Personal characteristics.

The interviews were conducted by three male research assistants with prior experience in qualitative research interviewing. The investigation team consisted of a physician with vast snakebite clinical experience, as well as a clinical research expert with a Master of epidemiology.

Connection with participants.

There was no history between interviewers and any of the participants. All participants were first informed by their unit leads about the invitation to participate and schedule an interview date. At the start of the interview, the interviewers made a personal introduction to each participant and gave a brief overview of their position within the study.

Management procedure.

The participants expressed knowledge about snake management at health facility level, as well as acknowledged that snake bites are dangerous and if not timely treated, can result in permanent disability, disfigurement, or even death. Fortunately, they self-reported/appraised themselves on the need to use clinical guidelines in the management of snake bites. For example, the participants noted that management of cases was based on the snakebite management guidelines and any available health facility-specific protocols. The participants showed knowledge on the supportive treatment procedures including local first aid and history taking from the cases that happen at the health facilities which is usually done when a patient is rushed there.

“…When you are rushed to the hospital before the anti-venom is given, they first give you IM or IV of hydrocortisone to neutralize the poison it has left in your body. After neutralizing with hydrocortisone, you are given also IV (antihistamines) to give you strength. Then you are given anti-snake venom and you are also subjected to a PPF [procaine penicillin fortified] treatment of 5 days."

(Nurse -Screening and linkage, IDI–1)

Participants emphasized that history taking and the local first aid provided at home were important for determining the type and severity of the snake bite. They emphasized these procedures give good guidance to guide the kind of supportive treatment to provide to the patients.

“If the client has given you good history of the snakebite and the type of the snake which has bitten him or her, then that is what we normally rely on that to give the treatment. Because there is not normally much investigation [such as] those laboratory investigations to determine whether this one (snake involved) is poisonous.”

(Nursing officer, IDI–6)

The study found that snake envenomation treatment involved first aid and adjuvant interventions. Some of the health facilities had a displayed protocol for managing patients, which most healthcare workers referred to. They also mentioned the Uganda Clinical guidelines 2016 and 2020 as reference materials for all health-related conditions and procedures. One nurse remarked

"[When handling these cases], we always refer ourselves to Uganda clinical guidelines, which provides brief information about [management of] those bites and stings. All the healthcare workers are given clinical guidelines of 2007, not the new updated one of 2020, because very few of them got it."

(Nurse, IDI–13)

Snakebite diagnosis based on signs and symptoms.

The study explored the knowledge and practices of healthcare workers regarding snakebite management. One key aspect was the process of identifying the type of snake that caused the bite. The participants admitted that patients often cannot provide accurate information about the snake’s color or species. Therefore, healthcare workers diagnose snakebites based on signs and symptoms. For example, for neurotoxic snakebites, they look for sweating, emasculation, and drooling of saliva. For cytotoxic snakebites, they look for swelling. For hemotoxic snakebites, they look for active bleeding. This approach helps healthcare workers to make a diagnosis even without detailed information about the snake. One participant remarked as follows

" We first try to ascertain which type of snake? Did they see the color or not? But sometimes, for them, they fail to see the type or the color of the snake. So, we always diagnose [suspect diagnosis] by basing on signs and symptoms. As for neurotoxic snakebites, you look for signs; sweating, and then drooling of saliva. That one we can easily diagnose. Then those ones with cytotoxic, we see the swelling. Then for hemotoxic, we always see active bleeding."

(Nurse, IDI–8)

Lack of up-to-date robust clinical guidelines.

Although some healthcare workers had self-reported their knowledge and utilization of Uganda clinical guidelines, they highlighted several barriers. For instance, except for Lacor Hospital which had comprehensive protocols for snakebite management, healthcare workers from other facilities highlighted a lack of robust clinical guidelines on snakebite management. They pointed out gaps in the national guidelines for snakebite cases. For example, the supportive treatment recommended in the guidelines was considered weak, and the guidelines were noted to be insufficient in detail.

One participant remarked as follows

“However, within the clinical guidelines, there exists a notable weakness. it suggests administering chlorphenamine, a relatively weak antihistamine, in tablet form. This is a concern when dealing with severe cases of envenomation, where patients may show clear signs of venomous effects. Given the circumstances, the efficacy of chlorphenamine is questionable and not deemed as a viable option.”

(Clinical officer, IDI–18)

Delayed health-seeking behavior for patients.

Healthcare workers mentioned the challenge of patients arriving late for medical attention at the health facility. This delay in seeking healthcare services for snakebite cases was seen as a major obstacle in managing such cases effectively. The healthcare workers said that this delay often led to adverse outcomes, such as poor health and sometimes death.

“One or two (patients) that pass away [in a year] [… .] in most cases, it is because they delayed to reach the facility. These individuals arrive late, so by the time we are attempting to admit them for medical care [Hospitalize], they are already in dire circumstances. For most of the people that come early, they are helped, given care, and they recover. Of course, we’ve had delays [many instances where patients are presented to hospital late] many hours after the snakebite. At times, the patient checks in the following day when the whole body is paralyzed. At this point, I really can’t do much [to save the patient]. It is one of the biggest challenges”.

(Medical officer, IDI–16)

Limited knowledge and skills.

Many healthcare workers in the study expressed a lack of adequate knowledge and skills in managing snakebite cases. They reported challenges in areas such as identifying snake species and applying appropriate treatment protocols. This lack of knowledge and skills raises concerns about the effectiveness of their interventions in snakebite management.

