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HOW TO USE APPLIED QUALITATIVE METHODS
TO DESIGN DRUG USE INTERVENTIONS
Introduction
GETTING READY
Chapter 1:
Overview of Methods
Chapter 2:
Planning a Qualitative Study
COLLECTING AND ANALYZING DATA
Chapter 3:
In-Depth Interview
Chapter 4:
Focus Group Discussion Method
Chapter 5:
Structured Observational Method
Chapter 6:
Structured Questionnaire Method
SYNTHESIZING DATA AND DESIGNING INTERVENTIONS
Chapter 7:
Synthesizing Data to Prepare for Interventions
Chapter 8:
Using the Study Results to Design Interventions
PRODUCED BY INRUD SOCIAL SCIENTISTS WORKING GROUP:
Daniel Kojo Arhinful
Ananda Mohan Das
Johana Prawitasari Hadiyono
Kris Heggenhougen
Nick Higginbotham
Folasade Bosede Iyun
Jonathan Quick
Dennis Ross-Degnan
WORKING DRAFT
December, 1996
INTRODUCTION
Why This Manual?
Improper use of medicines is a problem in every country. The 1985 WHO conference in Nairobi
focused attention on efforts to improve drug use practices in developing countries. Subsequent
efforts have included a search for standardized methodologies to study drug use, as well as costeffective interventions to improve it. Although some progress has been made, much remains to
be done.
The aim of this manual is to describe an approach for gathering data using applied qualitative
methods to design interventions to improve drug use. The manual has been designed for district
health officers, planners, and other personnel with little or no experience in those methods. The
methods include In-Depth Interview, Focus Group Discussion, Structured Observation, and
Structured Questionnaire. These methods have been modified and simplified to suit the practical
needs in the field.
In-Depth interview refers to one-on-one open-ended interactions between an interviewer and a
respondent. Focus Group Discussion involves bringing together a defined group of respondents
in order to investigate opinions and beliefs in an interactive setting. Structured Observation
records actual behaviors in settings of interest using a predetermined guide. Structured
Questionnaires use open- and close-ended que stions to investigate knowledge, attitudes, or
practices of a relatively large sample of respondents.
These methods can be used in many different ways. The focus of this manual is on how
they can be used to understand the determinants of a problem in drug use and barriers to
change in order to prepare effective interventions.
Studying Drug Use Problems
The use of medications in both developed and developing countries often shows a striking
discrepancy with principles of clinically acceptable practice. In most developing countries the
sources of misuse range from travelling drug peddlers and small grocery shops to prescribers in
teaching hospitals. Examples of some of the commonly encountered inappropriate drug use
include:
!
Excessive use of injections where oral treatment is more appropriate, e.g., in
malaria treatment;
!
Multiple drug prescriptions, such as the use of several items for one condition as
in diarrhea;
ii
!
The use of drugs when no drug is indicated, e.g., using antibiotics for simple ARI;
!
The use of the wrong drug for a specific condition requiring drug therapy, e.g.,
tetracycline in acute watery childhood diarrhea requiring ORS;
!
Self medication with prescription drugs such as psychotropics that are easily
purchased over the counter;
!
Patient non-compliance with a treatment regimen, such as failure to complete a
full course of antibiotic therapy;
!
The unnecessary use of drugs with adverse effects, e.g., dipyrone as a mild
analgesic;
!
The use of overly expensive drugs with cheaper alternatives, for example, a
cephalosporin rather than a penicillin antibiotic.
Consequences of Inappropriate Drug Use
Some of the identifiable public health consequences of inappropriate use of drugs include:
!
Increased morbidity and mortality due to avoidable treatment failures;
!
Increased risk of unwanted effects such as adverse drug reactions;
!
The emergence of drug resistance such as chloroquine resistance Plasmodium
Falciparum and penicillin resistance gonococci;
!
Waste of resources leading to increased costs and reduced availability of other
vital drugs;
!
Psychosocial effects such as when patients come to believe that there is "a pill for
every ill" which may cause increased demand for drugs.
Policy makers, planners, and others interested in promoting good health need specific, concrete
information in order to develop effective programs to tackle these problems. Since appropriate
drug use depends not only on providers but also on patients, studies to examine the reasons
underlying problems in drug use must target both providers and patients, as well as their
interactions. These studies must be broad enough to consider the complex of cultural, social,
economic, and structural factors that can influence behaviour. Applied qualitative methods can
be used to gather this kind of information in order to design an appropriate intervention.
iii
Designing Interventions to Improve Drug Use
Interventions to improve drug use can reduce unnecessary drug expenditures and lead to
improvement in the quality of health and medical care. Just as there are several factors giving
rise to drug use problems, there are also multiple intervention strategies to tackle them. Three
major approaches are educational, managerial, and regulatory. Educational approaches seek
to inform or persuade prescribers, dispensers, and patients to use drugs in rational ways.
Managerial approaches also guide decisions through the use of specific processes, forms,
packages or monetary incentives. Regulatory approaches, on the other hand, seek to restrict
decisions.
Any of these approaches may be used to introduce changes to improve drug use. However, the
success of an intervention will depend on the nature of a problem as well as the underlying
reasons for the problem. Experience from several programs indicates that it is usually more
effective to combine strategies to improve a single drug use problem. For example, when
planning to improve the treatment of ARI, in-service training programs can be combined with
supportive community education through the media. Or if working on diarrhea treatment,
regulations which limit access to anti-diarrheal drugs can be combined with the educational
approach of disseminating standard diarrhea treatment guidelines.
Many studies have succeeded in documenting drug use problems, but few have examined the
factors underlying these problems in a meaningful way. Yet such studies are needed to provide
policy makers and managers with useful insights into the types of interventions that might
succeed in correcting these problems. One of the main obstacles that has hindered such efforts
has been the lack of simple techniques to carry out these studies. This manual aims to fill this
gap and complement existing methods on how to study drug use.
Contents of The Manual
Following the Introduction, the manual includes three sections that describe a process for using
applied qualitative methods to study a drug use problem and design an intervention. These
sections are:
Section I: Getting Ready
1.
Overview of four applied qualitative methods and their strengths and weaknesses.
2.
Description of the steps involved in planning an applied qualitative study.
Section II: Collecting and Analyzing Data
3.
Detailed description of steps involved in using In-Depth Interview.
4.
Detailed description of steps involved in using Focus Group Discussion.
iv
5.
Detailed description of steps involved in using Structured Observation.
6.
Detailed description of steps involved in using a Structured Questionnaire.
