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[User] 9years

[Assistant] Okay and how long have you worked in Lira regional referral Hospital?

[User] 8 years

[Assistant] 8, Okay in these 8 years, do you mind describing like the kind of patients you see, the common illnesses you come across?

[User] The common illnesses are usually the, the infectious diseases, common ones are HIV related problems, malaria, then respiratory tract infections like pneumonia, TB then there are others which are related to nutrition disorders which is attributed to mal absorption disorders then I see also heart diseases especially in young children and those ones age around 20 to 40 ,then there are heart diseases also in elderly patients which are usually attributed to hypertension and then there are some other cases of heart diseases we see, which are like dilated heart disorders and then those ones in sickle cell and other heart disorders but the rheumatic heart disease cuts across up to older age groups .Then we have also apart from heart diseases we have hypertension ,diabetes, and then those ones are the commonest ones and the liver diseases especially hepatitis B, liver cirrhosis, liver cancers, and then other forms of cancers are actually now common especially non estrogen lymphomas in adults and then Burkett’s in children those are the common disorders we usually see in our environment.

[Assistant] Okay, thank you so much, so tell me a bit about your training on RHD, have you received any specific training during school?


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[User] 8 years

[Assistant] 8, Okay in these 8 years, do you mind describing like the kind of patients you see, the common illnesses you come across?

[User] The common illnesses are usually the, the infectious diseases, common ones are HIV related problems, malaria, then respiratory tract infections like pneumonia, TB then there are others which are related to nutrition disorders which is attributed to mal absorption disorders then I see also heart diseases especially in young children and those ones age around 20 to 40 ,then there are heart diseases also in elderly patients which are usually attributed to hypertension and then there are some other cases of heart diseases we see, which are like dilated heart disorders and then those ones in sickle cell and other heart disorders but the rheumatic heart disease cuts across up to older age groups .Then we have also apart from heart diseases we have hypertension ,diabetes, and then those ones are the commonest ones and the liver diseases especially hepatitis B, liver cirrhosis, liver cancers, and then other forms of cancers are actually now common especially non estrogen lymphomas in adults and then Burkett’s in children those are the common disorders we usually see in our environment.

[Assistant] Okay, thank you so much, so tell me a bit about your training on RHD, have you received any specific training during school?

[User] Me in particular I have been involved in heart disease management especially those ones who were in the 4c by then that is Mulago the ward meant for cardiac diseases, so I was involved in managing of these patients and mostly doing echocardiographs for those who cannot afford doing them from other places and then those managing those ones who were admitted with heart diseases, those are medically, who needed medical treatment so we have had several what they call horizontal trainings on management of heart patients.

[Assistant] So was that during, when? Before graduation or after graduation?


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[User] Me in particular I have been involved in heart disease management especially those ones who were in the 4c by then that is Mulago the ward meant for cardiac diseases, so I was involved in managing of these patients and mostly doing echocardiographs for those who cannot afford doing them from other places and then those managing those ones who were admitted with heart diseases, those are medically, who needed medical treatment so we have had several what they call horizontal trainings on management of heart patients.

[Assistant] So was that during, when? Before graduation or after graduation?

[User] Before that is when I was still there at Mulago before leaving that place this excludes this is not with in the 8 years because with in the 8 years we have just had the training concerning the management of Rheumatic heart disease in a study which was conducted much more earlier on how to use the v scan,

[Assistant] Okay

[User] Earlier on

[Assistant] So do you still remember when it was done and who conducted the training?


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[User] Before that is when I was still there at Mulago before leaving that place this excludes this is not with in the 8 years because with in the 8 years we have just had the training concerning the management of Rheumatic heart disease in a study which was conducted much more earlier on how to use the v scan,

[Assistant] Okay

[User] Earlier on

[Assistant] So do you still remember when it was done and who conducted the training?

[User] Which one which training?

[Assistant] The one for rheumatic heart disease, what you just mentioned about using V scans


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[User] Which one which training?

[Assistant] The one for rheumatic heart disease, what you just mentioned about using V scans

[User] The rheumatic heart disease training okay there is one which was about using V scans i think about 2 years ago my memory does...but that is about two years ago and I think that was yeah two years ago early last year that is now coming to two years yeah and then there is another one where I was facilitating the training for the, the community people on detecting rheumatic heart diseases, I was one of the facilitators. That was also about the same time

[Assistant] Okay

[User] Yes

[Assistant] Alright, then how many patients with RHD do you see let’s say per week?


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[User] The rheumatic heart disease training okay there is one which was about using V scans i think about 2 years ago my memory does...but that is about two years ago and I think that was yeah two years ago early last year that is now coming to two years yeah and then there is another one where I was facilitating the training for the, the community people on detecting rheumatic heart diseases, I was one of the facilitators. That was also about the same time

[Assistant] Okay

[User] Yes

[Assistant] Alright, then how many patients with RHD do you see let’s say per week?

[User] The new ones at least I would catch like two 2, 2 new ones those ones are usually in the ward but the old ones actually I can see between 3 -5 but sometimes they pick and meaning that most times you get them when they have now presented with heart failure

[Assistant] Okay, are these in patients or both in patients and out patients?


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[User] Yes

[Assistant] Alright, then how many patients with RHD do you see let’s say per week?

[User] The new ones at least I would catch like two 2, 2 new ones those ones are usually in the ward but the old ones actually I can see between 3 -5 but sometimes they pick and meaning that most times you get them when they have now presented with heart failure

[Assistant] Okay, are these in patients or both in patients and out patients?

[User] Ahh usually they are inpatients cause outpatients we have actually had issues of movement of the clinic so the clinic is now more not helping so much on the general medical clinic but otherwise in the outpatients we would get an equal amount especially you can get like about 2-3 new cases that is in outpatient basis but of course that was based on clinical judgment not usually based on other methods of evidence. Yeah

[Assistant] Okay then what’s your understanding of the cause of rheumatic heart disease


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[User] The new ones at least I would catch like two 2, 2 new ones those ones are usually in the ward but the old ones actually I can see between 3 -5 but sometimes they pick and meaning that most times you get them when they have now presented with heart failure

[Assistant] Okay, are these in patients or both in patients and out patients?

[User] Ahh usually they are inpatients cause outpatients we have actually had issues of movement of the clinic so the clinic is now more not helping so much on the general medical clinic but otherwise in the outpatients we would get an equal amount especially you can get like about 2-3 new cases that is in outpatient basis but of course that was based on clinical judgment not usually based on other methods of evidence. Yeah

[Assistant] Okay then what’s your understanding of the cause of rheumatic heart disease

[User] The cause of rheumatic heart disease as in how what predisposes it or what causes it?

[Assistant] What brings it about?


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[User] The treatment options we have antibiotics but they are usually out of stock in a year, you find particular options you need to have, they are out of stock like more than 50% of the time, so before we really had issues to do with the medications to give them but of recent we have had some improvement in the medications to give them, the penicillins have been available but of course the stock out has been actually quite frequent like just in the last 3-4, 5 months ago we didn’t even have those medication of course except for the project which has its own medications. But from way before that is over 7-8 years ago it has been a problem to access these drugs because most of the people have to buy these drugs, yeah

[Assistant] What’s your understanding of the long term prognosis of rheumatic heart disease?