“I have seen that many of my colleagues in health care, they don’t have enough knowledge about how to deal with snakebite cases. It doesn’t matter if they are nurses or doctors or specialists, they all struggle with snakebite management. Even myself, I have to admit that I’m not very confident in my skills. We have a big gap in our knowledge in this area, and it’s a very serious concern for us.”

(Medical officer, IDI–15)

At administrative level, participants highlighted that health facilities prioritize capacity building for other medical conditions over snakebite case management even in endemic districts.

“People are eager to learn more about snakebites, but they are left behind. The government and other partners don’t care about us, they only care about their own agendas. They ignore the need for proper training on snakebites. This makes us feel frustrated and helpless, because we can’t improve our knowledge and skills.”

(Medical officer, IDI–15)

Lack of antivenoms and high cost of treatment.

Lack of resources, especially adequate supplies of anti-venom, was a major obstacle in managing snakebites effectively, as healthcare workers reported. This shortage of anti-venom in health facilities, along with the high cost of treatment, posed significant challenges, especially for victims who could not afford the necessary care

“Sometimes they bring just about 10 doses of anti-venom for the whole three months [for entire hospital]. Can you imagine? It’s barely enough! And if it’s not available when a patient needs it, we have no choice but to ask them to buy it themselves. But you know, many of them cannot afford it. So instead, we have to make work with what we have [all alternative treatments available]. We give them hydrocortisone and antibiotics, but deep down, we know it’s not enough. We can only pray and hope for the best because there’s really nothing more we can do.”

(Senior nursing officer, IDI–5)

Poor referral systems.

Healthcare workers mentioned the challenges caused by poor referral systems and poor communication between health facilities, leading to difficulties in providing timely and appropriate treatment to snakebite patients. Participants stressed that the current ways of patient referral were unreliable, worsening the problem.

“We feel very bad when we see our patients suffering because of the problems in the referral system. Some patients are kept by other facilities for too long, even when they have serious conditions like cytotoxicity. When they come to us, their situation is very bad. Others need to go to higher-level facilities where they can get the right treatment, like antivenom for snake bites. But this process is also slow and can put their lives in danger. We wish we could do more to help our patients and give them the best care possible.”

(Nurse, IDI–8)

Increasing awareness and education about snakebite management among healthcare workers through training and workshops.

The participants emphasized that sharing experiences among themselves would be a valuable learning platform and an opportunity for professional growth. They recognized that snakebite cases can be challenging and complex, and by exchanging their experiences, healthcare workers who have never encountered such cases would benefit from the practical knowledge and insights of their colleagues. Through discussions and interactions, they could learn about different snakebite scenarios, the specific management approaches used, and the lessons learned from previous cases

“We need to attend those seminars because they help us to update our knowledge. The protocols keep changing, so we have to learn new things. We also get CMEs [Continuous medical education], which are good for our learning and our profession. We can also use Google [evidence search] to see how other hospitals are managing snakebite cases. It helps us to improve our practices and give better care to our patients”

(Nurse, IDI–13)

Increasing education and awareness about snakebite prevention and management in the general public.

Healthcare workers strongly emphasized the importance of community sensitization to enhance the understanding and knowledge of individuals and communities regarding the initial management of snakebite cases before reaching a health facility. They highlighted that by raising awareness and providing education in communities, individuals can learn valuable information and skills to respond quickly to snakebite incidents. This proactive approach empowers community members to administer appropriate first aid measures, which can significantly improve outcomes for snakebite victims

“Besides the CMEs, we should also integrate snakebite management with other healthcare activities when we go out for outreaches. For example, when we do surveillance for diseases like TB, COVID-19, or malaria, we should also look into snakebite cases. This would help us to know the situation in the community or the health center. We can check the register and see how many people have come for snakebite treatment in that health center. This integrated approach would help us to meet the comprehensive healthcare needs of the people.”

(Consultant physician, IDI–4)

Research into better snakebite management practices and alternative treatments for snakebite, to complement or replace antivenom.

One of the important opportunities highlighted was the need for research into improving snakebite management practices and finding alternative treatments to complement or replace antivenom. The participants recognized that current management approaches may have limitations and that there is a desire to find more effective solutions. This highlights the importance of ongoing research and innovation in snakebite management. One participant mentions

“I believe that conducting studies like this will greatly benefit us as medical practitioners. Such studies help us stay updated and informed. Your study on the management of snakebites is a valuable opportunity for our facility, as it allows us to better prepare ourselves for handling snakebite cases. This knowledge is crucial for us working in rural areas where snakebites are common.”

(Medical Officer, IDI—14)

Funding and budgeting considerations for supplies.

Participants highlighted the importance of funding as a key opportunity that could improve the health facility budget and the availability of necessary supplies for snakebite case management. Adequate funding would address the ongoing challenges of limited resources and shortages in essential items such as anti-venom, which are vital for treating snakebite patients. With increased financial support, health facilities would be better equipped to ensure a consistent supply of anti-venom and other medications, as well as invest in training programs for healthcare workers to enhance their skills and knowledge in snakebite management. One healthcare worker remarked as follows

“Yeah, when it comes to snake anti-venom, it’s not always readily available. We can still obtain it when needed, but not immediately [Not readily available]. I am aware that I have the authority to prescribe it, but there are certain strict regulations surrounding its prescription. I believe it’s due to its limited availability. If there were an abundant supply, say 10 vials without any shortage, then I would feel more confident [to easily prescribe it to patients]. However, I’m concerned that in a worst-case scenario, I might not be able to obtain it. So, proper budgeting is necessary to ensure its availability.”

(Medical Officer, IDI–16)