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

Interviewer: Thank you for giving us this time. This study is to determine how to provide better care for RHD, and that is Rheumatic Heart Disease. There are no right or wrong answers; we just want to hear your opinions. Please be frank and share your opinions. The data we gather is going to be kept confidential and we are not going to put your identity on any of the comments in the reports we produce. Tell me about yourself; how old are you?

Respondent: I am 58

Interviewer: What are your qualifications?

Respondent: I am an enrolled midwife

Interviewer: Where did you train from?

Respondent: Where I trained from?

Interviewer: Yeah

Respondent: Mbarara, and by that time it was school of Midwifery and nursing but now it is a university

Interviewer: Okay. So how long ago did you qualify?

Respondent: I have worked for so many years; I started here in 1986, July

Interviewer: Okay, and you have been here since then?

Respondent: Yes, it was my first postage and it is where I have been working all this time.

Interviewer: So doing your practice, what are the common illnesses that you have seen around here?

Respondent: In this unit we have the NCDs and those are non-communicable diseases, Diabetes mellitus, tonsillitis, hypertension, umm and also other diseases associated with those problems.

Interviewer: And when you look at the demographics of the patients, which are the common? By demographics I talk about age, sex. So the common patients you get lie in which age group?

Respondent: Now, we have also like in the DM, we also have young kids but at Wakiso they have a clinic for DM for young ones so we always send them there but here we have from ages up to 70 years.

Interviewer: And then, how about heart disease; is it a seen in many patients?

Respondent: At times, because here in our setting like tomorrow in the HT clinic, we always have a doctor here who always assesses them and they give her their complaints and then she prescribes accordingly.

Interviewer: So the clinic is always on Tuesday!

Respondent: Yeah, on Tuesday, the one for hypertension.

Interviewer: Do you participate in that clinic?

Respondent: Yeah, we do participate.

Interviewer: And then, tell me a little bit about your training in Rheumatic Heart Disease; have you ever received any specific training at school?

Respondent: Umm, I do recall. Anyway I think we passed through it but not in details.

Interviewer: Okay, but you have not had any training?

Respondent: No.

Interviewer: How about after training; have you had any training, any workshop where they talk about RHD

Respondent: umm we have gone for workshops but not majorly in this rheumatic whatever, but in other cases

Interviewer: So you have never had any training in RHD?

Respondent: Yes

Interviewer: So since you started practicing, or you have been here for a while, have you encountered any RHD patients?

Respondent: Yeah, I think in the HT clinic we have some like four because at times doctors always send them for whatever ... I have forgotten the name. They send them for checking their hearts although I have forgotten the term they use, then they come back for results and those ones are already on treatment.

Interviewer: Okay

Respondent: So they always send them there in they bring back the results since they are already on treatment.

Interviewer: So you see them!

Respondent: Yeah, I see them

Interviewer: When do you remember last seeing the last patient? In a week you see like how many?

Respondent: At times we can have none in a week and at times we can get, like tomorrow on a clinic day, there can be like two or three, but not always like on a daily basis.

Interviewer: So in a month you can see how many?

Respondent: In a month they can be either 5 or 6 around there

Interviewer: And then, are they mainly inpatient or outpatient?

Respondent: It depends on somebody’s condition; if he is very ill we always admit. If she can go back home, they prescribe for her and she goes and buys the drugs and they keep at home.

Interviewer: Now I am interested in what you have been taught about RHD; what is your understanding of the causes of Rheumatic Heart Disease? What do you think causes that disease?

Respondent: Causes, do I know the causes? [Laughs] I am not sure of them but maybe like someone with mainly high blood pressure and they put her on treatment but she doesn't respond well to the treatment, I think maybe people like that one may have that problem.

Interviewer: Do you know any link between sore throat and RHD? Are those two associated in any way?

Respondent: I think they may be related but I am not very sure whether they are.

Interviewer: You are not sure if they are related!

Respondent: Yes

Interviewer: Okay, so what were you thought that could be done to prevent Rheumatic Heart Disease during school?

Respondent: [laughs] let me see if I remember. But any way I think people should go for checkups to know their status, they check their blood pressure, you have to do exercises and diet also matters. Umm those ones who always have worries, okay that one you can’t miss to be there but I think people should not be worried every time because it hikes the blood pressure which may bring problems for them.