Section III: Synthesizing Data and Designing Interventions
7.
Description of how to synthesize data to prepare for interventions.
8.
How to use study results to design appropriate interventions.
How to Use the Manual
This manual is meant as a GUIDE, or as one useful example of how applied qualitative methods
can be used to develop an intervention. It is NOT meant as a set of strict instructions which must
be strictly followed in exactly the same way in all situations and settings.
Indeed, research methods will vary in relation to the problem, the changing context in which it
occurs, and the type of material and human resources available. The steps described here can be
modified and adapted to suit particular resources and study needs. However, steps described in
the four methods chapters are important and should be seriously considered by anyone planning
to use one or more of these methods.
v
GETTING READY
Chapter 1:
Overview of Methods
Chapter 2:
Planning a Qualitative Study
CHAPTER ONE
OVERVIEW OF APPLIED QUALITATIVE METHODS
This chapter provides an overview of several applied qualitative
methods. It begins with a brief description of these methods and a
table of their advantages and disadvantages. The chapter ends with
a brief description of how to use these methods to design
interventions.
1.10: What is Applied Qualitative Research?
Applied qualitative research combines simple, rapid assessment methods to find out about the
meanings of behaviour, and to determine why things are the way they are or why people
behave as they do. Some of the data collected by these methods may be quantified, but the
analysis itself is a qualitative one .
Applied qualitative assessment seeks to investigate a specific behavioral problem in enough
detail to suggest the best strategies for intervening to improve it. This involves understanding the
socio-cultural, economic, structural, and political contexts within which the behavior occurs. By
understanding motiva tions and constraints, an intervention can be targeted in the most effective
way.
1.11: Applied Qualitative Methods in Drug Use Studies
Applied qualitative methods are useful for investigating a wide range of drug use problems.
These may concern provider or patient behaviours, and the context in which the problem occurs.
Some ways these methods can contribute include:
!
exploring a topic about which little is known in order to provide insights for intervention;
!
investigating the feasibility, acceptability and appropriateness of potential interventions;
!
developing appropriate questionnaires at the early stage of a study;
!
validating quantitative data through "triangulation," i.e., the use of multiple methods;
!
complementing the quantitative component of a study by providing concrete examples or
explaining observed practices;
!
developing appropriate materials for educational interventions;
1-1
!
identifying problems in ongoing interventions and suggesting appropriate solutions;
!
assessing the impact of on-going or completed interventions.
Although applied qualitative methods can be used in all these ways, this manual will focus on
how they might contribute to designing the strongest possible interventions.
1.12: Summary of Advantages and Disadvantages
This manual describes four methods that have been particularly useful for understanding drug
use problems: in-depth interviews, focus group discussions, structured observations and
structured questionnaires. The following table briefly summarizes each of these methods and
their advantages and disadvantages.
Table 1.1: Summary of Main Features of Suggested Field Methods
Method
Advantages
Disadvantages
In-Depth Interview
Open-ended face to face
interactions, in which an
interviewer tries to elicit a
respondent=s knowledge,
opinions, feelings, or
behavior related to a defined
set of topics with no
predetermined list of
responses
Flexible and allows interviewer
more opportunity to ask questions
Permits observation of non-verbal
expressions of respondents
Can be difficult to find good
interviewers
Personal opinion of interviewer
may creep into interview
Personal contact with respondent
enhances good probing
Difficult to generalize results
Quicker and cheaper than
individual interviews involving
the same number of people
Depth of information may be
limited since it is hard to probe
individual ideas
Greater pool of expertise is tapped
than in individual interviews
Group consensus may inhibit
original, unorthodox, or minority
views
Focus Group Discussion
Open-ended discussions
facilitated by a trained
moderator with a small
homogeneous group (6-12) of
respondents on a defined list
of topics
Better way than individual
interviewing to explore sensitive
subjects in some cultures
Provides an excellent means of
obtaining information from
illiterate communities
1-2
A few people may dominate the
discussion
Success of a group discussion can
be unpredictable
Method
Structured Observation
Systematic recording of data
about a set of events or
interactions using a
predetermined format
Advantages
Disadvantages
It enables behavior to be recorded
in context
Presence of observer can affect
the subjects' behavior and thereby
bias the data
It affords an opportunity to
understand situational factors that
influence behavior
Observer's bias in recording can
affect the information obtained
It is very helpful in validating data
obtained by other methods
A structured format may limit the
type of information collected
It verifies what people do
compared to what they say they
do
Structured Questionnaire
Structured instrument
containing open- &/or closeend questions used with a
relatively large sample of
respondents to examine
knowledge, attitude, or
reported practices.
Samples are relatively large, so
results may be more generalizable
Respondents have little control
over the interview process
Data easily quantified and
analyzed
Little flexibility to collect data on
aspects of the problem not
covered in questionnaire
Findings can be compared with
those of similar studies
Structural rigidity may sometimes
influence responses
Can validate data from interviews,
focus groups, or observations
1.13: Choosing the Right Method(s)
Although the applied qualitative methods in this manual can be used to examine all the
underlying reasons of attitudes, behaviors and practice, each has its particular strengths and
weaknesses. Some methods may be better suited for certain situations or problems, for example:
a.
In-Depth Interview is a suitable choice where:
!
group interaction and peer pressure are likely to inhibit individual responses and
make discussion unproductive;
!
in certain cultures, when the topic is so sensitive that respondents would be
unwilling to talk openly in a group;
1-3
b.
c.
d.
!
it is necessary to know and understand how attitudes and behaviors link together
on an individual basis;
!
respondents are geographically dispersed or cannot be assembled.
Focus Group Discussion is a suitable choice if:
!
social network influences are strong and may influence the behavior of interest;
!
group interaction is highly desired and favored to stimulate a useful discussion;
!
the topic is not so embarrassing as to prompt respondents to withhold information
!
a single subject area is being examined, and differences of behavior are less
relevant;
!
an acceptable number of target respondents can be reasonably assembled at a
given location.
Structured Observation method is a suitable choice if:
!
the aim is to examine a behavior in its natural setting;
!
to see if what people actually do confirms or contradicts what they say they do;
!
collecting information on non-verbal aspects of behavior is highly desired;
!
validating data obtained with other methods.
Structured Questionnaires are most appropriate where:
!
when the questions of interest are already well known, and the objective is to
examine knowledge, attitudes, or practices in a defined population;
!
information is needed from a relatively larger sample in order to generalize results
from other methods;
!
there is a need to follow up a preliminary enquiry to enrich results.
