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

Interviewer: We are happy to have you here. What language could we use?

Respondent: Let’s use English

Interviewer: So we are going to ask you a few questions. In this study we want to know how we can provide better care for RHD. There are no right or wrong answers and we ask you to be frank and share your opinion. The data we gather is confidential and will not link your identity to any of the comments in any report that we produce. So first tell me about yourself; how old are you?

Respondent: I am 52 years old.

Interviewer: And what are your qualifications?

Respondent: first of all I was an enrolled nurse and then I went for a training of a nursing assistant and then I went back to upgrade for a certificate of a medical officer

Interviewer: Nice to meet you. So where did you train from?

Respondent: You mean for my nursing or ...

Interviewer: Nursing

Respondent: I trained from Masaka School of nursing and midwifery.

Interviewer: And then you went on to do a ...

Respondent: Still I went back to Masaka School of ...

Interviewer: Eh, you went back to Masaka!

Respondent: It was introduced there in 2001 from the Mulago Anesthetic Department.

Interviewer: How long have you been working here at Buwambo?

Respondent: This is the fourth year

Interviewer: Where were you before you came here?

Respondent: I started in Entebbe hospital. This program was started so that we can start individual health centers. So we started this program and when we finished they told us to come back to our health center points. So we came back and we were referred to Masaka and from there I came to Kasangati and then I came to Buwambo.

Interviewer: So when you look at the demographics of the patients for those years that you have practiced, how are they distributed; the age groups? Whom have you been seeing mainly in terms of age group or sex among the patients? Have you been seeing more women or more men?

Respondent: It is more women because I am mainly on cases of mothers with caesarean section

Interviewer: So you mainly work on mothers!

Respondent: yes, maybe ...

Interviewer: What are the common illnesses that you have treated here?

Respondent: It is malaria and maybe respiratory tract infections and diarrhea but most especially much of the malaria and respiratory tract infections.

Interviewer: So how often do you get children presenting with sore throat, adults presenting with sore throat?

Respondent: We get them.

Interviewer: So tell me about your training in RHD; have you had any specific training in Rheumatic Heart Disease when in school?

Respondent: I was still in nursing.

Interviewer: But you had some bit of training?

Respondent: Yes.

Interviewer: And then, after school did you have any training about Rheumatic Heart Disease?

Respondent: Not really.

Interviewer: Any CME, seminars where they talk about it?

Respondent: Maybe the CMEs when we have some conferences in the field

Interviewer: But not RHD

Respondent: No

Interviewer: So in a month how many RHD patients do you see here in Buwambo?

Respondent: I have never seen any.

Interviewer: So when did you last see an RHD patient?

Respondent: I was still in training

Interviewer: And in which hospital was that?

Respondent: Mulago hospital.

Interviewer: So here you have never had any one.

Respondent: No.

Interviewer: And then umm, I am now interested in the things they taught you about RHD; so what is your understanding of the causes of RHD?

Respondent: A patient will come with complaints of sore throat and if not treated properly, it can send to the heart maybe and start complaining of heart problems.

Interviewer: And have you had such patients complaining about sore throat which is not normal?

Respondent: There are there.

Interviewer: How do you handle those patients?

Respondent: We give them some antibiotics, we start with oral if it's acute, and we give the IV injections and then continue with oral antibiotics, maybe capsules.

Interviewer: Do those patients come early or they usually present in late stages?

Respondent: They don't come early because we may ask the patient and they say, ‘I've been swallowing some herbs’ these native drugs.

Interviewer: So they first use herbs before they come!

Respondent: And at times it starts with flu, so they be like, ‘I have been taking some tablets’ maybe tablets with some Panadol

Interviewer: This one you have answered it. It was asking; are you aware of any link between RHD and sore throat? Are they associated?

Respondent: I don't know. I think there maybe but I wasn't aware.

Interviewer: So what were you told can be done to prevent RHD? What can we do?

Respondent: Maybe to give some health information to the public on how someone can approach the health worker very quickly so that she can get treatment early.

Interviewer: And then those that have not gotten RHD, what can they do to prevent it?

Respondent: I don't know.

Interviewer: Okay. And how can we treat RHD? What were you taught about the treatment of RHD?

Respondent: I don't know.

Interviewer: You don't know how it's treated!

Respondent: I don't know.