[User] The long term prognosis treated early good outcome good prognosis treated late creates a lot of problem in terms of medical pill burden, financial losses, complications from heart diseases heart failures with eventually the patients may succumb to heart failure if they don’t really attend the clinics cardiac clinics but when caught early the prognosis is good really when caught early but caught late we have had problems of issues to do with transplants ,valve replacement which is very costly and this place is one of the highest poverty levels with highest poverty levels in the country I think we are if not number 2 or 3 just in terms of poverty levels all of the country so people don’t afford to have those expensive cardiac surgeries and eventually they end up dying but when caught early ,it has a good prognosis but when caught late the prognosis usually tends to be poor since even the management becomes a little bit expensive and complicated for the local community to sustain it.

[Assistant] Do you recall the last patient you saw with RHD

[User] This morning

[Assistant] Okay you could just give me their brief summary of their visit like


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[User] This morning

[Assistant] Okay you could just give me their brief summary of their visit like

[User] This morning,

[Assistant] Yes

[User] Ah,this is a the child who is about I think is fourteen, I think fourteen years has been on and off in the hospital has clinically presented with features of congestive cardiac failure the heart all the valves are affected, regurgitation of all the valve and dilatations of the heart chambers with ejection fraction very reduced less than 40, can’t walk, and aaah can’t sleep at night without coughing excessively, and has been really weak but that has been because the child first all of did not, did not come back, and the reason they gave for not coming back for drugs was that they did not have transport, and secondly the care taker says that they didn’t have any other person to help them do so from home so they couldn’t carry the young girl to the hospital. But general over look she is picking up and I think she may eventually need valve replacement but of course being poor even at this level, it may be quiet difficult for her to access those valve replacement because the stage where she is the heart failure is one where, you now need those cardiac assisted valves , those mechanical ones and maybe valve replacement, yeah the ICDs may benefit the child may benefit from those ICDS but coming from a poor family that you can’t even come back for just a medical review for a cardiac disease is bad enough so those are the kind of patients we eventually end up seeing, yeah

[Assistant] Okay quite sad for that one, then on average like what is the average age for your patients?


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[User] This morning,

[Assistant] Yes

[User] Ah,this is a the child who is about I think is fourteen, I think fourteen years has been on and off in the hospital has clinically presented with features of congestive cardiac failure the heart all the valves are affected, regurgitation of all the valve and dilatations of the heart chambers with ejection fraction very reduced less than 40, can’t walk, and aaah can’t sleep at night without coughing excessively, and has been really weak but that has been because the child first all of did not, did not come back, and the reason they gave for not coming back for drugs was that they did not have transport, and secondly the care taker says that they didn’t have any other person to help them do so from home so they couldn’t carry the young girl to the hospital. But general over look she is picking up and I think she may eventually need valve replacement but of course being poor even at this level, it may be quiet difficult for her to access those valve replacement because the stage where she is the heart failure is one where, you now need those cardiac assisted valves , those mechanical ones and maybe valve replacement, yeah the ICDs may benefit the child may benefit from those ICDS but coming from a poor family that you can’t even come back for just a medical review for a cardiac disease is bad enough so those are the kind of patients we eventually end up seeing, yeah

[Assistant] Okay quite sad for that one, then on average like what is the average age for your patients?

[User] The ages are usually, the ones I have been seeing are between, between 5 I see them between 5 up to about 20 for children then there is that group I usually find late about 40s they, usually present when they are now having other issues then the Rheumatic heart disease just got worst that’s why they present back to the hospital, but the Majority are age between 5 to 20 the ones I see

[Assistant] Okay, are most of them in school or and working or most of them just left work and are out of school because of the illness?


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[User] The ages are usually, the ones I have been seeing are between, between 5 I see them between 5 up to about 20 for children then there is that group I usually find late about 40s they, usually present when they are now having other issues then the Rheumatic heart disease just got worst that’s why they present back to the hospital, but the Majority are age between 5 to 20 the ones I see

[Assistant] Okay, are most of them in school or and working or most of them just left work and are out of school because of the illness?

[User] These are children, they don’t work most of the children are actually because of illnesses, they are actually the school drop outs ,majority of them very few are struggling with school because they have problems of first of all the distances, they move to schools on foot, then also the care takers, then leave alone that those ones who go to school they have problems that they lack those ones who can take them to school, and sometimes they even default on coming back for medicine and then they eventually develop heart failure from home then they just drop off school and because of a lot of financial constraints they end up just staying at home and parents prefer treating I mean they give preferential treatment to children without heart diseases but sometime it’s unfortunate you may find like 2 or 3 children from the same family have the same thing so sometimes it becomes also a little bit stressful for the families but the older people usually they are not doing anything because they have been ill, they can’t move , exhaustion intolerance they are usually they are in the vicious cycle of poverty, they are sick, they can’t do anything then also poverty sets in because they are doing nothing and yet you need to spend on drugs spend money on drugs and so on so they are really not productive in their own communities because of illnesses.

[Assistant] Okay

[User] Yes

[Assistant] And these the ones you interact with are they aware of the link between sore throat, acute rheumatic fever and rheumatic heart disease?


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[User] Yes

[Assistant] And these the ones you interact with are they aware of the link between sore throat, acute rheumatic fever and rheumatic heart disease?

[User] They are beginning to pick because of this research and ahh the cardiac program which has started with in the hospital they are beginning to pick but before it was absolutely not connected absolutely it is me as a medical person who knew but the community had their own way of attributing heart diseases just like I give you an example of three children all with rheumatic heart disease in the same family they said it was because of these traditional witch crafts at home that is why all the three children had rheumatic heart disease basically it shows that most people didn’t know much about rheumatic heart disease they know there is a heart disease but they didn’t know the one that they could do something about and the commonest one near them because thee commonest here is rheumatic heart disease in more than actually even 50 60% is just the majority basically.

[Assistant] And then these ones who present, what symptoms do they always describe to you

[User] Most of them just present with symptoms of heart failure they can’t walk, lower limb swelling, they get tired, they feel dizzy some people come when they have collapsed , others come when they can’t sit, can’t breathe, can’t sleep, with excessive cough others even come coughing blood so they come very sick.

[Assistant] And then how is the follow up and adherence?


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[User] They are beginning to pick because of this research and ahh the cardiac program which has started with in the hospital they are beginning to pick but before it was absolutely not connected absolutely it is me as a medical person who knew but the community had their own way of attributing heart diseases just like I give you an example of three children all with rheumatic heart disease in the same family they said it was because of these traditional witch crafts at home that is why all the three children had rheumatic heart disease basically it shows that most people didn’t know much about rheumatic heart disease they know there is a heart disease but they didn’t know the one that they could do something about and the commonest one near them because thee commonest here is rheumatic heart disease in more than actually even 50 60% is just the majority basically.