Although each method has specific strengths, an approach using a number of different methods
in complementary fashion may be the most comprehensive and effective way to study a problem.
1-4
CHAPTER TWO
PLANNING AN APPLIED QUALITATIVE STUDY
This chapter outlines the various activities involved in planning an
applied qualitative drug use study. Following a brief section on the
need for a resource person when applying these techniques, the
chapter describes the major steps involved in implementing a
study. It concludes with a summary of common implementation
problems.
2.10: Is There Need For a Resource Person?
The information provided in this manual is designed to enable investigators to be as self
dependent as possible. However, health professionals typically do not have training or
experience in using applied qualitative methods. In many cases, it will be necessary for such
people who intend using this manual to seek assistance from someone familiar with these
methods. How much assistance is needed will depend upon the previous experience of the
investigator(s), personality skills, the size of the study, and the resources available to it.
When considering using the services of a resource person, look for someone who:
!
analyses situations critically;
!
recognizes and avoids bias;
!
is socially sensitive to others= feelings;
!
possesses good powers of observation;
!
has good interactional qualities.
Where might you find such a resource person? These skills are traditionally associated with
social scientists in such disciplines as anthropology, sociology, psychology, or communication
studies. However, training alone is not as important as experience in actually using applied
qualitative methods in the field. In practice, such people are often not easy to come by,
especially at the district level in most countries. If they are available at all, they may be much
in demand and the resources for engaging them may be limited.
2-1
Apart from social scientists, you could also look for health or medical colleagues who have had
training in public health and some experience using similar techniques. Sometimes social and
community wo rkers with experience in research could prove equally useful.
2-2
The assistance of an experienced resource person is likely to be
necessary if you have no previous training and experience in using
applied qualitative methods. It is advisable to find such a resource
person before using these methods for the first time.
2.20: Steps in Planning an Applied Qualitative Study
The recommended steps in implementing an applied qualitative study are:
STEPS IN PLANNING AN APPLIED QUALITATIVE STUDY
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
2.21.
Form a Working Group
Identify a Specific Problem
Formulate Specific Questions
Choose a Package of Study Methods
Identify Study Groups
Plan for implementation
STEP 1: Form a Working Group
One important decision in the early stages of a study is to determine who will be involved in
planning and implementation. The success of the study depends to a large extent on the calibre of
those who will be involved in implementing it.
a.
Multidisciplinary Study Team
There are no formal criteria for determining who should be involved. This will vary with the
aims and purpose of the study. Nevertheless, as mentioned above, it is ideal if co- investigators
have had training and experience in a relevant field. If not, assistance of an experienced resource
person should be sought before using these methods for the first time.
One excellent strategy is to form a multi-disciplinary team. Ideally, such a team would involve
medical and para- medical personnel as well as social scientists. In addition, it may be helpful to
include policy makers, planners, and others who are likely to benefit or implement the results of
the study. Clearly, if a resource person will assist in implementing the methods, it would be
appropriate to include him or her as a member of the multi-disciplinary team.
2-3
The role of the study team is to make major decisions regarding planning and implementation.
Using their individual expertise and joint experience, the team can assist in keeping the study
focussed on relevant issues, and drawing insights from the findings.
b.
Field Staff
Usually, field staff will be recruited to collect data. Teachers, nurses, pharmacists, and other
health staff often prove to be good and reliable data collectors. When selecting the members of a
field team, some of the essential qualities to look for include:
!
familiarity with the culture of the people being studied;
!
ability to establish rapport and gain confidence and trust;
!
knowledge of health care system and drug use terms;
!
ability to speak the local language;
!
ability to listen well.
Depending upon the study situation, one or more of the following categories of field staff may be
required:
!
Supervisor(s): to coordinate field work, monitor the performance of interviewers
or other field staff, and assure the quality and consistency of data collection.
!
Moderator: to facilitate focus group discussions.
!
Interviewers: to guide respondents from topic to topic and record responses in
in-depth or structured interviews.
!
Observers : to observe and encode as much as possible events, situations, or
behaviors according to a pre-defined protocol.
!
Recorders: to take notes about the topics discussed by respondents in a manner
that will not affect the flow of a discussion as a non-participant observer.
!
Assistants: to assist focus group moderators or interviewers to run sessions
smoothly, especially when interference from crowds and children must be
avoided.
!
Translators : to translate for respondents or transcribe responses where field staff
and respondents do not speak a common language.
2-4
!
2.22.
Administrative Personnel: to handle administrative business and finances
related to the study.
STEP 2: Identify a Specific Problem
Every study begins with the recognition of a problem. The first task in a study is to identify and
state explicitly the problem to be investigated.
a.
What is a study problem?
A problem is a perceived difficulty or an observed discrepancy between what should be and what
is. "The problem" is important to every study since it will guide the specific questions that must
be raised by the investigator.
Examples of problems that could be addressed in an applied qualitative study might be:
!
a high proportion of patients in public health facilities receiving injectable
vitamins and analgesics;
!
continuing use of antidiarrheals in children among private practitioners;
!
high frequency of antibiotic use for primary care patients with upper respiratory
infections;
!
greater use in hospital outpatient departments of nonsteroidal anti- inflammatory
drugs than aspirin or paracetamol.
Some key principles to keep in mind when selecting a problem to investigate in an applied
qualitative study are:
b.
!
the problem should be important, either clinically or economically;
!
the problem should be focused and specific;
!
there should be some uncertainty about the causes of the problem or the way to
address it most effectively.
Background Information
After you specify the problem, it is a good idea to review what is already known about it. This
helps to guide the subsequent investigation, prevent duplication, and suggest appropriate
questions that need to be answered. Useful sources of background information are reports of
previous and other related studies on this topic, clinical records or administrative data, or
2-5
educated opinion consisting of published and unpublished papers and articles. Such information
may be available from the ministry of health, the drug regulatory agency, international
organizations, drug companies, or private organizations involved in health care.
2.23.
STEP 3: Formulate Specific Questions
The objective of the types of studies we describe in this manual is to provide the information
needed to design an intervention. Once a problem has been identified, it is useful to narrow the
focus of a study to a limited set of questions that may influence what kind of intervention is
selected.
It is helpful to plan and formulate questions in a structured way in order to make sure that no
aspects of the problem or study topic are missed. For example, the case study from Pelotas,
Brazil (Table 2.1), shows how one team developed a set of questions to guide an applied
qualitative research study before undertaking an intervention to improve diarrhea treatment.
