Phase I: Healthcare access and use for Bwindi Impenetrable National Park staff.

Data were collected using a short qualitative individual interview guide (data in S1 Text). Pilot interviews with one Bwindi Community Hospital staff member and two park rangers were carried out before data collection began. Three different groups were included: 1) park wardens, rangers, porters, and security personnel were asked about health facilities available to them, health seeking behavior, and instances when one would take time off work because of illness 2) two senior Bwindi Community Hospital staff members (head doctor or nurse) were interviewed about services provided by BCH, including immunizations, preventative healthcare, and other treatments for conditions prevalent in the area, and 3) a senior member of BINP management was asked about what policies are in place for staff sick leave, how prevention and care services are provided to staff, and what policies are implemented to minimize disease exposure and transmission between staff and gorillas, and what procedures are followed if staff accidentally expose gorillas to infections. Interviews were de-identified by giving participants a number at the time of the interview, and recording their job title, age and gender.

Semi-structured qualitative interviews were conducted among 46 participants in English. Interviews were carried out by the student investigator Maya Homsy King and a research assistant from the Bwindi area. Maya is a White female Master of Public Health Student at the University of California Berkeley, who grew up in Uganda. She has prior experience conducting qualitative interviews in Uganda and has formal training in qualitative analysis. Informed consent and purpose of the study was explained prior to beginning the interview. Interviews were comprised of nine questions and lasted 30 minutes on average. Data were recorded via handwritten notes, and short field notes were made after the interviews each day. No interviews were audio-recorded due to IRB constraints. All interviews took place at participants’ places of work, e.g., ranger stations and visitor centers. Each sector at BINP has a building where rangers report to work, and researchers were given an empty room or secluded outdoor space to conduct interviews with rangers who were not in the field. No people other than the interviewer and participant were present during the interview, no repeat interviews were carried out, and transcripts were not returned to participants. Thirteen participants were interviewed at Buhoma, 15 at Ruhija, 15 at Nkuringo, two senior staff at BCH, and one senior member of BINP management. Participants at BINP were given a new umbrella for as a token of appreciation for their time while participating in the study.

Phase II: Key informant interviews regarding employee health programs at other wild great ape sites.

Key informant (KI) interviews were conducted with individuals who are knowledgeable about the employee health programs at their great ape site using a qualitative interview guide (data in S2 Text). Individuals were contacted if: 1) they worked at a wild great ape site; and 2) had knowledge of employee health protocols at their place of work. KI’s sites included national parks, a research reserve and a rehabilitation center (Table 3). Key informants were given a list of questions (S2 Text) and the informed consent document for participants to read and sign. Five interviews were conducted, and transcription software was used to transcribe the interview. No repeat interviews were carried out and transcripts were not returned to participants. Interviews lasted 30 to 40 minutes. Questions were centered around employee health practices at participants’ places of work and included information on preventive healthcare practices at wild great ape sites, PPE regulations, and what healthcare is available to employees.

After analysis of the data, a summary of recommendations and findings was submitted to the Chief Warden at BINP, the Research and Monitoring ranger, and head rangers at each participating sector. Unfortunately, it is impossible to ensure that individual participants receive results as we did not retain identifying information for them, but the study team received a detailed response from the Chief Warden acknowledging the results, detailing progress already made on healthcare at BINP, and using the results to find ways forward for all recommendations. The full draft version of this paper has been also shared with the Chief Warden, staff at BCH and all KIs.

Employees do not obtain regular physical examinations, nor do they receive regular deworming.

All employees of UWA were insured by AAR, an East African health insurance company. Rangers have a comprehensive plan, which most of them say covers all common ailments and treatment for them and their families (up to 4 people), although it did not cover preventive physical exams. Porters, who were classified as ‘support staff,’ were not insured and had to pay out of pocket for services at any private facility. Only select hospitals were enrolled in UWA’s insurance scheme; private clinics were not covered by the insurance scheme. For all rangers other than those stationed at Buhoma (who could walk to Bwindi Community Hospital), private clinics were more convenient; hospitals were over an hour’s drive away. Many participants said they were satisfied with the insurance, and glad that it was available to them, however all participants had to pay out of pocket for any preventive service they requested.

“They do all the tests for whatever you’re suffering from. If you’re not suffering from anything, and you want to check your condition, insurance doesn’t cover it.”