[Assistant] And then these ones who present, what symptoms do they always describe to you

[User] Most of them just present with symptoms of heart failure they can’t walk, lower limb swelling, they get tired, they feel dizzy some people come when they have collapsed , others come when they can’t sit, can’t breathe, can’t sleep, with excessive cough others even come coughing blood so they come very sick.

[Assistant] And then how is the follow up and adherence?

[User] Before this project, Makerere guys from Uganda Heart Institute., we had tried to have a program where we were giving them injection of benzathine penicillin every four weeks but of course the guideline was saying three weeks but because of transport problems and they come from far and so on we just had to increase one more week so at least we do one month. And they would basically come for the treatment sometimes they would buy some times the hospital has but stock out are actually quite a number. And before also this this rheumatic heart disease program which is from Makerere the one from Heart Institute before that one, the mortality was a little bit high so most of them would also die actually, but now at least they are they are living a more reasonable life the quality of life is I think more reasonable now.

[Assistant] That’s nice to hear and then what sorts of barriers do they commonly state to getting care that they need?


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[User] Doing well in what aspect?

[Assistant]
In terms of health Respondent. I don’t know

Laughs, okay what hasn’t the district the leadership in the district not done well what do you think they are not doing well?

[User] they have not prioritized the heart diseases that’s one thing I know that’s the part they have not really prioritized prevention diagnosis and treatment of heart diseases

[Assistant] So why do you think they haven’t really prioritized it so much?

[User] I think there has been less emphasis put on it I don’t know whether it is the money or what I don’t know I don’t know I can’t speak for them I don’t know but they have not done really much about it may be they themselves also they really need to be informed about the magnitude of the problem may be they also don’t know I don’t know may be data use is poor so they can’t really whatever figure out the burden as such.

[Assistant] And then about the funding of health care in general and then with RHD in particular, are you happy about it?


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[User] they have not prioritized the heart diseases that’s one thing I know that’s the part they have not really prioritized prevention diagnosis and treatment of heart diseases

[Assistant] So why do you think they haven’t really prioritized it so much?

[User] I think there has been less emphasis put on it I don’t know whether it is the money or what I don’t know I don’t know I can’t speak for them I don’t know but they have not done really much about it may be they themselves also they really need to be informed about the magnitude of the problem may be they also don’t know I don’t know may be data use is poor so they can’t really whatever figure out the burden as such.

[Assistant] And then about the funding of health care in general and then with RHD in particular, are you happy about it?

[User] Health care funding has been poor and they usually emphasis key priority areas then priority of course is based on each and every institution what their priorities are and you can only set something to be your priority if you know the problem if you know the magnitude of the problem and as I told you earlier on, the data use in data collection capturing, collection, recording analysis and use of in the hospitals concerning heart diseases is extremely poor so it doesn’t really reflect what is on the ground and of course as you know there is a trend now that where the money is put that’s where you have more data collected for you and other places where money is not put data will not be collected and it will appear as if it is not there when it is there and for us at the front line medical personnel treating these patients we find them but to them it is not a big issue because they have not taken a deliberate step to look for these cases record them and holistically handle it according to the disease burden.

[Assistant] So you feel we have a big problem with the record system?


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[User] I think there has been less emphasis put on it I don’t know whether it is the money or what I don’t know I don’t know I can’t speak for them I don’t know but they have not done really much about it may be they themselves also they really need to be informed about the magnitude of the problem may be they also don’t know I don’t know may be data use is poor so they can’t really whatever figure out the burden as such.

[Assistant] And then about the funding of health care in general and then with RHD in particular, are you happy about it?

[User] Health care funding has been poor and they usually emphasis key priority areas then priority of course is based on each and every institution what their priorities are and you can only set something to be your priority if you know the problem if you know the magnitude of the problem and as I told you earlier on, the data use in data collection capturing, collection, recording analysis and use of in the hospitals concerning heart diseases is extremely poor so it doesn’t really reflect what is on the ground and of course as you know there is a trend now that where the money is put that’s where you have more data collected for you and other places where money is not put data will not be collected and it will appear as if it is not there when it is there and for us at the front line medical personnel treating these patients we find them but to them it is not a big issue because they have not taken a deliberate step to look for these cases record them and holistically handle it according to the disease burden.

[Assistant] So you feel we have a big problem with the record system?

[User] Record system terrible, the financing system terrible

[Assistant] And it could be affecting the financing


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[User] Record system terrible, the financing system terrible

[Assistant] And it could be affecting the financing

[User] Exactly it is affecting also because once you don’t, once what is not recorded it means it is not done therefore the same principle applies to them when it comes to budgeting.

[Assistant] Okay

[User] So they look as if it is not a big problem but it is

[Assistant] I get it


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[User] Exactly it is affecting also because once you don’t, once what is not recorded it means it is not done therefore the same principle applies to them when it comes to budgeting.

[Assistant] Okay

[User] So they look as if it is not a big problem but it is

[Assistant] I get it

[User]
Then what about the health workers are you happy about the numbers the qualifications that you have at the hospital

Health workers are few health workers are pretty few and they are very demotivated and they also lack knowledge in managing most of these cases of heart diseases and as I told you most people run where there is money so where you don’t get allowances for the activities, you don’t go there so cardiac diseases you don’t see allowances so no one wants to go where there is no allowance. HIV program you find people there, TB program you find people there

[Assistant] Because there are allowances?


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[User] So they look as if it is not a big problem but it is

[Assistant] I get it

[User]
Then what about the health workers are you happy about the numbers the qualifications that you have at the hospital

Health workers are few health workers are pretty few and they are very demotivated and they also lack knowledge in managing most of these cases of heart diseases and as I told you most people run where there is money so where you don’t get allowances for the activities, you don’t go there so cardiac diseases you don’t see allowances so no one wants to go where there is no allowance. HIV program you find people there, TB program you find people there

[Assistant] Because there are allowances?

[User] Because there are allowances for people who get involved in those activities

[Assistant] So you think there should be motivation of people?


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[User] The medications I,

[Assistant] Benzathine and anticoagulation medicine?

[User] With the program from the heart institute this research they have been there for those patients but before that and am quite sure even after that if there is no, no any post program planning done for those patients we will go back to where we were where drugs are procured.

[Assistant] What about in the hospital

[User] Drugs are few

[Assistant] In the pharmacy


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[User] Drugs are few

[Assistant] In the pharmacy

[User] They are there, few, if it is brought but greater majority as said earlier on it is out of stock for most part of the year.

[Assistant] Okay

[User] Yes

[Assistant] Ahh, you talked about diagnostics being available


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[User] They are there, few, if it is brought but greater majority as said earlier on it is out of stock for most part of the year.

[Assistant] Okay

[User] Yes

[Assistant] Ahh, you talked about diagnostics being available

[User] Diagnostics are not available but right now we are riding on the back of the researches being done in the hospital by heart institute so that’s what we are benefiting from by sending those patients there but of course once they leave we go back to square zero

[Assistant] Okay, and then do you have guidelines and protocols for RHD care?