Your task at this point is to develop a similar set of questions to guide your own study. The
questions should seek to explore the problem you have identified in more depth. For example,
they might examine aspects of the local social, cultural, or economic environment that influence
the problem selected. They might seek to explore beliefs, attitudes, or misconceptions of health
workers or patients related to the problem. When developing these questions, consider
brainstorming with those in authority and other influential persons or groups in the potential
target population to learn more about the way they think about the problem at hand.
The following are some examples of the kinds of questions that may be answered about drug use
behavior in most health care settings using applied qualitative methods. The questions are all
designed to provide useful information for selecting the type of intervention that might be
effective, or for targeting the intervention to particular individuals or behaviors. The questions
have been arranged in the structured format followed in the Brazil case study.
2-6
CASE STUDY: IMPROVING DIARRHEA TREATMENT IN PELOTAS, BRAZIL
A health center record review in Pelotas, Brazil, found specific problems in diarrhea treatment in children under five.
Prior to launching an educational intervention for physicians to improve practices, the study team used patient exit
interviews, physician and patient in-depth interviews, and observations of treatment episodes to answer the following
questions:
To Describe the Problem in Greater Detail
!
Are treatment practices the same in health centers managed by the municipality, university, and state
government?
!
Is inadequate knowledge about diarrhea or its treatment a common problem among physicians and
patients?
!
What knowledge deficits exist about the causes and diagnosis of diarrhea? About the need for ORS?
About the dangers of specific anti-diarrheas? About the efficacy of antibiotics or anti-parasitics?
!
How do physicians think other physicians manage diarrhea?
To Decide if an Intervention is Feasible
!
How much do patient expectations influence physicians' treatment choices?
!
How satisfied are patients with different kinds of treatment for diarrhea?
!
How important is maintaining patient satisfaction to physicians?
!
Do physicians feel that patients are capable of learning if the effort was made to explain about diarrhea
and its treatments to them?
!
Would physicians or other staff members have time for counseling patients about diarrhea or other
health problems?
To Target the Intervention
!
How often do mothers ask directly for specific types of treatment?
!
Are there non-verbal ways that mothers influence physician decision-making?
!
How do physicians respond when asked for certain treatments?
!
Do physicians feel a group identity with colleagues at the health center?
!
To which respected peers do physicians turn with questions about treatment?
!
How often do physicians approach colleagues with medical questions?
To Define Specific Intervention Messages
!
How important to physicians is the self-image of being a knowledgeable scientist or powerful healer?
!
When physicians have changed their practices in the past, what has stimulated them to do so, and how
do they feel about these changes?
!
What do physicians think about prototype materials developed to promote correct diarrhea practices?
To Decide Format and Style of the Intervention
!
How do physicians get information about new health problems or drugs?
!
Do they ever attend continuing education sessions, and are they useful?
!
Do they read any journals and which ones?
!
Do they learn about drugs from drug package inserts, advertisements, or drug company representatives,
and is this information valuable?
!
How do physicians respond when presented with summaries of the practices of their health center in
relation to all similar facilities?
!
How do physicians feel about different models for continuing education: group seminars, visits by
medical experts, visits by pharmacists?
2-7
a.
b.
c.
To Describe a Problem in Greater Detail
!
Do practices vary greatly by location, health facility, or health provider?
!
Do deficits in knowledge contribute to problem practices?
!
What specific areas of knowledge are deficient: diagnostic procedures, drug
efficacy, drug dosing, etc.?
!
Do health providers think their practices are the same as or different from their
peers?
!
Do problem practices vary by diagnosis, type of patient, time of month, etc.?
To Decide if an Intervention is Feasible
!
What is the communication like between patients and health providers?
!
How often do patients express a preference for a certain drug or type of therapy?
!
How satisfied are patients with the care they receive?
!
What specific aspects of care contribute to patient satisfaction?
!
How important is satisfying patients to health providers?
!
Do health workers try to educate patients about their illness or the drugs they
prescribe?
!
Are there severe constraints in the work environment that would prevent health
providers from changing their behavior?
!
Are there proper drugs available at all times?
!
Are health providers interested in improving their practices?
!
Are the administrative authorities supportive of the types of changes proposed?
To Target the Intervention
!
Are there particular health providers or facilities with especially poor practices?
!
What is the relationship between an individual provider and the group in which he
or she practices?
2-8
d.
e.
!
Are there features of the social, cultural, or behavioral context that could be used
to influence the practices of individual health workers or patients?
!
Are there particular people whose opinion is especially influential with health
providers?
!
Would it be possible to recruit these opinion leaders to assist in implementing the
intervention?
!
Is it possible to reduce the general problem of interest to more specific behaviors
or practices that it would be easier to change?
To Define Specific Intervention Messages
!
Can specific myths about practice be identified that it is possible to debunk with
scientific facts?
!
Are there specific areas of miscommunication between patients and health
providers that can be highlighted in an intervention?
!
What kinds of educational materials are available to health providers or patients?
!
When health providers or patients have changed in the past, what was it that
caused them to change?
!
How do health workers or patients respond to prototype intervention materials?
To Decide Format and Style of Intervention
!
What sources of information do health providers use to learn about health
problems or drugs?
!
What educational programs have health workers already attended?
!
What model of continuing education is most highly rated: group seminars,
workshops, visits by medical experts, etc.?
!
How often do health workers interact with drug company representatives?
!
Is information from drug companies considered to be biased?
!
Do health workers have access to any unbiased sources of drug information?
2-9
2.24.
!
Are there any ways for health workers to review their practices for the problem of
interest: regular utilization reports, practice audits, departmental reviews, etc.?
!
How do health workers respond when given summaries of their own practices?
STEP 4: Choose a Package of Study Methods
Once the study questions have been specified, you are ready to determine what methods will be
suitable to answer these questions. When deciding which methods are most appropriate, there
are a few general issues to consider.
!
The nature of the problem, and the amount of information needed to choose
among alternative intervention strategies;
!
The resources needed to gather, process, and analyze the data;
!
The time frame available to carry out and complete the study;
!
The local research capacity to carry out and complete the study;
!
The feasibility of implementing each method in the specific local environment,
taking into account attitudes, logistics, and time frame.
Assuming that resources and capacities are not a serious constraint, then the selection of methods
is based on their advantages and disadvantages (see Table 1.1 and Section 1.13). Each method is
best suited for answering different types of questions. The methods chosen should reflect the
questions to be answered for a particular study. It is often best to explore a given question by
more than one method.