Ranger-guide, Ruhija, 39 y/o, F

Therefore, many participants said they only went to a health facility if they had symptoms, and there was no regulation in place mandating physical examinations for any employees. Fewer porters than rangers described going to a health facility for a physical exam. Those who went for physical exams gave reasons such as sexually transmitted infection (STI) testing, especially HIV, and antenatal visits for women.

“I go there to check myself and some special treatment that are not at the clinics near here. I also go to test blood for general issues—if you’re sick and don’t know the cause. After 6 or 3 months I would go just to check even if not sick.” Private ranger,

Nkuringo, 32 y/o, M

In addition to the cost, whether participants went for regular physical exams depended on personal attitudes towards their own health or having a chronic condition, such as allergies, that necessitated regular visits to a health facility. Many participants said they only went to a health facility if they were experiencing symptoms, and while a few said they went regularly for physical exams without symptoms.

Finally, porters and rangers said that they rarely, if ever, took deworming medication. Participants said only children took deworming medication at regular intervals. A few said that they took the medication every few months of their own volition, because the health facility reminded them, or when they felt abdominal discomfort. One participant said they used herbs from the forest for deworming purposes.

Diagnostics are mostly available at hospitals, not clinics or government health centers, and medications are frequently unavailable at health centers.

Interviewees stated that the hospitals they access to consistently had the laboratory facilities and equipment to diagnose a range of conditions, but clinics were more limited. Participants mentioned availability of blood, urine, and stool sample diagnostic testing at hospitals, as well as ultrasound scans, X-rays and a larger number of staff qualified to operate this equipment. Bwindi Community Hospital provided screenings including tuberculosis, blood pressure, and Hepatitis B and STIs for pregnant women, which were covered under the consultation fee. These services were not present at clinics or health centers. At BCH, screening for helminthic infections is done on a symptomatic basis, and triage for respiratory symptoms and temperature happens as soon as patients enter the gate of the facility.

“If you are pregnant, a Hepatitis B screening is required, as well as other STIs. Some screenings are included in general care- for example, TB screening starts at triage (with a questionnaire), blood pressure is taken.”

Senior BCH staff, 35 y/o, M

Some clinics had malaria, pregnancy, and STI testing, but some were said to have no testing capacity at all. Clinics were rarely said to have any scanning capabilities. Several participants expressed their wish for better-equipped facilities nearer to their workplaces, especially relating to diagnostic capabilities.

“If the clinic could test people, they would be doing well. We need scanning, x-rays, fridges for keeping some medicines.”

Ranger-tracker, Nkuringo, 26 y/o, F

Another important factor in the choice of healthcare facility was the availability of medications. Many people cited lack of available medication at government health centers near them, which is why private clinics or hospitals were the facility of choice for most people. Availability of treatment at clinics was variable; participants at Ruhija frequently described clinics consistently stocking medication, while participants at Nkuringo were more likely to mention that even clinics sometimes had no medication, or only had over-the-counter pain relievers.

Mostly in clinics you find only one person, or the clinic is closed. We need more clinics; the government could provide more health centers. In most cases, in clinics you can request for tablets, and they don’t have. Mostly they deal with minor illnesses and tablets.

Ranger, Nkuringo, 37 y/o, F.

Treatment of chronic or severe illness happens at hospitals, whereas acute conditions are treated at clinics.

One frequently mentioned recommendation by staff was to have a health provider within the park for BINP staff. Reasons for this included the slow nature of services at many hospitals and the distance staff must travel to reach better equipped facilities, which is especially important when staff need urgent care. The clinic is much faster, and in most cases closer to where the participants reside (Fig 2). The wait time reported at hospitals varied from 30 minutes to a whole day, but participants said that it depended on the time of day, and on how many patients were waiting to receive care.

“To me, what would be important is that the organization should have clinics within working places. If you fall seriously sick, you have to be rushed to far places. Pregnant staff who are rushed to nearest places sometimes lost the baby. It is hard to find a good facility near the ranger post.”

Ranger-guide, Ruhija, 39 y/o, F

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Fig 2. Types of health facilities used by park staff at BINP and their pros and cons according to the majority of participants.

https://doi.org/10.1371/journal.pone.0299220.g002

Participants reported going to the hospital rather than the clinic for issues they perceived to be more serious, except when a condition needed to be treated immediately, in which case they went to the closest clinic (Fig 2). In many cases, despite the fact that it cost money, participants would go to a nearby clinic first, and if a condition was not resolved, they would make the trip to the hospital. Serious conditions were more likely to warrant testing to determine the cause of the illness, and thus was more likely to require a trip to a hospital. The factors of transport availability and cost were mentioned multiple times as limiting factors in accessing better-equipped facilities where insurance is accepted.