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[User] Yes

[Assistant] Ahh, you talked about diagnostics being available

[User] Diagnostics are not available but right now we are riding on the back of the researches being done in the hospital by heart institute so that’s what we are benefiting from by sending those patients there but of course once they leave we go back to square zero

[Assistant] Okay, and then do you have guidelines and protocols for RHD care?

[User] We are using the national guide the national guidelines the one from Heart Institute but of course me as a doctor I use other two guidelines the one for American Heart Association, the European Cardiac Assoc society I combine those ones to use but we have our guideline by Uganda Heart Institute that it is used and is working well.

[Assistant] Okay that’s nice, lastly, we talk about perception of patient outcomes generally do you think that they, they are getting the care that they need especially surgery?


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[User] Diagnostics are not available but right now we are riding on the back of the researches being done in the hospital by heart institute so that’s what we are benefiting from by sending those patients there but of course once they leave we go back to square zero

[Assistant] Okay, and then do you have guidelines and protocols for RHD care?

[User] We are using the national guide the national guidelines the one from Heart Institute but of course me as a doctor I use other two guidelines the one for American Heart Association, the European Cardiac Assoc society I combine those ones to use but we have our guideline by Uganda Heart Institute that it is used and is working well.

[Assistant] Okay that’s nice, lastly, we talk about perception of patient outcomes generally do you think that they, they are getting the care that they need especially surgery?

[User] No, no

[Assistant] Why is that so?


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[User] We are using the national guide the national guidelines the one from Heart Institute but of course me as a doctor I use other two guidelines the one for American Heart Association, the European Cardiac Assoc society I combine those ones to use but we have our guideline by Uganda Heart Institute that it is used and is working well.

[Assistant] Okay that’s nice, lastly, we talk about perception of patient outcomes generally do you think that they, they are getting the care that they need especially surgery?

[User] No, no

[Assistant] Why is that so?

[User] I think it is finances, these patients, the surgical aspect, most of them you refer some of them need more advanced surgeries and they need to be referred may be to India because of lack of tools to use from that side of heart institute so they tell them that they need to be sent to India but the cases that end up in Mulago where they can do with the tools they have ,they have actually been doing them and, and with really I would say with 100% good out comes, those ones they have done I think they have scored almost 100% I haven’t heard any scenario where they have failed okay may be they are there but the failure rates of those ones I have sent has been zero so those ones

[Assistant] Okay meaning they are doing well


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[User] No, no

[Assistant] Why is that so?

[User] I think it is finances, these patients, the surgical aspect, most of them you refer some of them need more advanced surgeries and they need to be referred may be to India because of lack of tools to use from that side of heart institute so they tell them that they need to be sent to India but the cases that end up in Mulago where they can do with the tools they have ,they have actually been doing them and, and with really I would say with 100% good out comes, those ones they have done I think they have scored almost 100% I haven’t heard any scenario where they have failed okay may be they are there but the failure rates of those ones I have sent has been zero so those ones

[Assistant] Okay meaning they are doing well

[User] Yes it’s only those they have deferred because of the reasons of the tools to be used on them

[Assistant] Then do you have any patient safety concerns and quality of care concerns?


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[User] I think it is finances, these patients, the surgical aspect, most of them you refer some of them need more advanced surgeries and they need to be referred may be to India because of lack of tools to use from that side of heart institute so they tell them that they need to be sent to India but the cases that end up in Mulago where they can do with the tools they have ,they have actually been doing them and, and with really I would say with 100% good out comes, those ones they have done I think they have scored almost 100% I haven’t heard any scenario where they have failed okay may be they are there but the failure rates of those ones I have sent has been zero so those ones

[Assistant] Okay meaning they are doing well

[User] Yes it’s only those they have deferred because of the reasons of the tools to be used on them

[Assistant] Then do you have any patient safety concerns and quality of care concerns?

[User] The safety concerns is that they don’t know who is supposed to be like their main source of help so sometimes when you send them down there to the clinics I mean in the health centers for them to be injected some times they think they may be injected by someone who doesn’t know how to inject properly so it is issue to do with pain they may inject without lignocaine the pain attributed to the injection that’s basically their worries of course the safety concerns of the surgeries to be done which are done in heart institute they are usually minor because it is not a safety concern it’s more of worries whether it can be done because most of these surgeries were not done in Uganda so they would only be concerned whether it can it can also be done now in Uganda that’s all.

[Assistant] Then do you have you do you think there are preventable deaths that occur in the hospital?


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[User] Yes it’s only those they have deferred because of the reasons of the tools to be used on them

[Assistant] Then do you have any patient safety concerns and quality of care concerns?

[User] The safety concerns is that they don’t know who is supposed to be like their main source of help so sometimes when you send them down there to the clinics I mean in the health centers for them to be injected some times they think they may be injected by someone who doesn’t know how to inject properly so it is issue to do with pain they may inject without lignocaine the pain attributed to the injection that’s basically their worries of course the safety concerns of the surgeries to be done which are done in heart institute they are usually minor because it is not a safety concern it’s more of worries whether it can be done because most of these surgeries were not done in Uganda so they would only be concerned whether it can it can also be done now in Uganda that’s all.

[Assistant] Then do you have you do you think there are preventable deaths that occur in the hospital?

[User] A million, too many.

[Assistant] Why do you think so?


[System] Act as an information elicitation agent for academic interviews.

[User] A million, too many.

[Assistant] Why do you think so?

[User] Why do I think so, when you come with heart failure and you don’t have a basic drug like Lasix and you die from volume overload is that death from a cause you cannot prevent?, Isn’t it so?

[Assistant] Yeah

[User] Yes, so, there are deaths which you can prevent, patients come with heart rate over 160 you don’t have IV drugs to slow the heart rate down they end up with stroke or a myocardial infarct just because you can’t slow it down yeah they are preventable causes really .

[Assistant] So due to lack of medicines and supplies


[System] Act as an information elicitation agent for academic interviews.

[User] Yes, so, there are deaths which you can prevent, patients come with heart rate over 160 you don’t have IV drugs to slow the heart rate down they end up with stroke or a myocardial infarct just because you can’t slow it down yeah they are preventable causes really .

[Assistant] So due to lack of medicines and supplies

[User] Medicines and yeah medicines and supplies to be used including diagnostics ECG for example not there in the hospital apart from the one of the research it’s not there it can’t be done

[Assistant] I see

[User] So you make a lot of diagnosis from ECG alone but if you can’t make that diagnosis then you die you will die from something they would have stopped, so there are a bunch of people who die from preventable causes, yes

[Assistant] And do you think there are patients who dying in the community without presenting to the hospital?


[System] Act as an information elicitation agent for academic interviews.

[User] Medicines and yeah medicines and supplies to be used including diagnostics ECG for example not there in the hospital apart from the one of the research it’s not there it can’t be done

[Assistant] I see

[User] So you make a lot of diagnosis from ECG alone but if you can’t make that diagnosis then you die you will die from something they would have stopped, so there are a bunch of people who die from preventable causes, yes

[Assistant] And do you think there are patients who dying in the community without presenting to the hospital?