For example, Table 2.1 describes the set of study questions selected by the team in Pelothas,
Brazil, that was investigating reasons for inappropriate diarrhea treatment in public health
centers. They settled on a package consisting of (1) patient exit interviews using structured
questionnaires; (2) in-depth interviews with a sub-sample of these patients scheduled at a later
time; (3) in-depth interviews with a sample of physicians working in the health centers; and (4)
structured observations of 5-10 diarrhea cases treated by each physician.
The brief exit interviews were used to answer questions about patient knowledge and
satisfaction. The long in-depth patient interviews explored attitudes and beliefs about diarrhea in
greater detail, and investigated willingness to change treatment. Physician in-depth interviews
provided detailed information about knowledge, attitudes, peer relationships, and sources of
information. Focus groups were not used because of concerns about the logistics of assembling
groups of doctors. Structured observations were used to learn about patient-doctor
communication, and diagnostic and treatment practices.
2-10
2.25.
STEP 5: Identify Study Groups
One basic decision in any study is how to identify the study population. It is important that the
sampling procedures are clearly determined at the beginning of the study since the quality of
information will depend to a large extent on the choice of respondents.
In drug use studies, the study units may be patients, prescribers in health facilities, providers in
communities, and many others. Correct sampling involves the selection of a study group that is
representative of the study population. Such a group has all the important characteristics of the
population being studied. Incorrect sampling, that is, selecting a group that is not representative,
can seriously bias study results.
Sampling procedures can be categorized into probability and non-probability methods.
Probability sampling methods are generally appropriate for quantitative studies, where there is a
large population of interest, and random selection methods are used to choose the members to
include in a study. Of the methods discussed in this manual, probability sampling would usually
only be used for large questionnaire surveys (or perhaps a large survey of structured observations
involving a number of health providers). Some of the methods for probability sampling are
introduced in Annex A.
Non-probability sampling is not based on a list of all the possible members of a study population,
also known as a sampling frame. Instead, study members are chosen purposively, with an eye to
representing the population in a certain way, or according to quotas.
The key issue in drawing samples for applied qualitative research is being sure to gather
information about all the important subgroups in the population. For example, in a study to look
in more depth at ARI treatment practices, it may be important to look separately at: practices of
para-medics vs. physicians; practices in rural vs. urban facilities; practices for children under five
vs. older patients. This would mean including enough people from each of these subgroups to be
able to compare and contrast them.
How many people are enough? For in-depth interviews and focus groups, the objective is to get
a general idea of the practices, beliefs, opinions, etc. in each important subgroup in order to be
able to target the intervention appropriately. If there are consistent results, this would mean that
only aout two focus groups per subgroup, or 3-4 in-depth interviews, would be needed. If the
results in a subgroup are inconsistent, then additional focus groups or interviews would be
conducted until the reasons for inconsistency are understood.
For structured questionnaires (and sometimes for structured observations), a larger sample is
required in order to generate quantitative summaries like percentages or averages. In these cases,
a good general rule is to include 25-30 members in each important study subgroup, For example,
a study might compare 25-30 urban health workers with an equal number of their rural
colleagues. More detail about sampling is included in each of the following chapters describing
the individual methods.
2-11
2.26.
STEP 6: Plan for Implementation
The final step before embarking upon the work is to map out the sequence of how various
activities will proceed. This will require attention to the following activities:
a.
Choose Site(s) and Location(s) to be Used for the Study
The specific geographic areas and health facilities need to be identified, keeping in mind the
need to represent the larger population. Visit sites to become familiar with the people and
logistics. This visit also provides an opportunity to arrange and prepare for subsequent activities
including:
!
Obtaining the necessary permission for the study from concerned
authorities/people in the community.
!
Identifying how study participants will be selected.
!
Locating and arranging sites for group discussions and interviews when
necessary.
!
Obtaining basic descriptive information about the area/facility.
!
Recruiting any support staff in the community that may be needed.
In addition, the visit will afford an opportunity to decide the date and time for implementing
individual methods. Consider the activities of the group or the community and their schedules
before this decision is made.
b.
Select Coordinators for Each Study Component
If the study will include multiple methods, it may be advisable to identify coordinators for each
method. These coordinators will be responsible for identifying field staff, training them for their
specific tasks, supervising the field work, and preparing the data for analysis.
c.
Plan the Schedule for Individual Study Components
Some studies using multiple methods will implement all methods at the same time in the same
sites. The plan for this type of study requires coordinating roles within each study team and
scheduling the work of study teams within the selected study population (see Table 2.1).
2-12
COMPOSITION OF STUDY TEAMS
Team No. 1:
1.1
In-depth
(Administrator)
Dr. Mannan
In-depth
(Medical Officer)
Dr. Mannan
FGD
(Mothers)
Dr. Shamsun
Nahar (Moderator)
Dr.
Faisal
(Note-taker)
Intercept
(Mothers)
Ms. Panna
Observation
Dr. Mahamud
1.2
1.3
1.4
1.5
Team No. 2:
2.1
2.2
2.3
In-depth
(Administrator)
In-depth
(Medical Officer)
F G D (Mothers)
(Moderator)
2.4
2.5
Intercept
Observation
Dr.
Dr. Iftikar
Dr. Iftikar
Khadiza
Mr. Matin, Dr. Jamal (Note-takers)
(Mothers)
Dr. Khadiza
Dr. Rashid
FIELD VISIT SCHEDULE
Date
Place of Visit
26.07.92
Sunday
(1) Sonargaon THC
27.07.92
Monday
(1) Bhaluka THC
(2) Sreepur THC
Team 1
Team 2
29.07.92
Tuesday
(1) Dhamrai THC
(2) Uthali THC
Team 1
Team 2
2-13
Team 1
(2) Gajaria THC
Team 2
Some studies may require one applied qualitative method to be completed before another can
begin, for example, if focus groups are being used to develop specific items that will appear in a
later questionnaire. Another example would be if patient-physician observations needed to take
place before in-depth interviews with physicians were carried out to avoid biasing physician
behavior dur ing the observations. The timing, sequencing, and coordination of components
should be organized in the overall study schedule.
After completing a schedule of study components, it is time to shift to the steps needed to
implement each applied qualitative method. These steps are covered in detail in each of the four
chapters which follow.
2-14
COLLECTING AND ANALYZING DATA
Chapter 3:
In-Depth Interview
Chapter 4:
Focus Group Discussion Method
Chapter 5:
Structured Observational Method
Chapter 6:
Structured Questionnaire Method
CHAPTER THREE
IN-DEPTH INTERVIEWS
This chapter focuses on the use of in-depth interviews as an applied
qualitative method in drug use studies. It begins with a brief overview of
the technique and continues with a description of the various steps
involved in carrying out an applied qualitative study using the in-depth
interview method.