Interviewer: And then, if they offered training in RHD would you like it?

Respondent: Yeah.

Interviewer: Which areas would you want to?

Respondent: umm in that ... where you can ask the patient, “have you had any past problems?” before giving medicine to that patient. I would like to have that training; to have some questions before you review that patient. It is also good to review the health of that patient.

Interviewer: Which other area would you want to be trained in as far as RHD management? Like what topics?

Respondent: Topics like respiratory tract infections, sore throat, even sore mouth; diseases to do with this system of maybe with the alimentary system.

Interviewer: So what is your understanding of the long term prognosis of RHD?

Respondent: Someone has a chronic heart which can even cause stroke.

Interviewer: Can RHD heal?

Respondent: I don’t know but if not treated properly well it can cause heart attack which cannot be cured.

Interviewer: Have you encountered any RHD patients? You said here no!

Respondent: No.

Interviewer: Where did you encounter them?

Respondent: In Mulago.

Interviewer: So when as the last time you encountered an RHD patient?

Respondent: About thirteen years back.

Interviewer: Do you remember how that patient presented? What were the complaints?

Respondent: That had a disease that she complained about difficulty in breathing plus pain, that whenever she would sleep she would feel uncomfortable.

Interviewer: So how did you manage that patient?

Respondent: We referred that patient to the consultancy room.

Interviewer: During that time how many RHD patients did you see?

Respondent: I don’t remember.

Interviewer: Were they many or few?

Respondent: They were few.

Interviewer: And if you look at their demographics; how were they? Where they children, adults?

Respondent: Some were children, some were adults.

Interviewer: But what were they mostly?

Respondent: They were adults.

Interviewer: Working or not working? Were they working adults or mostly at home?

Respondent: People who were mostly at home.

Interviewer: Do you think these patients know the link between sore throat, acute rheumatic fever and RHD? Do they know that those three are associated?

Respondent: No, they don’t know unless they are taught.

Interviewer: So for the symptoms you said that they complained of chest pain and difficulty in breathing!

Respondent: Yes

Interviewer: How about their follow up did they come back when you told them to?

Respondent: Yes they would come back.

Interviewer: What would motivate them to come back?

Respondent: When they see they are still ... they are not comfortable with the treatment, of course they come back.

Interviewer: What things motivated you?

Respondent: I don’t have.

Interviewer: Did you have some that were missing treatment or missing appointments?

Respondent: Yes they were there because we would ask them, “Why have you not come back?” and they be like, “you see I had some problems” or “I didn’t have transport and yet they are coming from far.

Interviewer: Okay, what else?

Respondent: ‘I had some social problems at home.’

Interviewer: ‘Social’ like which problem?

Respondent: Like some problem at their home ... I don’t know how I can explain it. Someone might have an issue at home or a wrangles at home that she has to settle.

Interviewer: Did you have the drugs for RHD?

Respondent: No, we used to give drugs that were available.

Interviewer: Like which ones did you give? Do you know the names of the drugs that used to be available?

Respondent: Antibiotics

Interviewer: So for those are the barriers they were telling you; transport, social problems. So how about you; what do you think were the barriers they faced getting treatment?

Respondent: The drugs which are ... maybe there needs to be more enlightenment in the CMEs to know how to treat the patient.

Interviewer: What else? What are the other barriers that you can think of?

Respondent: Maybe and some motivation

Interviewer: in what way?

Respondent: Some motivation in maybe transport

Interviewer: Do you think that when you give them drugs they take them?

Respondent: I think so; they take them because they are the ones who are suffering so they have to take them.

Interviewer: Now let us look at the local system barriers; we want to know which pieces are working for you and why you think so. Let’s look at the administration; let’s start with the district; is that one working for you as you do your work here? Do you deal with them here?

Respondent: No

Interviewer: But with other things when you are working, do you see the administration ... does it contribute to you doing your work? Do you see it motivating you to do your work?

Respondent: Not much

Interviewer: Why?

Respondent: They don’t give enough supplies, the drugs are not there and you have to explain to the patients, ‘that drug is not there so maybe you have to go and buy it’ and yet that patient doesn’t have much. We have problem in our health centers IIIs and IVs; those drugs are not there.

Interviewer: Where’s the problem; is it the people who bring it in or its coming from ...