[User] A bunch of them because I have gone for burials and when they talk you can co relate the history to the cause of death and you can tell this is from a heart disease ,you can tell, so many die there

[Assistant] And why you think those ones are actually not coming to the hospital?


[System] Act as an information elicitation agent for academic interviews.

[User] So you make a lot of diagnosis from ECG alone but if you can’t make that diagnosis then you die you will die from something they would have stopped, so there are a bunch of people who die from preventable causes, yes

[Assistant] And do you think there are patients who dying in the community without presenting to the hospital?

[User] A bunch of them because I have gone for burials and when they talk you can co relate the history to the cause of death and you can tell this is from a heart disease ,you can tell, so many die there

[Assistant] And why you think those ones are actually not coming to the hospital?

[User] It’s partly poverty, partly ignorance, partly lack of information of services offered, partly because of frustration, social issues at home, transport or partly the services are not available where they stay, they have to trek a long distance to the next best place where they can get a doctor like you see most doctors now are only found in health Centre 4s and hospitals even health Centre 4s the doctors are not available and even if they are available they may not be I mean they may not be I mean more, more, able to comprehensively handle these cases yeah they are not competent enough.

[Assistant] Thank you so much now in your opinion what are like give me one or two most important things ministry of health could do to improve out comes


[System] Act as an information elicitation agent for academic interviews.

[User] A bunch of them because I have gone for burials and when they talk you can co relate the history to the cause of death and you can tell this is from a heart disease ,you can tell, so many die there

[Assistant] And why you think those ones are actually not coming to the hospital?

[User] It’s partly poverty, partly ignorance, partly lack of information of services offered, partly because of frustration, social issues at home, transport or partly the services are not available where they stay, they have to trek a long distance to the next best place where they can get a doctor like you see most doctors now are only found in health Centre 4s and hospitals even health Centre 4s the doctors are not available and even if they are available they may not be I mean they may not be I mean more, more, able to comprehensively handle these cases yeah they are not competent enough.

[Assistant] Thank you so much now in your opinion what are like give me one or two most important things ministry of health could do to improve out comes

[User] Ministry of health, let them improve diagnostics and then supplies of the drugs and then diagnostics, supplies of drugs then they, they need to prioritize heart diseases just like the way they prioritize other diseases where there is priority they put funds and where they put funds there are results you don’t put funds no results.

[Assistant] Okay, thank you so much, do you have any other thing to say?


[System] Act as an information elicitation agent for academic interviews.

[User] It’s partly poverty, partly ignorance, partly lack of information of services offered, partly because of frustration, social issues at home, transport or partly the services are not available where they stay, they have to trek a long distance to the next best place where they can get a doctor like you see most doctors now are only found in health Centre 4s and hospitals even health Centre 4s the doctors are not available and even if they are available they may not be I mean they may not be I mean more, more, able to comprehensively handle these cases yeah they are not competent enough.

[Assistant] Thank you so much now in your opinion what are like give me one or two most important things ministry of health could do to improve out comes

[User] Ministry of health, let them improve diagnostics and then supplies of the drugs and then diagnostics, supplies of drugs then they, they need to prioritize heart diseases just like the way they prioritize other diseases where there is priority they put funds and where they put funds there are results you don’t put funds no results.

[Assistant] Okay, thank you so much, do you have any other thing to say?

[User] Nothing.

[Assistant] Nothing, okay, thank you so much for accepting to participate in this interview ahh your views will really help us in making care of rheumatic heart disease better.


[System] Act as an information elicitation agent for academic interviews.

[User] Am 25 years of age

[Assistant] Ok, your qualifications?

[User] Am a medical clinical officer

[Assistant] Alright, where did you train from?

[User] From Kampala school of health science

[Assistant] when was that?


[System] Act as an information elicitation agent for academic interviews.

[User] Am a medical clinical officer

[Assistant] Alright, where did you train from?

[User] From Kampala school of health science

[Assistant] when was that?

[User] From 2013- 2016

[Assistant] Ok, so when did you qualify?


[System] Act as an information elicitation agent for academic interviews.

[User] From Kampala school of health science

[Assistant] when was that?

[User] From 2013- 2016

[Assistant] Ok, so when did you qualify?

[User] I qualified in 2017 April

[Assistant] So, 2017, so how long have you been working hare in Lira regional referral hospital?


[System] Act as an information elicitation agent for academic interviews.

[User] From 2013- 2016

[Assistant] Ok, so when did you qualify?

[User] I qualified in 2017 April

[Assistant] So, 2017, so how long have you been working hare in Lira regional referral hospital?

[User] 1 year and 6 months

[Assistant] Ok majorly which patients do you usually see during your time here in lira regional hospital?


[System] Act as an information elicitation agent for academic interviews.

[User] I qualified in 2017 April

[Assistant] So, 2017, so how long have you been working hare in Lira regional referral hospital?

[User] 1 year and 6 months

[Assistant] Ok majorly which patients do you usually see during your time here in lira regional hospital?

[User] Patients like in age group from 5-19 years

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


[System] Act as an information elicitation agent for academic interviews.

[User] 1 year and 6 months

[Assistant] Ok majorly which patients do you usually see during your time here in lira regional hospital?

[User] Patients like in age group from 5-19 years

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

[User] Yes, I normally see cases like pharyngitis, laminitis, UTI’s, malaria, osteomyelitis and others

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


[System] Act as an information elicitation agent for academic interviews.

[User] Children? Children below 5 years we have pneumonia

[Assistant] Ok

[User] We have bronchitis

[Assistant] Yes

[User] We have dysentery and people with sore throats

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


[System] Act as an information elicitation agent for academic interviews.

[User] We have bronchitis

[Assistant] Yes

[User] We have dysentery and people with sore throats

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

[User] 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

[Assistant] And then do you ever see people above 19 years in your practice?


[System] Act as an information elicitation agent for academic interviews.

[User] We have dysentery and people with sore throats

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

[User] 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

[Assistant] And then do you ever see people above 19 years in your practice?

[User] Yes

[Assistant] So, which are the common illness you see in those ones above 19 year?


[System] Act as an information elicitation agent for academic interviews.

[User] Like...we have diabetes, asthmatic patients

[Assistant] Ok

[User] People with recurrent tonsillitis

[Assistant] Yes

[User] Then UTI’s

[Assistant] Ok have you ever received any training on RHD?


[System] Act as an information elicitation agent for academic interviews.

[User] People with recurrent tonsillitis

[Assistant] Yes

[User] Then UTI’s

[Assistant] Ok have you ever received any training on RHD?

[User] No

[Assistant] Not even in school?


[System] Act as an information elicitation agent for academic interviews.

[User] No

[Assistant] Not even in school?

[User] In school?

[Assistant] Yes

[User] Yes

[Assistant] What do you remember about what you were trained in school?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] What do you remember about what you were trained in school?