Interviewer: What were you told about how to treat a patient with Rheumatic Heart Disease?

Respondent: This being a big hospital, we always get patients that have been already seen, like we have a physician here and if the case is for him they are always sent there and a doctor prescribes for them. Then for us we just give the treatment.

Interviewer: What treatment do you usually give these patients who have Rheumatic Heart Disease?

Respondent: Umm, it depends; we just give according to the prescription but I think most of their drugs, like maybe Trovas and what. Some of them we don’t have them at the hospital. They are sent to go and buy them. But if they are prescribed what we have, we always give them.

Interviewer: Okay, is there any that you have that you know treats this disease?

Respondent: No because it is always a combination of the hypertension drugs and the other. So for us we just give what we have and we tell them to go and buy what we don’t have.

Interviewer: Do you stock Benzathine?

Respondent: Benzathine injection? Yeah; in our outpatient we have but here we don’t

Interviewer: What about Warfarin?

Respondent: That one I don’t know whether we have it because for us we always order what we supply to our patients. So some of the drugs are being supplied through the pharmacy at the OPD

Interviewer: So you don’t have those drugs!

Respondent: No

Interviewer: Then, are there any aspects of Rheumatic Heart Disease management which you think you need more training in?

Respondent: Yeah; if there is a chance of being trained, we want to be trained

Interviewer: Which areas would you want to be trained in managing Rheumatic Heart Disease?

Respondent: Umm, management throughout the management, the drugs, the dose and how to talk to these patients to give them advice accordingly.

Interviewer: So what is your understanding about the long-term prognosis of Rheumatic Heart Disease?

Respondent: What I understand is that if someone has that problem for so long, either she is not getting the drugs properly or taking them properly and the thing just continues to be there.

Interviewer: Okay, tell me about your encounters with these patients who have Rheumatic Heart Disease. Do you remember the last one you saw?

Respondent: Umm, usually when they are given the prescription to go and buy the drugs, they always complain that they have no money. Others may say, "I am a lone; I have no one of my kids because they all died." They always have complaints.

Interviewer: Okay. And umm, the last one you saw, was it a female or a male? How old was the last patient you saw?

Respondent: Umm, the last one was a lady

Interviewer: How old was she?

Respondent: She was between 60 and 70

Interviewer: What did she complain of? What symptoms did she describe when she came here?

Respondent: So some have different matters: others are weak and they complain of having sleepless nights at times, no appetite, and palpitations

Interviewer: when you look at these patients do you think they know of an association between RHD and sore throat?

Respondent: I don’t think.

Interviewer: They don’t know!

Respondent: Yeah

Interviewer: And then, when you give them the drugs and treatment do you think they adhere to the treatment? Do they come back for follow up?

Respondent: Yeah, they always come back because we always give them a return date.

Interviewer: And what motivates them to come back?

Respondent: They care about their life:they do care. When you tell them to come back on such a day they always come back.

Interviewer: Do you have some who miss?

Respondent: Not usually. Maybe someone can miss if she is weak and don’t have any one to bring her. That’s when one misses.

Interviewer: And the distance they travel; where do they come from normally?

Respondent: Within Entebbe, others may come like from Kajjansi, Ndejje around there. Even some can come from Kampala, because we have cases which changed from Mulago and started to come here.

Interviewer: Although they stay in Kampala?

Respondent: Yes.

Interviewer: Why do you think?

Respondent: Maybe they are comfortable coming here because at times they were saying the numbers in Mulago are overwhelming so they decided to come to Entebbe or they don't stay long like in Mulago.

Interviewer: Now, you know for Rheumatic Heart Disease, patients have to come monthly to get their treatment. So for those who don't come why do you think they miss coming for their doses? Why do you think some people stay in the community?

Respondent: Some may get tired, others may have someone to buy the same drugs if they have the prescription. They may tell someone, "you go to the drug shop and buy those drugs" and they continue taking.

Interviewer: Any other reason why some people choose not to come?

Respondent: Others its poverty; transport can fail them, others maybe be very weak and they can't come alone and there’s no one to help bring them.

Interviewer: Okay, for those few who you said do not come on time, which other reasons do they say for missing doses?

