?

Respondent: Yes, follow up and adherence is very good for our clients

Interviewer: Do you do follow up for OPD as well?

Respondent: No

Interviewer: So how do you find out if they are really following their treatment? How they have been adhering for their medication?

Respondent: I normally come to the clinic where they do their further investigations and management and I try to check on

Interviewer: Ok, alright, so what sorts of barriers do they commonly state to getting the care that they need?

Respondent: So, what they normally tell me about the difficulties they get in their case, like one day one of them told me that whenever they come, they take a lot of time

Interviewer: Ok, what else?

Respondent: sometimes they even say like when they are moving from their villages to the healthcare point. They always delay and sometimes the mode of their coming like transport, like sometimes when they are in for their...like I say, like the day when they say you come for treatment

Interviewer: Yes

Respondent: The revisit day, so they say whenever they are coming, sometimes they don’t get transport from where they are coming from and they delay

Interviewer: Other than the delay, do they also give you other barriers like the challenges they face to getting health care that they need?

Respondent: So what I can recall about the challenges, they normally get like when they are referred maybe to a...like treatment section, so when they say like this treatment, we are going to maybe give you a package and you go to the nearby health facility, when you find it difficulties to come to the referral hospital by trained health workers from the health facilities like I can say from H/C 111,H/C IV within their localities, they normally say that from there, the health worker are harsh on them sometimes

Interviewer: Ok

Respondent: They don’t care about them to the expectations they want

Interviewer: ok then, that was according to them right, now this question is what barriers or what challenges do you perceive that they face in getting what they need according to you

Respondent: My challenges?

Interviewer: No, the challenges you assume or you feel the patient get in receiving health care that should...like what do you think the patients are facing? The other one was on the point of the patients, what they tell you they face but this time around, it’s you, looking at it in their views, what you feel that they face, the challenges.

Respondent: The challenges they face according to me?

Interviewer: Yes

Respondent: One I can say, to me I see they come when they are already, like I can say they are traumatised

Interviewer: Ok

Respondent: Whenever you try to explain what is happening to them, they still have that mentality that this thing is like this? Why is this so different from others, so it refers me back to my first statement that they are traumatised?

Interviewer: Ok, what else do you think that they face? Other challenges that they face?

Respondent: stigma

Interviewer: Ok

Respondent: Yes

Interviewer: Ok, any other things?

Respondent: That’s according to me, how whenever they come

Interviewer: Ok and then this is in terms of health system barriers, is the administration working for you and leadership in the district like do you think it’s doing well?

Respondent: To me I think there is a gap

Interviewer: like?

Respondent: One is communication gap

Interviewer: Ok, do you mind explaining this

Respondent: The way I can explain my communication gap between the districts as you have stated, sometimes you find that the district does not even give the adequate information of what is taking place, they give partially

Interviewer: ok, other than communication gap, anything else?

Respondent: I can say yes, like teamwork

Interviewer: You feel like there is no team work

Respondent: Yes

Interviewer: Or there is team work

Respondent: You can say there is adequate team work

Interviewer: Ok then, in terms of funding for health care in generally on RHD in particular, do you think they are aware of this information?

Respondent: Can you please come again?

Interviewer: Like what do you think the district or like let’s say in terms of funding for health care

Respondent: Yes

Interviewer: What do you think, ok generally and particularly RHD, what do you think is not being done well

Respondent: Like when...

Interviewer: And the funding

Respondent: And the funding?

Interviewer: Yes

Respondent: Underfunding like I can say that there is also inadequate mentorship for ARF

Interviewer: Ok, other than that, anything else?

Respondent: That is what I can state

Interviewer: Ok and then when you look at the health workers, what you think it’s not working well for them

Respondent: In what ways?

Interviewer: In terms of just like, let’s say, what do you think is being done well for you and why do you think so? Like what you think should have been done which is actually not being done

Respondent: Yes

Interviewer: You as a health worker

Respondent: I can say in terms of facilitations?

Interviewer: Yes

Respondent: It is not being done well because sometime you see we have like I can say there, staffs only strictly working on those things, they don’t involve others, so in the process, it brings tension between that then they will say that maybe these are the people specifically working for that like I can say ARF

Interviewer: Yes

Respondent: So that is what I can explain about that

Interviewer: Ok, what would bring about the team bit you talked about previously?