3.10:
Overview
3.11:
What is an In-Depth Interview?
An in-depth interview is a qualitative research technique that allows person to person discussion.
It can lead to increased insight into people's thoughts, feelings, and behavior on important issues.
This type of interview is often unstructured and therefore permits the interviewer to encourage an
informant (respondent) to talk at length about the topic of interest.
The in-depth interview uses a flexible interview approach. It aims to ask questions to explain the
reasons underlying a problem or practice in a target group. You can use the technique to gather
ideas, to gather information, and to develop materials for drug use interventions.
3.12:
Use of In-Depth Interview in Drug Use Studies
One effective way to understand the reasons underlying problem behaviors is in-depth analysis.
In drug use studies, areas in which the method can be used include:
!
In pilot studies to generate ideas.
!
To obtain greater depth of information on a topic of interest as a supplement to data
received from other methods, e.g., structured questionnaire.
!
To evaluate the impacts of interventions on attitudes or beliefs.
This section will consider only how in-depth interviews are used to gather data to prepare for
interventions.
3-1
3.20. Steps in Using In-depth Interview to Study Drug Use Problems
The activities involved in using in-depth interview to study drug use problems can be organized
into a series of steps. These are summarized below. A detailed discussion of each step follows
the summary.
TABLE 3.1: Summary of Key Steps in Conducting In-depth Interview
Step 1: Plan how you will conduct the in-depth interviews.
Step 2: Decide who your respondents will be.
Step 3: Prepare interview guide for each category of informants.
Step 4: Select your interviewers.
Step 5: Train the interviewers.
Step 6: Conduct the actual interviews.
Step 7: Analyse the data.
Step 8: Write a report and recommend intervention(s).
3.21. STEP 1: Plan How You Will Carry out the In-depth Interview
Once the decision to use in-depth interview has been taken, very important planning decisions
and preparations are needed. These include designing the study, identifying the target group,
preparing for the fieldwork, and collecting and analysing the data.
a.
Consider the Need for a Resource Person
Because the technique may be new to most health oriented professionals, one of the first
planning decisions to consider is the need for a resource person, particularly if the investigator is
not confident enough with the application of the method. Other things to consider before you
decide to seek the assistance of a resource person are the size of the study and the resources
available to it.
3-2
In a small exploratory study with limited resources, you could rely on a colleague who had used
the method before. However, in a big study to ascertain the reasons for some observed problem
behaviour, you may need the assistance of a social scientist who is well experienced in the actual
use of the method.(See Section 2.10 for more tips on qualities to consider when in need of a
resource person).
b.
Role of a Resource Pe rson
Essentially, the role of any resource person at this stage will be to assist in planning the technical
details of the study. This will include:
!
how to obtain the study informants;
!
development of interviewing guides;
!
how to proceed with the field work;
!
training of interviewers and other field staf;
!
guidance in subsequent analysis of the field data.
These aspects of the study are very important, and such professional support needs to be
seriously considered if the principal investigator is not too confident about the method.
3.22. STEP 2: Decide Who Your Informants (Respondents) Will be
Identifying respondents from whom you can obtain the information you need is a very important
part of the study since the sources of information affects the quality of data obtained. You must
therefore identify key informants who can provide useful information for the study.
a.
Determining Who to Select for the In-Depth Interviews
The first thing to bear in mind is that in-depth interviews take much more time than structured
questionnaires. It is therefore not usually practicable to interview a large sample. A typical
study might include 3-4 interviews with respondents in each of 4 subgroups of interest, for a total
of less than 20 interviews. To account for the small sample size, those selected for the in-depth
interview must be people who are well informed about the issue to provide relevant information.
Usually informants are selected for in-depth interviews in a purposive manner, that is, people
with specific demographic/social characteristics are chosen to represent a defined subgroup.
This involves identifying individuals from the target groups who are and must be knowledgeable
about the study topic. Depending upon the nature of the problem and composition of the target
population, respondents are selected from various identifiable subgroups. Respondents selected
must be fairly representative of the various groups in the study population for this technique to
be useful.
3-3
b.
Selecting Informants: Some Examples
Let us consider a study about the overuse of antibiotics in the treatment of ARI in children. After
deciding to use in-depth interviews, a study team may have identified the following target
groups:
!
prescribers working in primary, secondary, and/or tertiary health care facilities;
!
dispensers working in these same health care facilities;
!
mothers with children under the age of five in the community;
!
operators of drug outlets in the private or informal sector.
The following example (Figure 3.1) describes two ways in which participants could be selected
to represent these target groups.
3-4
Figure 3.1:
Example 1:
Examples Showing How Respondents May Be Selected
To identify representative prescribers in public health facilities:
!
List the names and locations of all health facilities in the district separately
according to levels, i.e., all community clinics, all health posts/centers, all
district hospitals.
!
Select a small number of facilities in which the interviews are to be conducted,
e.g., 2 community clinics, 2 health centers, 1 hospital.
!
In each facility, choose one health worker in each category to be interviewed,
e.g., village health worker, officer- in-charge, paramedic, dispenser, or pediatric
specialist.
If the information from the selected respondents is not consistent, additional facilities and
respondents can be chosen in the same way until the reasons for the inconsistency are
understood.
Example 2:
To identify representative mothers of children under the age of five
recently treated for ARI:
!
Contact the selected health facilities in the study district.
!
Get a list of children under the age of five treated for recent episodes of ARI
(ideally within two weeks preceding the study to enhance recall by mothers
who will be interviewed).
!
Decide on reasonable number of mothers to be interviewed, e.g. 2 mothers
treated at each of five facilities.
!
Contact the mothers in their homes and arrange interviews.
If it is not feasible to identify mothers from clinic records, it may be necessary to draw the
sample in the community. Village elders or local administration after have lists of families
and family members. Families should be visited until two recent cases of ARI are identified.
3-5
c.
Hints for Selecting Informants for In-Depth Interviews
Some hints to consider when making your final selection of key informants are:
3.23.
!
The informants should be unknown to the interviewers, if at all possible, in order
not to increase the likelihood of their giving biased responses.
!
They should not have previous knowledge of the specific issue of study.
!
A conscious attempt should be made to select different categories of individuals
in each target group, for example, by age, gender, status, education.