Respondent: Some are just reluctant; someone may have no reason and they say "doctor I didn’t come, I couldn't." So like that, when there’s no major problem. At times when they feel okay they just relax but there are others who are very active, when you tell them to come on such a day, they do.

Interviewer: Why do some people come when they are very sick?

Respondent: That one at times when the drugs are finished they stay without taking them so someone can spend like a month without taking the drug and when they feel very sick, they are like "let me go back to the hospital, I am going to die from here."

Interviewer: Okay and then, what sort of barriers do you face when providing services to these patients like those who come with Rheumatic Heart Disease or even other conditions?

Respondent: Others are too poor; they may come when we have stock outs so you tell them we have prescribed a list of drugs then they say, “doctor!! I won’t be able to buy it because I do not have any money. Even the transport to get here someone just helped me with it!”. Such things; poverty, no transport, no care takers. It being a chronic disease, others are just neglected by those who can buy them drugs. They say “hold on there’s no money, I will buy when I get money.”

Interviewer: Okay, and then let’s look at the local health system barriers on the side of the providers. I am going to be mentioning some of the things and tell me if they are working for you or not and tell me why. Let’s look at the administration here; is working for you? Is it helping you do your work well?

Respondent: It would have but at times the stocks in this hospital is always not enough because they may think the drugs they are supplying will take us for three months but within one month the drugs are out of stock.

Interviewer: What is hindering those people who ask for the drugs to have do better projection so that they ask for enough drugs?

Respondent: They always limit them, like they can say we want this and this but they go on cutting the budget, and the money they are supposed to use to order for things is not enough.

Interviewer: Okay, and then what else is not working for you with the administration or what is working for you in administration?

Respondent: Umm, any way it’s always the stock outs but we used to have some people, like MRC guys who used to give us some drugs which was doing good for us because at that time apart from insulin from the DM patients, we used to have the tablets for hypertension, the DM drugs were always in plenty but these days they withdrew. They had come in for five years and now that they are over, like now the insulin is out of stock and we don’t have any, so the people coming on Wednesday will cry from here. First of all insulin is very expensive, some can afford and some can’t afford to buy. Even the tablets, like now they brought only 30,000. So already we are... it’s not even a month but the drugs are already finished. So such problems are there, mainly stock outs.

Interviewer: How about leadership in the district; is it working for you?

Respondent: Huh, that one [Laughs] ... I don’t know but for us if things are there, we always order and we give our patients and they become happy.

Interviewer: How about the funding for health care in general?

Respondent: But the funding I think they are limited so much, they don’t give them enough. They should add on because the patients are increasing every day. Like here in our clinic, we always get new cases every Wednesday, those of DM on Wednesday and those of blood pressure every Tuesday.

Interviewer: How about funding for Rheumatic Heart Disease in particular. How do you see it here in the hospital?

Respondent: That one I really don’t know maybe you can get a better from pharmacist who always orders for drugs. I think he knows the better answer for that.

Interviewer: Okay, if you look at the health care worker numbers and qualifications, how are they? Let’s start with numbers; are they working for you? The staff numbers!

Respondent: The staff numbers, when we are so busy we get some assistance from other staffs but the hospital is going to be lifted to a referral status, so we are expecting to be given more nurses and other professionals.

Interviewer: How about the qualifications of health workers here, is it working for you?

Respondent: The qualifications, I think it’s good because most people have gone back to school so they have added on books.

Interviewer: Waiting time for patients; how is it?

Respondent: We are trying to limit it because like here now when we have very many patients, we try to give them numbers so they don’t complain “I came first, or you are passing me.” So we give them numbers and we are in different whatever, so someone may be taking the blood pressure, others weighing, recording the NCD books, clinical officers prescribing, others dispense and record in the books. The way we follow the orders, they don’t over stay.

Interviewer: How about the quality of care you give them; how do you look at it?

Respondent: We always give them health talks and we always tell them to ask questions where they don’t understand.

Interviewer: And the medicine you have talked about, tell me about the heart failure drugs. Do you have them in stock here?

Respondent: At times we have, there are some promoters who always come and supply us some. They have done a lot because they give us some and we give to them (patients). At times we give a full dose and at times we give some and tell them “if these ones get done make sure you buy and finish the dose”

Interviewer: How about the anti-coagulation drugs; do you have them here?

Respondent: I think they are there.