Respondent: I don’t know where the main problem is, but we put in the requisition but it doesn’t come. I have been in the store but the drugs am supposed use have not yet appeared.

Interviewer: So what are you going to do with your patient?

Respondent: I will tell them my in-charge that we don’t have drugs or maybe we look for another way we can anaesthetize the patient because there are those which can be available, for example when mothers are going for anesthesia, these days we use general methods but these days they are not available.

Interviewer: So what is your view about the administration within here? Is it working for you?

Respondent: [chuckles] I am always in touch with my in-charge. I request for drugs and if they are not there then, she says that they are supposed to be sent by the district.

Interviewer: So are you happy? Is it working for you?

Respondent: Not really.

Interviewer: Okay, if you look at the funding for health care is it working for you?

Respondent: No, but they have tried.

Interviewer: Where do they need to improve?

Respondent: In areas where we are finding problems, maybe in supply of drugs and others.

Interviewer: Apart from drugs which other supplies do you normally lack?

Respondent: Now some of the machines are down; they are not working because they are old so we need to replace them.

Interviewer: Like what machines?

Respondent: Our operating table has taken not even ...

Interviewer: And what do they say? Do you raise the issues? What do they say?

Respondent: We raised the issue but they say they are still working on it, so maybe they need some time. So if we have a patient with a referral, we don’t have the magnet although it is really not in good condition. Blood bank; we don’t have access to the blood in case a patient needs blood.

Interviewer: What do you do?

Respondent: We really suffer, and indeed we have to get some mortality rates.

Interviewer: What is the nearest health you send them to?

Respondent: Of course we take them to Kawempe. It is either to Kawempe or Bombo Hospital, in the barracks.

Interviewer: And then when you look at funding for RHD, how is it? Is it working?

Respondent: Not really because I am not so much into technical issues.

Interviewer: How about the number of health workers; how are they?

Respondent: They are few, in fact we need some more. We need more staffs according to the numbers which are supposed to be in a Health Centre IV.

Interviewer: Okay, how about the qualifications of the health workers around? Do you have enough qualified workers?

Respondent: Yes, we have enough.

Interviewer: Do you have any cadre of a health worker who can work on RHD patients here?

Respondent: Maybe the medical officer.

Interviewer: How many do you have here?

Respondent: They are two.

Interviewer: And they are around!

Respondent: Right now they are not but when we call them, they come.

Interviewer: How is the waiting time for patients here?

Respondent: Waiting time for calling the doctor?

Interviewer: Waiting time before they see a health worker.

Respondent: They are always here in the morning and afternoon.

Interviewer: If someone came at 8am, what time would they leave, the outpatient?

Respondent: Processing a patient can take a long time; it can take like 2-3hours.

Interviewer: How about the quality of care; how is it here?

Respondent: That one I cannot [chuckles] ... but we care for them.

Interviewer: If you are to gauge yourself, where do you fall?

Respondent: [laughs] I do like care.

Interviewer: Generally, the center, where would you put them? 40%? 50%?

Respondent: I cannot say it is 100% or 80% because everybody has his or her ... but it could be 60%

Interviewer: What do you think has hindered the health center from moving from 60 to 100? What are those gaps that need to be filled?

Respondent: First of all the staffing, maybe even the distance because we don’t have residential staff. Most of us come from far.

Interviewer: Okay, and then if you look at the medication do you think you have medication for heart failure? Do you have heart failure drugs?

Respondent: We have got this Aspirin and I remember giving it to those hypertensive patients

Interviewer: Do you have anti-coagulation drugs? Warfarin and the like?

Respondent: We don’t have.

Interviewer: You don’t have! By the way, health centers are meant to handle RHD?

Respondent: No, we settle acute rheumatic fever and we also handle those coming in for follow up for infections maybe and those kind of things. Maybe they need to be given their injections.

Interviewer: What injections? Do you have Benzathine?

Respondent: Benzathine we have.

Interviewer: Do you get patients who need it?

Respondent: We get patients with ARF.

Interviewer: How about RHD?

Respondent: That one I don’t know.

Interviewer: How about the diagnostics here; do you think they are working for you?

Respondent: That one maybe you can ask the laboratory people; they are the ones who know about that.

Interviewer: But do you have echocardiography here?

Respondent: No, it is not there.