STEP 3: Prepare an Interview Guide for Each Category of Respondents
The guide consists of a list of questions or topics to be discussed by interviewers with
respondents in the field. The quality of data obtained depends to a large extent on the quality of
questions in the guide. A good guide uses general, non-directive questions or phrases
instead of direct questions that may end up in "Yes" or "No" answers. The task of the
investigator or team of investigators involves reviewing the study topics to develop questions
that will yield relevant responses. Following are suggested stages in developing the interview
guide:
a.
Framing the Questions
1.
List the most important topics to be explored in the study.
For example, for a study investigating the overuse of antibiotics in the treatment of ARI in
children, we could list some of the specific topics for in-depth interviews with health workers:
2.
!
which particular antibiotics are being used;
!
symptoms associated with perceived need for antibiotics;
!
reasons for prescribing antibiotics for the common cold;
!
reported patient preference for drugs;
!
sources of information about antibiotics.
Identify relevant subtopics for each of the study topics
Each major topic can be broken into specific subtopics that can be explored during the
interviews. For example, in relation to reasons for prescribing antibiotics to treat common colds,
we can list the following sub-themes:
3-6
!
beliefs about respiratory infections;
!
efficacy of antibiotic s in treating infections.
3.
Make a draft of possible questions that could be explored with respondents about
these sub-topics.
4.
Check each question against the overall study questions and take out those that are
not needed to answer one or more of the study questions.
5.
Check the questions again to ensure that they can help initiate discussion.
Ensure that your questions are:
b.
!
clear and unambiguous;
!
simple and easy to understand;
!
not answerable by a simple Ayes@ or Ano@;
!
reasonable and within the experience of the targeted respondents.
Construction of Probes
When writing the guide, build in useful "probes" to assist the interviewer. Probes are devices
used to prompt a respondent to speak further when an initial question fails to elicit the
desired information. Suppose in our antibiotic illustration the following question is asked of a
prescriber:
What would your reaction be if you were advised by the District Medical Officer
to stop the use of antibiotics in the treatment of ARI in children?
Answer: Well, I guess we'll have to wait and see what happens when the time
comes.
Here the respondent avoided answering the question. If his answer is accepted, his attitude about
a policy against the use of antibiotics in treating ARI will not be known. It is helpful to
anticipate this difficulty, and to construct "probe questions" in advance to cater for these
situations.
An example might be:
How would you feel about the DMO issuing such a directive?
The creation of appropriate probes brings a measure of control to a potentially haphazard form of
questioning.
3-7
c.
Sequence of Topics
In general, the order of topics in in-depth interviews is never rigidly defined. Rather this is left at
the discretion of the interviewer and is determined by the flow of the discussion. This is one of
the reasons why interviewers need to be well trained in the art of interviewing.
Design the guide in such a way that similar types of information will be elicited from all
respondents. However, the particular phrasing of questions and their order or sequence may be
re-defined to fit the characteristics of each interview.
Example of Interview Guide
Figure 3.2. shows a list of questions that may be asked in an in-depth interview to investigate the
use of antibiotics by prescribers in treating ARI in children. The interview may not necessarily
follow this order. More examples of in-depth interview guides are provided in annexes.
3-8
FIGURE 2:
Example of Interview Guide
Use of Antibiotics in the Treatment of
common cold (ARI) in Children.
Interview Guide for Prescribers
Introduction: Self introduction, name and general affiliation
Purpose of Interview
We are aware that common cold (ARI) is one of the common health problems of children
in this community. We are interested in knowing your views about this problem and how
it is managed. It will be appreciated if we could spend some time together to discuss this
issue.
Interview Begins
Clinic Experience
How long have you been working as a (doctor, paramedic, etc.)?
How long have you been working at this clinic?
How many patients do you see in a day?
How many of these patients are under the age of five?
Diagnosis
Could you please describe how respiratory infections present themselves in children in this
community?
How do you decide on severity of case?
What are some of the symptoms of severe respiratory infection?
Is it hard to recognize these symptoms?
Treatment
How do you usually treat mild respiratory infection in children?
Do you always treat coughs this way or do you sometimes treat them differently?
If yes: How do you decide on how to treat a cough?
Do mothers sometimes ask for particular medicines?
Use of Antibiotics
When should someone prescribe an antibiotic for a child with common cold?
Which antibiotics are the best to prescribe?
and so forth
3-9
3.24.
STEP 4: Select Your Interviewers
The success of an in-depth interview depends in large part on the qualities of the interviewer.
Much more communication skill is required tha n would be needed for administering ordinary
questionnaire interviews.
The role of the interviewer is to keep a discussion going by asking useful questions until he or
she gets an appropriate response. This demands certain qualities in those selected for the task.
The following qualifications are useful to consider:
!
Formal training in social science or interviewing is an advantage though not a prerequisite.
!
When social scientists are not available, people with secondary education in
health- related areas such as nurses and community development workers or
social workers with some experience in interviewing may also be suitable.
Good interviewers are people who easily gain peoples= confidence and cooperation, speak
clearly, and are good listeners. Additional qualities to consider are:
!
knowledge of drug use issues;
!
self confidence;
!
ability to establish rapport;
!
confident but not pompous;
!
unassuming personality;
!
politeness;
!
articulate enough to prompt respondents to talk.
3-10
3.25.
STEP 5: Train the Interviewers
Training provides an opportunity to prepare the field team for their task. All field workers
involved in a study attend a common training session so they can start with a common
understanding of study objectives and procedures. Even experienced interviewers need to be
trained, since each study will have its unique objectives, target groups, and study instruments.
a.
Duration of Training
Training should be long enough to allow all aspects of the study to be tackled before the actual
field work. The length of time may vary depending upon the size of the study and calibre of the
field team. In general, however, this may take two to three days.
An ideal location free from interference with the daily work routine of the field team must be
secured for the training sessions. In order not to disrupt the sessions all materials and provisions,
including snacks and lunch, should ideally be provided on site.
b.
Training Sessions
At the beginning of the training, materials such as the study guides, protocols, and handouts
should be given to the interviewers so that they can study them and raise any general queries
during the training. The trainer must explain and discuss these materials with the interviewers.
The discussion of each material should be allotted reasonable time to make it effective. The
trainer should encourage a friendly and conducive atmosphere for free exchange of comments
and questions.