[User] 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

[Assistant] Ok

[User] Yes, and how to manage them

[Assistant] Ok, what do you remember?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes, and how to manage them

[Assistant] Ok, what do you remember?

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

[Assistant] Ok

[User] Yes

[Assistant] Alright, ever since graduation, have you received any training on RHD?


[System] Act as an information elicitation agent for academic interviews.

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

[Assistant] Ok

[User] Yes

[Assistant] Alright, ever since graduation, have you received any training on RHD?

[User] No

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


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Alright, ever since graduation, have you received any training on RHD?

[User] No

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

[User] During my clinic day they can come, they can, so far they can be 3 in a day

[Assistant] 3 in a day? Ok... and these patients, do you see both the inpatients and the outpatients? Or you...


[System] Act as an information elicitation agent for academic interviews.

[User] No

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

[User] During my clinic day they can come, they can, so far they can be 3 in a day

[Assistant] 3 in a day? Ok... and these patients, do you see both the inpatients and the outpatients? Or you...

[User] Outpatient department?

[Assistant] You are based in outpatient?


[System] Act as an information elicitation agent for academic interviews.

[User] During my clinic day they can come, they can, so far they can be 3 in a day

[Assistant] 3 in a day? Ok... and these patients, do you see both the inpatients and the outpatients? Or you...

[User] Outpatient department?

[Assistant] You are based in outpatient?

[User] Yes

[Assistant] So are you based in that


[System] Act as an information elicitation agent for academic interviews.

[User] Outpatient department?

[Assistant] You are based in outpatient?

[User] Yes

[Assistant] So are you based in that

[User] Yes

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


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

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

[User] According to my understanding, rheumatic fever disease according to me, it’s caused by bacteria

[Assistant] Ok

[User] Yes

[Assistant] And then are you aware of the link between sore throat and RHD?


[System] Act as an information elicitation agent for academic interviews.

[User] According to my understanding, rheumatic fever disease according to me, it’s caused by bacteria

[Assistant] Ok

[User] Yes

[Assistant] And then are you aware of the link between sore throat and RHD?

[User] Actually, not very

[Assistant] What do you mean by not very, so like do you have an idea?


[System] Act as an information elicitation agent for academic interviews.

[User] Actually, not very

[Assistant] What do you mean by not very, so like do you have an idea?

[User] So, I have the idea that I was just with it from school

[Assistant] Ok

[User] Yes

[Assistant] So, what do you remember?


[System] Act as an information elicitation agent for academic interviews.

[User] 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...

[Assistant] Ok

[User] 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

[Assistant] Yes

[User] That is what I know

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


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Yes

[User] That is what I know

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

[User] No but I can say it’s in a group of streptococcal A, group A

[Assistant] Ok..., alright...ah... were you taught about what can be done to prevent RHD?


[System] Act as an information elicitation agent for academic interviews.

[User] That is what I know

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

[User] No but I can say it’s in a group of streptococcal A, group A

[Assistant] Ok..., alright...ah... were you taught about what can be done to prevent RHD?

[User] Yes, a little bit, I was given how to treatment of rheumatic fever disease

[Assistant] What else under prevention?


[System] Act as an information elicitation agent for academic interviews.

[User] Under prevention I was also taught...under prevention ...early diagnosis and treatment

[Assistant] Ok...anything else?

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

[Assistant] Ok

[User] After you have given treatment, you need to make follow up, yes

[Assistant] Alright, and then what were you taught about the treatment option for RHD?


[System] Act as an information elicitation agent for academic interviews.

[User] After you have given treatment, you need to make follow up, yes

[Assistant] Alright, and then what were you taught about the treatment option for RHD?

[User] Treatment option?

[Assistant] Yes

[User] 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

[Assistant] Ok, anything else concerning treatment?


[System] Act as an information elicitation agent for academic interviews.

[User] Treatment option?

[Assistant] Yes

[User] 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

[Assistant] Ok, anything else concerning treatment?

[User] So, things which I can add about the treatment, it’s just time, its long treatment time

[Assistant] what do you understand about the long-term prognosis of RHD?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok, anything else concerning treatment?

[User] So, things which I can add about the treatment, it’s just time, its long treatment time

[Assistant] what do you understand about the long-term prognosis of RHD?

[User] 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

[Assistant] No, the prognosis is like the outcome


[System] Act as an information elicitation agent for academic interviews.

[User] Yes. The long-term outcome of rheumatic fever disease?

[Assistant] Yes ,

[User] 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

[Assistant] Yes

[User] 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

[Assistant] Ok, anything else concerning that?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Yes

[User] 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

[Assistant] Ok, anything else concerning that?

[User] That is the information

[Assistant] Ok, when do you recall the last patient, when was the last time you saw a patient with RHD?


[System] Act as an information elicitation agent for academic interviews.

[User] That is the information

[Assistant] Ok, when do you recall the last patient, when was the last time you saw a patient with RHD?

[User] The last time I saw a patient with acute rheumatic fever was in sept...was in July

[Assistant] July eh?

[User] Yes

[Assistant] Ok, could you tell me about, like summarise the visit like the description, the presentations


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok

[User] 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.

[Assistant] Ok

[User] And slight increase in temperature, sometimes it increases and drops drastically, it increases and drops drastically

[Assistant] Ok... other than that what else?


[System] Act as an information elicitation agent for academic interviews.

[User] 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.

[Assistant] Ok

[User] And slight increase in temperature, sometimes it increases and drops drastically, it increases and drops drastically

[Assistant] Ok... other than that what else?

[User] 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

[Assistant] Ok, so what was your management plan for them?


[System] Act as an information elicitation agent for academic interviews.

[User] As per outpatient, after me looking at those signs and symptoms

[Assistant] Ok

[User] So, I had to send them to a clinic where they are supposed to be seen

[Assistant] OK

[User] 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

[Assistant] So, for you, you only suspect


[System] Act as an information elicitation agent for academic interviews.

[User] So, I had to send them to a clinic where they are supposed to be seen

[Assistant] OK

[User] 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

[Assistant] So, for you, you only suspect

[User] Yes

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


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] So, for you, you only suspect

[User] Yes

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

[User] According to the age groups?

[Assistant] Yes, on average, the age


[System] Act as an information elicitation agent for academic interviews.

[User] According to the age groups?

[Assistant] Yes, on average, the age

[User] The age? It’s majorly from the age, you can say from 8-12 majorly

[Assistant] From 8-12?

[User] Yes

[Assistant] Ok are most of them in school or...l?


[System] Act as an information elicitation agent for academic interviews.

[User] The age? It’s majorly from the age, you can say from 8-12 majorly

[Assistant] From 8-12?

[User] Yes

[Assistant] Ok are most of them in school or...l?

[User] 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

[Assistant] Ok, so you don’t have any who come and they are not in school?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Ok are most of them in school or...l?

[User] 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

[Assistant] Ok, so you don’t have any who come and they are not in school?

[User] Others come and tell you that am no longer in school

[Assistant] Ok, so they give reasons why they are no longer in school?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok, so you don’t have any who come and they are not in school?