Respondent: Yes

Interviewer: Ok and why do you think it’s happening like that

Respondent: The way I think it’s happening like that because there is a principle which says a boss will always be a boss right, so when someone is above you and said something, there is no way you can go beyond that person

Interviewer: Ok, and that’s happening here like for the different health workers.

Respondent: I can say yes

Interviewer: Has it happened in several department or we have specific...

Respondent: So, like in my department, so it has happened because you see like when like the fellow staff like my fellow staff, they say you go to that people, you will handle that case, so it means there is a gap between there

Interviewer: Ok, so do we have like are the medicines available in the hospital?

Respondent: For ARF

Interviewer: Ok, generally

Respondent: Yes, the medicine for ARF is available

Interviewer: So, what would you say, it’s not working well for you, let’s say in terms of medication

Respondent: In terms of medication?

Interviewer: Let’s say benzamine penicillin, heart failure drugs

Respondent: So, I think I have no problem with medication

Interviewer: Ok

Respondent: Yes

Interviewer: You think it’s available

Respondent: Its available 24 hours

Interviewer: Ok, even heart failure drugs?

Respondent: Yes

Interviewer: Do you do echo cardiography in our facility?

Respondent: Yes

Interviewer: Yes, you do echo? And everyone has access to it?

Respondent: Yes

Interviewer: Ok and then how would you describe your record department?

Respondent: The record department I would say, there is still gaps in the record department

Interviewer: ok do you mind explaining that?

Respondent: Yes, the reason why I have said the record gaps like am looking in the outpatient where we like see patient referred from a health facility, we don’t have registers to record those ones referred or those ones we have seen, then we have sent to the clinic for ARF

Interviewer: Ok, so we still have that record gaps

Respondent: In terms of the registers

Interviewer: Do you have like an ARF register for RHD patients in your department?

Respondent: No, I don’t have in my department

Interviewer: Oh... what of any, do you ever record or keep any information concerning those patients?

Respondent: No

Interviewer: Ok, in your department, do you like have any guidelines and protocol for RHD care

Respondent: Yes

Interviewer: Including the referral pathways?

Respondent: No

Interviewer: But you have the guidelines, right?

Respondent: Yes

Interviewer: We were looking at the barriers to the local health system but now let’s look at the enablers, what do you think that the administration and leadership in the district has done well for you or for the district in general?

Respondent: Let’s say they have done best in sensitising the community

Interviewer: Ok

Respondent: Yes

Interviewer: What else?

Respondent: that is what I can say

Interviewer: Ok what of in terms of funding of health acre

Respondent: Funding health care?

Interviewer: Yes

Respondent: I think in the funding of the health care within, from the district

Interviewer: Yes, ok that one could go as far as government, in general ministry of health, do you think or what has been done well in terms of funding of health care and for ARD in particular?

Respondent: I think the funding is fine according to me

Interviewer: Ok, so what are you happy about in terms of its funding?

Respondent: In terms of its funding, am happy about like when there is follow up, some times when we don’t do a follow-up or generally don’t follow up, we normally lose our clients so with follow up and the ... I am...can say that majorly the transport refunds for those ones who are enrolled now is quite, I can say it’s quite good

Interviewer: Ok and then what of the health workers, what do you think you are doing well, ok all the other health workers generally in terms of waiting time and the quality of care offered to patents?

Respondent: I think the health workers, we have improved

Interviewer: Ok what do you think they are doing well, like when you look at them and the services they are offering, what do you...do you think they are doing well?

Respondent: Like I can say the clinic is doing well because you see like the referral funds has been given to majorly the health facilities within and where the patients are coming from or I can say the clients

Interviewer: Yes

Respondent: Whenever they hear about this, they go to health facilities, they are given forms, they make the work easy when they come, and we do our assessment where they get the exact help from.

Interviewer: And then ok I had asked about medication previously: do you think like what do you think the hospital is doing well in terms of medications like for the clients?

Respondent: So, the hospital is doing well in terms of medications like one, we don’t have like stock out of those drugs within the facility

Interviewer: Ok so at all times you have like BPG drugs, the anti-coagulation drugs and the anti-heart failure drugs available?