“At clinics, you can go for consultation, history taking, some tests and treatment. At BCH, you can go for tests for different illnesses, HIV, some treatments and medicines. BCH is the most used- you can also access screening for diabetes, hepatitis B, malaria and hypertension.”

Porter, Buhoma, 43 y/o,F

Participants differed in how they reported reacting to symptoms of malaria; some reported going to the clinic to buy medication, while others would go to the hospital to be tested and treated. All participants perceived ‘general body weakness’, meaning a feeling of fatigue and muscle weakness as serious. Unless it was only ‘mild weakness’, respondents said that body weakness and fatigue warranted staying home from work and seeking diagnosis and treatment.

“[I go to the hospital for] mostly malaria and fever. For cough and flu, I visit the clinic. Sometimes, for small wounds, like a cut, I go without [going to either the clinic or hospital]. When I’m suffering from malaria, they get blood, take it to the lab and give me drugs.”

Porter, Ruhija, 36 y/o, M

Participants said they usually go to the clinic for severe stomach problems and resolve less severe stomach issues by themselves. Some participants mentioned that they suffered from stomach ulcers, and these sometimes warranted a visit to the hospital. Local herbs were also mentioned as treatments for ulcers in Nkuringo and Ruhija.

“For ulcers, we visit an old woman who can give you a medicine, called ebiculinganyi. She dries it inside the house and makes it a paste and you drink. At the hospital, they give you magnesium and if you don’t feel okay after that, you can try the herbs.”

Porter, Ruhija, 31 y/o, M

Participants also stated that they sometimes use traditional medicines for the treatment of other ailments, such as cough, flu, malaria, and stomach problems. However, when asked about visiting traditional healers, all participants denied using their services, and mention of traditional healers at times provoked laughter or emphatic denial of the use of their services.

Common ailments including cough, flu, and malaria could be treated using the first-aid kits that UWA keeps at each office in the four sectors of the park. The kit is stocked with medication for common ailments and with bandages. These supplies are free for rangers to use, and many of them mentioned that they would look there first before going to buy medication from the clinic. However, respondents frequently said the kits were not restocked as often as necessary and could be understocked for months on end.

Finally, respondent’s perception of staff and their qualifications, as well as the way they treat patients, was of importance in making decisions for healthcare. Participants said that staff at hospitals were more qualified than those at clinics, which is one reason why more serious illnesses warranted a visit to the hospital (Fig 2). Some participants however mentioned harsh treatment by providers at hospitals because of understaffing.

Rangers take time off depending on personal opinions of risk to themselves and to gorillas and assessment of what duties can be performed while ill.

Decisions on whether to come to work depended on individual opinions of risk to themselves and to the gorillas, and assessment of what duties could be performed while ill. Some participants mentioned doctor’s opinions or prescriptions determining how long they would stay away from work, and park management described that the length of necessary sick leave was determined by a doctor’s recommendation. Rangers had allowance for up to 6 months of paid sick leave, if necessary, but this must be proven with a doctor’s note. They also have eight days off per month including weekends (regardless of whether they are sick), which are sometimes used to take time off for less severe issues like cough, headache, and gastrointestinal issues. Porters are paid every day they work and not otherwise.

Many rangers said that they would do ‘simple work’ if they had mild symptoms such as headaches or mild cough or flu. Reasons given frequently included the risk of transmission to gorillas, as well as not being able to hike for long periods of time when sick. ‘Simple work’ encompassed office work or gatekeeping, but not going into the forest. Some people said that they would skip work for ‘running stomach’ (diarrhea), as this would make hiking or dealing with clients challenging.

“Mostly when we are sick, we may even transmit diseases to gorillas, and you may have no energy. When I’m sick, I report to supervisors. Sometimes, they advices me to go to the nearest clinic or hospital. Sometimes they assist with transport if I am in the field.”

Ranger-tracker, Buhoma, 35 y/o, M

There were some exceptions when people would come to work. A few rangers said that they would go into the forest with respiratory symptoms, including mild cough or cold, but that they would wear a mask.

“Sometimes I may have headache and still go to work. Sometimes I may have cough and flu and still go when it is not strong [severe]. If it’s strong, I can’t go for hiking.”