Interviewer: You have!

Respondent: They might be there in the pharmacy or the stores because other drugs we can’t know because we don’t know much.

Interviewer: How about BPG, do you have it?

Respondent: What is that?

Interviewer: How about diagnostics like echo-cardiography?

Respondent: That one I am not very sure.

Interviewer: How about the heart patients here, do they get examined?

Respondent: The doctors examine and then at times they refer them to physicians to be checked. At times they are given whatever to go and check.

Interviewer: Okay, and then when you look at the health information system or the medical record system you have here, is it working for you? The way you keep records, the way information flows from in-patient to out-patient, or in case you need information from another department is it easy to access that information and does it flow ...

Respondent: I think that one is easy although now we are starting a system of using computers in every unit, so we are starting that system here. We are not yet used to it and the computers are not enough but every unit is being given a computer. I think it will be good.

Interviewer: Okay, and then do you have registers for different diseases like for Acute Rheumatic fever, and Rheumatic Heart Disease?

Respondent: We have one for NCD and the general one.

Interviewer: And do you have guidelines and protocols for Rheumatic Heart Disease care here?

Respondent: Umm these promoters used to give us some but as we are having 5As, those that are not laminated are not supposed to put on the wall to stick, but we have some.

Interviewer: For which diseases?

Respondent: Like that one for DM.

Interviewer: How about for Rheumatic Heart Disease; do you have any?

Respondent: There was a time they gave us some but we had nowhere to hang them.

Interviewer: Who gave you those ones?

Respondent: Those promoters they come and distribute their drugs.

Interviewer: But have you seen any guidelines on how to manage Rheumatic Heart Disease?

Respondent: I think others but not our unit. I think in the ward, those people who admit patients might have some but for us here we don’t have because for us we don't admit; we just work on them and they go.

Interviewer: I understand, so for these things I have mentioned what has worked for you? Administration, funding, health care workers, drugs, information flow and guidelines, what is working for you here?

Respondent: But I think a combination of all; it is good if it is in the system.

Interviewer: But currently is it working for you?

Respondent: There are some loopholes somewhere. It is not 100%, but they are try.

Interviewer: So where do you want them to put more effort?

Respondent: I think the stock outs; if the drugs are there and the patient comes and you give him everything, it will be good.

Interviewer: So what makes you to keep working despite those short comings?

Respondent: It is positive attitude, and then the umm, and good working relationship and team work.

Interviewer: Now let’s look at your perception of patient outcomes; generally do you think patients get the care they need here?

Respondent: Yeah, they always appreciate and at times they bring us some things and be like, “doctors, thanks for treating us. You are so caring.” They appreciate.

Interviewer: Okay, do you have any patient safety or quality of care concerns here?

Respondent: Umm ... no

Interviewer: You don’t have any!

Respondent: We don’t have any except that they are too forgetful; at times they forget their things here and we give them back but stealing here in our place, no.

Interviewer: How about when you are providing them with services, do you feel like people do whatever it takes to make sure they are given services in a hygienic and safest way?

Respondent: Yeah, for us here I am sure the cleanliness is okay. We don't have any issues.

Interviewer: Okay, so if you look at the quality of care for your patients here, how is it?

Respondent: The quality, it is good.

Interviewer: Why?

Respondent: Because first of all we are clean and we always work in a clean environment, we do the needful. We have drug envelops where we always pack for them; we have no problem.

Interviewer: Have you seen any preventable deaths here occurring here? A death which wouldn’t have occurred but it occurred.

Respondent: No, maybe on the wards when they are admitted but here we have never had such.

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

Respondent: Yeah, there are there who are dying.

Interviewer: Why?

Respondent: Some of them have that thinking that they are being bewitched and they just use local herbs assuming they have been bewitched, so they can die from there. Others are too poor; transport is a problem or someone to escorts them is at times the problem.

Interviewer: And then in your opinion what are the two main things Ministry of health can do to improve outcomes in our hospitals?

Respondent: I think they should do outreaches deep in the villages and just talk to those people as they come to know such diseases, the signs and symptoms and what they should do. Umm ... I think that can work.

Interviewer: Okay, anything else before we stop?

Respondent: No.

Interviewer: Okay, thank you so much for your contribution and input to this study, we shall use the information to make there’s improvement in RHD services.