Respondent: Yes

Interviewer: Ok and you said they can get all these drugs from the pharmacy /hospital pharmacy?

Respondent: Yes

Interviewer: There is no time they are supposed to buy?

Respondent: I have never come across that

Interviewer: Ok and then in the records, what are they doing well, what have they done well? records department

Respondent: Records department?

Interviewer: Yes

Respondent: I think they are doing well because they are capturing the data when these clients come

Interviewer: Ok

Respondent: they are there like the time they have reported like even taking other vitals, the return date, the return date, they have been captured in the register, I can say in the register but in the outpatient is still the problem to us

Interviewer: So, concerning your perception of patient outcomes ah...do you think they get the care they need or not? Like most especially surgery

Respondent: surgery?

Interviewer: Yes

Respondent: For the case of surgery, I have never come cross

Interviewer: Ok

Respondent: Yes

Interviewer: And why do you think the? Is surgery offered in lira regional referral hospital? Concerning RHD

Respondent: That one I have never come across

Interviewer: Ok

Respondent: Yes

Interviewer: That one you not sure?

Respondent: I am not sure

Interviewer: Ok, but aside from surgery do you think these patients are getting the care they need

Respondent: Yes

Interviewer: According to you

Respondent: According to me

Interviewer: Ok do you have any patient safety or quality of care concerns?

Respondent: To me, no

Interviewer: No! Ok like you feel the patients are safe in the hospital

Respondent: Yes

Interviewer: Not concerned about anything? , what of the quality of care, like is it really fine

Respondent: Yes, it’s the quality of care they are giving them is fine

Interviewer: You don’t have any doubts

Respondent: I don’t have

Interviewer: Or worries about it

Respondent: I don’t have any doubts or worries about it

Interviewer: Ok, during you...This time around that you have been in the hospital, are there any preventable deaths that you think you could have been actually stopped in the hospital

Respondent: Yes ,according to ARF, when we ,they are early diagnosis and put on treatment, we prevent like substance which may happen, when we like they could have been where they not minding about what is happening to them ,we put them on treatment, it means we are preventing other complications of the heart

Interviewer: Ok, ah...So now leaving a side the ARF and ARHD

Respondent: Yes

Interviewer: Have you like are there any prevented deaths that could have been occurred in the hospital that you feel shouldn’t have happened? Like you look like this person wouldn’t have died had this and that been done?

Respondent: No

Interviewer: No?

Respondent: Yes

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

Respondent: Yes

Interviewer: What do think is causing that?

Respondent: In the community?

Interviewer: Yes

Respondent: Like I can say knowledge gap

Interviewer: like could you mind explaining further?

Respondent: I can say knowledge gap in terms of like we have like few staffs who can explain and may be sensitise the community about, maybe what is happening ,currently happening

Interviewer: Ok

Respondent: Yes

Interviewer: Alright..., now for these patients who die in the community before they even reach in the hospital, what do you think causes that?

Respondent: Sometimes the cause of those things is like when we have like culture and religion

Interviewer: Yes

Respondent: So, you find where religion is saying ah...this is manageable by prayers, so it’s not treated to medical, others you find this culture is saying with this complaints like this kind of infections

Interviewer: Yes

Respondent: We use like local herbs, so they don’t dwell with modern techniques, like I can say with the lines of medicines, So there are cultures which they do away with those things

Interviewer: Ok, in your option, what do you think are the...ok in your opinion on ..,that do you think are the most important things that ministry of health could do to improve on outcomes of this place?

Respondent: More training of staffs and village health teams to sensitise the community

Interviewer: Ok, what else?

Respondent: I have said about training of staffs and more VHT’s and putting monitoring and evaluation teams

Interviewer: Where do you think that could be placed?

Respondent: like I can say in the referral hospital,

Interviewer: Thank you so much, aside from that, do you have anything you have to say?

Respondent: like?

Interviewer: To add on

Respondent: which area specifically?

Interviewer: Anything, anything concerning what we have learnt, and what we have said today

Respondent: No

Interviewer: No! Ok thank you for taking Part in this interview, yeah, thank you, we shall get back to you