[User] Others come and tell you that am no longer in school

[Assistant] Ok, so they give reasons why they are no longer in school?

[User] Yes

[Assistant] And what reasons do they give?


[System] Act as an information elicitation agent for academic interviews.

[User] Others come and tell you that am no longer in school

[Assistant] Ok, so they give reasons why they are no longer in school?

[User] Yes

[Assistant] And what reasons do they give?

[User] 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

[Assistant] But not because of the disease?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] And what reasons do they give?

[User] 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

[Assistant] But not because of the disease?

[User] Yes

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


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

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

[User] 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

[Assistant] Ok

[User] 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

[Assistant] Ok, whenever they come to you, what sorts of symptoms do they describe to you, most of your patients?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok

[User] 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

[Assistant] Ok, whenever they come to you, what sorts of symptoms do they describe to you, most of your patients?

[User] 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

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


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok, whenever they come to you, what sorts of symptoms do they describe to you, most of your patients?

[User] 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

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

[User] So, when they come, we normally record it in our medical record forms what they are telling us about what they are experiencing

[Assistant] 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...


[System] Act as an information elicitation agent for academic interviews.

[User] 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

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

[User] So, when they come, we normally record it in our medical record forms what they are telling us about what they are experiencing

[Assistant] 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...

[User] 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

[Assistant] Any other thing other than that they come and explain to you?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok

[User] Yes

[Assistant] Anything else

[User] Like others say they muscular pains

[Assistant] Ok, is that all


[System] Act as an information elicitation agent for academic interviews.

[User] Like others say they muscular pains

[Assistant] Ok, is that all

[User] That is what I can recall

[Assistant] Can recall?

[User] Yes

[Assistant] Ok, so generally about the follow up and adherence, is it good?


[System] Act as an information elicitation agent for academic interviews.

[User] That is what I can recall

[Assistant] Can recall?

[User] Yes

[Assistant] Ok, so generally about the follow up and adherence, is it good?

[User] Yes, follow up and adherence is very good for our clients

[Assistant] Do you do follow up for OPD as well?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Ok, so generally about the follow up and adherence, is it good?

[User] Yes, follow up and adherence is very good for our clients

[Assistant] Do you do follow up for OPD as well?

[User] No

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


[System] Act as an information elicitation agent for academic interviews.

[User] Yes, follow up and adherence is very good for our clients

[Assistant] Do you do follow up for OPD as well?

[User] No

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

[User] I normally come to the clinic where they do their further investigations and management and I try to check on

[Assistant] Ok, alright, so what sorts of barriers do they commonly state to getting the care that they need?


[System] Act as an information elicitation agent for academic interviews.

[User] No

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

[User] I normally come to the clinic where they do their further investigations and management and I try to check on

[Assistant] Ok, alright, so what sorts of barriers do they commonly state to getting the care that they need?

[User] 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

[Assistant] Ok, what else?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok, what else?

[User] 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

[Assistant] Yes

[User] 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

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


[System] Act as an information elicitation agent for academic interviews.

[User] 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

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

[User] 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

[Assistant] Ok

[User] They don’t care about them to the expectations they want

[Assistant] 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


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok

[User] They don’t care about them to the expectations they want

[Assistant] 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

[User] My challenges?

[Assistant] 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.


[System] Act as an information elicitation agent for academic interviews.

[User] The challenges they face according to me?

[Assistant] Yes

[User] One I can say, to me I see they come when they are already, like I can say they are traumatised

[Assistant] Ok

[User] 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?

[Assistant] Ok, what else do you think that they face? Other challenges that they face?


[System] Act as an information elicitation agent for academic interviews.

[User] 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?

[Assistant] Ok, what else do you think that they face? Other challenges that they face?

[User] stigma

[Assistant] Ok

[User] Yes

[Assistant] Ok, any other things?


[System] Act as an information elicitation agent for academic interviews.

[User] stigma

[Assistant] Ok

[User] Yes

[Assistant] Ok, any other things?

[User] That’s according to me, how whenever they come

[Assistant] 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?


[System] Act as an information elicitation agent for academic interviews.

[User] That’s according to me, how whenever they come

[Assistant] 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?

[User] To me I think there is a gap

[Assistant] like?

[User] One is communication gap

[Assistant] Ok, do you mind explaining this


[System] Act as an information elicitation agent for academic interviews.

[User] To me I think there is a gap

[Assistant] like?

[User] One is communication gap

[Assistant] Ok, do you mind explaining this

[User] 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

[Assistant] ok, other than communication gap, anything else?


[System] Act as an information elicitation agent for academic interviews.

[User] One is communication gap

[Assistant] Ok, do you mind explaining this

[User] 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

[Assistant] ok, other than communication gap, anything else?

[User] I can say yes, like teamwork

[Assistant] You feel like there is no team work


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] ok, other than communication gap, anything else?

[User] I can say yes, like teamwork

[Assistant] You feel like there is no team work

[User] Yes

[Assistant] Or there is team work


[System] Act as an information elicitation agent for academic interviews.

[User] I can say yes, like teamwork

[Assistant] You feel like there is no team work

[User] Yes

[Assistant] Or there is team work

[User] You can say there is adequate team work

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


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Or there is team work

[User] You can say there is adequate team work

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

[User] Can you please come again?

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


[System] Act as an information elicitation agent for academic interviews.

[User] You can say there is adequate team work

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

[User] Can you please come again?

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

[User] Yes

[Assistant] What do you think, ok generally and particularly RHD, what do you think is not being done well


[System] Act as an information elicitation agent for academic interviews.

[User] Can you please come again?

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

[User] Yes

[Assistant] What do you think, ok generally and particularly RHD, what do you think is not being done well

[User] Like when...

[Assistant] And the funding


[System] Act as an information elicitation agent for academic interviews.

[User] Like when...

[Assistant] And the funding

[User] And the funding?

[Assistant] Yes

[User] Underfunding like I can say that there is also inadequate mentorship for ARF

[Assistant] Ok, other than that, anything else?


[System] Act as an information elicitation agent for academic interviews.

[User] And the funding?

[Assistant] Yes

[User] Underfunding like I can say that there is also inadequate mentorship for ARF

[Assistant] Ok, other than that, anything else?

[User] That is what I can state

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


[System] Act as an information elicitation agent for academic interviews.

[User] Underfunding like I can say that there is also inadequate mentorship for ARF

[Assistant] Ok, other than that, anything else?

[User] That is what I can state

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

[User] In what ways?

[Assistant] 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


[System] Act as an information elicitation agent for academic interviews.

[User] That is what I can state

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

[User] In what ways?

[Assistant] 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

[User] Yes

[Assistant] You as a health worker


[System] Act as an information elicitation agent for academic interviews.

[User] I can say in terms of facilitations?

[Assistant] Yes

[User] 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

[Assistant] Yes

[User] So that is what I can explain about that

[Assistant] Ok, what would bring about the team bit you talked about previously?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Yes

[User] So that is what I can explain about that

[Assistant] Ok, what would bring about the team bit you talked about previously?