Ranger, Nkuringo, 37 y/o, F

Rangers knew that respiratory infections were dangerous for gorillas but mentioned that understaffing put pressure on them to come back to work before they felt fully recovered. It was unclear whether supervisors, a personal sense of obligation, or co-workers were the source of this pressure.

“It depends on how you feel to come back [to work]. Maybe the pressure at work and the high season can force you to come back.”

Ranger-guide, Ruhija, 39 y/o, F

Most sites do not provide for preventive healthcare.

Sites 3 and 4 were the only ones that provided staff with an annual health check with a physician. Site 3 described screening for TB and HIV yearly. Site 3 dewormed humans as often as the apes are dewormed, every 3 or 6 months. At Site 4, deworming medication was only given if symptoms were present, similar to all the other sites. Site 4 contracted a doctor from the national health service to provide free annual health checks to park staff including screening for malaria and other infectious diseases such as, TB, COVID-19, respiratory syncytial virus, and human metapneumovirus. The country they are based in also has a national health insurance scheme.

“Then we collaborate with the doctor, the national doctor from the public hospital. So, we send our trackers and all the people who are working in the park to go in the hospital and the doctor is going to consult them, and to treat them against the disease.”

—Site 04

Site 4 received funding from a European organization for staff healthcare. Although Site 2 also received external funding, they did not have an annual health check and staff seek services as needed. Site 4 requires park staff, who usually spend two weeks in the field, to take a rapid test for COVID-19 every time they go to the field from camp and one week later.

Three of the six sites (sites 1,3 and 4) mentioned providing vaccinations against Hepatitis B, and COVID-19. Hepatitis B is not currently a concern for zooanthroponotic transmission. KIs from sites 1 and 4 mentioned that provision of the Hepatitis B vaccination was a governmental initiative and happened once people were recruited into the park service. Sites 0, 2 and 5 did not require any vaccinations.

Staff must travel outside the site to access healthcare.

Staff normally had to travel outside their place of work to access healthcare, except for site 1. Site 1 has a dispensary within the park with employee health workers present. The KI described that this was normally the first point of care for sick employees, and from there they were normally referred to hospitals outside the park.

Site 4 brings in a doctor from the national health system once per year to provide an annual physical exam to employees, but otherwise employees go to the government hospital for their healthcare. Sites 2 and 5 described being especially far from healthcare facilities. Site 2 described being 70 km away from the nearest village or town, meaning employees normally sought healthcare on their time off, as they get two weeks off every six weeks. Site 3 described providing most healthcare through the NGO, although it was not clear where Site 3 was in comparison to the nearest health facility.

Access to diagnostics varies across sites.

Sites 1 and 4 had access to a laboratory onsite with capacity to test for infectious diseases of concern to great apes, including hMPV and RSV. Other sites relied on access to healthcare facilities outside the park for diagnostic testing. At Site 3 new employees were screened for TB, herpesvirus, HIV, Hepatitis A, B and C, and COVID, and are tested for TB and HIV yearly.

The feasibility of referrals and access to facilities where diagnostic testing and screenings happen depends on the site itself. Some sites, such as Site 1, are closer to urban centers where hospitals and clinics are accessible, whereas others, like Sites 2 and 5 are remote and difficult to access.

All sites have PPE, and clothing requirements for staff, some have quarantine requirements.

All sites have PPE requirements for staff, with a minimum of a facemask worn when near primates, and with the most conservative requiring that staff change clothes and shoes before and after going to the forest. Site 0 has uniforms for staff, but staff wear these uniforms at the administrative building as well as in the forest. Site 2 has a structure to change clothes on the boundary of the forest, where staff put on forest clothes, and then change into camp clothes after returning from the forest. Sites 1 and 3 also require changing clothes and shoes before going to the forest, or interacting with primates, while Site 4 only implements cleaning shoes with bleach before and after going to the field. Site 5 only requires a face mask, but the primates at this site are not habituated to humans and therefore typically stay far from people.

Site 2 has a quarantine period of three days for individuals who leave the site and come back. During this quarantine period they stay in camp but are not allowed to interact with the chimps. The key informant from Site 2 described that the quarantine used to be five days, but because of loss of staff during the COVID-19 pandemic, they had to reduce it to three days. Site 4 also has a quarantine period of about one week for staff that come back to camp; they admitted it was difficult to implement by did not specify why.