Interviewer: When you look at your medical records system, how is it here? How do you keep your records here? Are you satisfied with the way they are kept, the way you access them, the way information flows from in-patient and out- patient?

Respondent: They are not well handled because we do not have a medical records ... eh, by the way it is there but the way it is handled is not good. It is not one that they can use. Sometimes you can look for records when they are lost.

Interviewer: And then do you have registers for ARF that you keep here?

Respondent: No.

Interviewer: You said you don’t have those for RHD!

Respondent: Yes.

Interviewer: And do you have protocol and guidelines for RHD care?

Respondent: We have got these medical guidelines.

Interviewer: But do you know the referral path for RHD patients?

Respondent: No.

Interviewer: Which factor is working for you here? What are you happy with that you say this has enabled me to work?

Respondent: Generally we work on everybody who comes here but ...

Interviewer: What motivates you?

Respondent: To work? Of course I have to work.

Interviewer: Okay. Let’s look at the perceptions of patients’ outcomes; do you think the patients get the care they need here?

Respondent: That is difficult; maybe you have to ask them

Interviewer: in your opinion

Respondent: Maybe we are trying, we are trying. If a patient comes and he doesn’t get what she needs, he will go back home when he is not okay

Interviewer: For instance what can the patient go back without?

Respondent: of course we have to tell the patient to go and buy the drug

Interviewer: So if a patient with RHD came to Buwambo will that patient be handled here?

Respondent: We can handle first then we refer the patient. Maybe what I can add is that the medicine bought is little and when it is used up, we have to wait for some months. Like now we only have the Panadols

Interviewer: And you said you don’t know where the problem is?

Respondent: I don’t know.

Interviewer: Okay. If you look at patients’ safety, do you think patients’ safety issues are respected here?

Respondent: They are respected.

Interviewer: Why do you think so?

Respondent: Because a patient is a patient who comes and you have to handle that patient well, and confidentially.

Interviewer: So they are handled in a confidential way?

Respondent: Yes, like we have some special clinics like the ART clinic, we have some departments like the youth departments.

Interviewer: What can we do to improve the quality of care in our patients?

Respondent: Some improvement in areas like motivation and having CMEs.

Interviewer: Do you have the CMEs are not?

Respondent: We no longer have CMEs; we used to have them.

Interviewer: What happened?

Respondent: I don’t know.

Interviewer: How was the attendance?

Respondent: The attendance was bad because when you call the people, the turn up would be low.

Interviewer: Have you seen any preventable death in a place like here?

Respondent: I don’t know.

Interviewer: What could cause that?

Respondent: Maybe the patient may take long to get the treatment when the drug are not here and yet what he is suffering from can be treated

Interviewer: Okay, any other?

Respondent: That is it.

Interviewer: So in your opinion what are the two most important things Ministry of Health can do to improve the outcomes in our patients?

Respondent: Just to improve on the supervision and supply of drugs.

Interviewer: Do you get supervisions from like the district?

Respondent: Sometimes we get but maybe because of our rural places, they take long to come.

Interviewer: So when they supervise are your needs or issues raised?

Respondent: We raise them but they end there; they don’t work on them.

Interviewer: Okay, so drugs and supervision!

Respondent: Yes.

Interviewer: Anything else?

Respondent: No.

Interviewer: And then at least you have seen the RHD patients, what can we do for them?

Respondent: So far we have not had any.

Interviewer: But in general because at least you have seen them somewhere, what can be done to make sure they can come for care?

Respondent: To get them their drugs so that they can take them

Interviewer: How can we help them to come for their drugs? What can we do to motivate them?

Respondent: Outreaches and advising them to take their drugs

Interviewer: Who should advise them?

Respondent: Any health worker

Interviewer: Anything just before we close?

Respondent: Now I thank you for coming, and after this, are you going to come and maybe give some assistance in that area of RHD?

Interviewer: Why we do this is we want to see the gaps because we can’t fill them when we don’t know where they are. That’s why we come to health centers to get the different views to know what they don’t know which is going to help us.

Respondent: Because we always have some supervision from the district, the municipality but these people are failing to come through our in-charge and I don’t know why.

Interviewer: After these results are out, this will be the foundation to see which areas and which centers need to be boasted with learning. Thank you very much. Anything else?

Respondent: No