[User] Yes

[Assistant] Ok and why do you think it’s happening like that


[System] Act as an information elicitation agent for academic interviews.

[User] So that is what I can explain about that

[Assistant] Ok, what would bring about the team bit you talked about previously?

[User] Yes

[Assistant] Ok and why do you think it’s happening like that

[User] 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

[Assistant] Ok, and that’s happening here like for the different health workers.


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Ok and why do you think it’s happening like that

[User] 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

[Assistant] Ok, and that’s happening here like for the different health workers.

[User] I can say yes

[Assistant] Has it happened in several department or we have specific...


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok, and that’s happening here like for the different health workers.

[User] I can say yes

[Assistant] Has it happened in several department or we have specific...

[User] 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

[Assistant] Ok, so do we have like are the medicines available in the hospital?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok, so do we have like are the medicines available in the hospital?

[User] For ARF

[Assistant] Ok, generally

[User] Yes, the medicine for ARF is available

[Assistant] So, what would you say, it’s not working well for you, let’s say in terms of medication


[System] Act as an information elicitation agent for academic interviews.

[User] For ARF

[Assistant] Ok, generally

[User] Yes, the medicine for ARF is available

[Assistant] So, what would you say, it’s not working well for you, let’s say in terms of medication

[User] In terms of medication?

[Assistant] Let’s say benzamine penicillin, heart failure drugs


[System] Act as an information elicitation agent for academic interviews.

[User] In terms of medication?

[Assistant] Let’s say benzamine penicillin, heart failure drugs

[User] So, I think I have no problem with medication

[Assistant] Ok

[User] Yes

[Assistant] You think it’s available


[System] Act as an information elicitation agent for academic interviews.

[User] So, I think I have no problem with medication

[Assistant] Ok

[User] Yes

[Assistant] You think it’s available

[User] Its available 24 hours

[Assistant] Ok, even heart failure drugs?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] You think it’s available

[User] Its available 24 hours

[Assistant] Ok, even heart failure drugs?

[User] Yes

[Assistant] Do you do echo cardiography in our facility?


[System] Act as an information elicitation agent for academic interviews.

[User] Its available 24 hours

[Assistant] Ok, even heart failure drugs?

[User] Yes

[Assistant] Do you do echo cardiography in our facility?

[User] Yes

[Assistant] Yes, you do echo? And everyone has access to it?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Do you do echo cardiography in our facility?

[User] Yes

[Assistant] Yes, you do echo? And everyone has access to it?

[User] Yes

[Assistant] Ok and then how would you describe your record department?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Yes, you do echo? And everyone has access to it?

[User] Yes

[Assistant] Ok and then how would you describe your record department?

[User] The record department I would say, there is still gaps in the record department

[Assistant] ok do you mind explaining that?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Ok and then how would you describe your record department?

[User] The record department I would say, there is still gaps in the record department

[Assistant] ok do you mind explaining that?

[User] 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

[Assistant] Ok, so we still have that record gaps


[System] Act as an information elicitation agent for academic interviews.

[User] The record department I would say, there is still gaps in the record department

[Assistant] ok do you mind explaining that?

[User] 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

[Assistant] Ok, so we still have that record gaps

[User] In terms of the registers

[Assistant] Do you have like an ARF register for RHD patients in your department?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Ok, so we still have that record gaps

[User] In terms of the registers

[Assistant] Do you have like an ARF register for RHD patients in your department?

[User] No, I don’t have in my department

[Assistant] Oh... what of any, do you ever record or keep any information concerning those patients?


[System] Act as an information elicitation agent for academic interviews.

[User] In terms of the registers

[Assistant] Do you have like an ARF register for RHD patients in your department?

[User] No, I don’t have in my department

[Assistant] Oh... what of any, do you ever record or keep any information concerning those patients?

[User] No

[Assistant] Ok, in your department, do you like have any guidelines and protocol for RHD care


[System] Act as an information elicitation agent for academic interviews.

[User] No, I don’t have in my department

[Assistant] Oh... what of any, do you ever record or keep any information concerning those patients?

[User] No

[Assistant] Ok, in your department, do you like have any guidelines and protocol for RHD care

[User] Yes

[Assistant] Including the referral pathways?


[System] Act as an information elicitation agent for academic interviews.

[User] No

[Assistant] Ok, in your department, do you like have any guidelines and protocol for RHD care

[User] Yes

[Assistant] Including the referral pathways?

[User] No

[Assistant] But you have the guidelines, right?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Including the referral pathways?

[User] No

[Assistant] But you have the guidelines, right?

[User] Yes

[Assistant] 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?


[System] Act as an information elicitation agent for academic interviews.

[User] Let’s say they have done best in sensitising the community

[Assistant] Ok

[User] Yes

[Assistant] What else?

[User] that is what I can say

[Assistant] Ok what of in terms of funding of health acre


[System] Act as an information elicitation agent for academic interviews.

[User] that is what I can say

[Assistant] Ok what of in terms of funding of health acre

[User] Funding health care?

[Assistant] Yes

[User] I think in the funding of the health care within, from the district

[Assistant] 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?


[System] Act as an information elicitation agent for academic interviews.

[User] Funding health care?

[Assistant] Yes

[User] I think in the funding of the health care within, from the district

[Assistant] 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?

[User] I think the funding is fine according to me

[Assistant] Ok, so what are you happy about in terms of its funding?


[System] Act as an information elicitation agent for academic interviews.

[User] I think in the funding of the health care within, from the district

[Assistant] 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?

[User] I think the funding is fine according to me

[Assistant] Ok, so what are you happy about in terms of its funding?

[User] 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

[Assistant] 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?


[System] Act as an information elicitation agent for academic interviews.

[User] I think the funding is fine according to me

[Assistant] Ok, so what are you happy about in terms of its funding?

[User] 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

[Assistant] 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?

[User] I think the health workers, we have improved

[Assistant] 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?


[System] Act as an information elicitation agent for academic interviews.

[User] I think the health workers, we have improved

[Assistant] 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?

[User] 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

[Assistant] Yes

[User] 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.

[Assistant] 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?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

[Assistant] Yes

[User] 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.

[Assistant] 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?

[User] 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

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


[System] Act as an information elicitation agent for academic interviews.

[User] 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.

[Assistant] 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?

[User] 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

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

[User] Yes

[Assistant] Ok and you said they can get all these drugs from the pharmacy /hospital pharmacy?


[System] Act as an information elicitation agent for academic interviews.

[User] 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

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

[User] Yes

[Assistant] Ok and you said they can get all these drugs from the pharmacy /hospital pharmacy?

[User] Yes

[Assistant] There is no time they are supposed to buy?


[System] Act as an information elicitation agent for academic interviews.

[User] Yes

[Assistant] Ok and you said they can get all these drugs from the pharmacy /hospital pharmacy?

[User] Yes

[Assistant] There is no time they are supposed to buy?

[User] I have never come across that

[Assistant] Ok and then in the records, what are they doing well, what have they done well? records department