The training program can be organized in stages with specific objectives. Prepare an agenda
before assembling the interviewers. Sessions will be needed on both theoretical and practical
aspects of the study. The theoretical aspects cover topics including:
!
outline of the goals and objectives of the study;
!
overview of in-depth interviews;
!
how to conduct in-depth interviews, i.e., starting, moderating, and ending the
interview;
!
how to take notes during interviews;
!
outline of possible implementation problems;
!
how to analyze the data and write a report.
3-11
The practical aspects of the training involve:
!
role plays;
!
pilot testing.
Role Play:
Provide an opportunity for each interviewer to role play the interview to gain experience before
going to the field. Such role plays are also a great help in evaluating the effectiveness of
individual interviewers. Go over the interview guide as many times as there are questions and
comments raised by interviewers.
Pilot Testing
Before the actual fieldwork, you should plan to conduct a pilot test in a group similar to the
target group in terms of study characteristics. This exercise affords an opportunity for the
investigator and the study team to evaluate the appropriateness of the interview guides. It also
enables interviewers to put into practice the skills they have learned before the actual interview.
After the pilot test the study team should meet to discuss the experience in the field. Problems
relating to the appropriateness, clarity, or ambiguity in the use of the guide, as well as others
relating to respondents and the study environment, can then be fully discussed.
Discuss any issues of translation of guides and/or notes at the training sessions. To avoid later
problems, ensure that all translations are thoroughly reviewed before the group moves into the
field.
3-12
TABLE 3.3: Tips on How to Conduct an In-depth Interview
The "Dos"
!
!
!
!
!
!
!
Begin interview with a friendly and familiar greeting.
Listen with attention to capture every piece of information from
respondents.
Explore key words, phrases, idioms, terms as they occur in the
discussion.
Listen to impressions, topics avoided by informant, deliberate distortions and misconceptions or misunderstandings. Take prompt action
to explore each of these. Where appropriate, use "probes."
Ensure a natural flow of discussion by guiding informant from one topic
to the next.
"Play dumb"(be silent) to give the respondent plenty of room to talk.
Be open to unexpected information.
"The Don'ts"
!
!
!
!
Influence or bias responses by introducing one's own perceptions or
asking leading questions which encourage a particular response.
Move too quickly from one topic to the next
Interrupt the informant.
Do not mislead about the subject matter in order to obtain information.
3-13
c.
Outline Procedures for Subs equent Data Analysis
You can use the opportunity provided by the field test to outline procedures for the subsequent
data analysis. This involves the following steps:
3.26.
!
Create teams (about two for this purpose) to discuss the questions to be answered.
!
Review notes of the interviewer=s observations.
!
Review each sub-theme in the interview guide for all groups of respondents, e.g.,
prescribers, mothers.
!
Write out key findings from each subtopic for subsequent analysis. This may
include the following:
-
demographic and socio-economic characteristics of this category of
respondents;
-
major points of agreement across all interviews;
-
substantial points of disagreement between interviews;
-
any conclusions or implications for the design of an intervention.
-
group's suggestions on what to do to reduce overuse of antibiotics.
STEP 6:
Conduct the Actual Interviews
After completing the pilot test, you are ready to start the actual data collection. Before moving
into the field, however, you need to make preparations to ensure that the field work proceeds
well without any logistical problems.
a.
Preparing for the Interviews
Preparations should include the following:
!
The target respondents must be contacted and a definite appointment made with
them before the actual interview. It is usually best for interviews to be held in a
neutral place away from any health facility or the respondent=s home where
distractions are likely. Make sure that respondents will be available at the
scheduled time.
!
If the interview process will involve travel by the field team, arrangements for
transport must be made early to ensure that the team arrives at the location on
time on the day of the interview.
3-14
!
b.
Besides identification cards and letters of introduction, interviewers should check
to ensure they have all that is required in the field. This may include: interview
guide, pen/pencil, notebook, tape recorder, batteries, cassettes, snacks, and water.
Conducting the Interview
On the day of the interview, the interviewer should arrive early to ensure that all arrangements
are ready. When both interviewer and informant are seated, the interview can proceed as
follows:
1.
Introduction
The respondent must be made to feel completely at ease and uninhibited in order to make
the interaction enjoyable. In his/her introduction, the interviewer should:
2.
!
introduce him/herself and affiliation;
!
explain the general purpose of the interview to the informant (e.g., for prescribers:
to investigate the treatment of ARI in children; for mothers: to find out how ARI
is affecting children in the community.
!
impress upon the respondent that his/her opinion is important. This can be
repeated during the interview. People enjoy expressing their opinion about an
issue once they are assured that it is important and legitimate.
!
ask informant to introduce him/herself;
!
establish rapport and assure the informant of the confidentiality of the interview.
Interviewing
The interview is directed at understanding the issues outlined in the guide. Begin with
less sensitive issues, and move to specific issues when the informant is sufficiently
relaxed.
Remain alert to both verbal information and non-verbal behavior. If necessary, the
respondent may be allowed to attend to office or home distractions during the interview.
The interviewer can take advantage of such breaks to read his/her notes or check the
guide to ensure adequate focus of the interview. Watch for time constraints on the part of
respondent and apologize for time taken, with assurance to finish the interview on time.
The interviewer should also try to adopt techniques to persuade the respondent to:
!
elaborate on points, e.g., "What happens next? Can you please elaborate?"... etc.
!
clarify issues: "What year did you join this clinic?"
3-15
!
3.
focus on new dimensions of the issue: "Can we talk about other drugs used apart
from penicillin?@
Wrap-Up
The interview should be concluded by thanking the respondent and allowing a few
minutes for free discussion. Once the interview is formally completed, the interviewer
should:
c.
!
Go over his/her field notes quickly to make any on-the-spot corrections and seek
necessary clarifications before leaving. More complete notes can be made at a
later time.
!
If a tape recorder was used, check and label tapes before departing the interview
site. A new tape should be used for each interview.
Managing the Field Data
The data from each interview must be managed appropriately to facilitate subsequent analysis.
The following tasks are involved:
1.
Field editing
At the end of each interview, interviewers should review their notes and verbatim reports
to make sure that they make sense in relation to the study questions. Comments or any
observations made during the interview can also be added or clarified.
Before leaving the field, interviewers should complete short summaries of the discussion,
ensuring that any additional notes on the interview are included.
2.
De-briefing
At the end of each field trip or on a regular basis during a long study, the field supervisor
or study coordinator should interview the interviewers to find out their experiences in the
field. This de-briefing should cover any problems encountered in administering the guide
as well as any new themes or findings from the field. While the field work lasts, it is
possible to make changes in the guide to incorporate new ideas. Irrelevant questions
should also be removed from the guide.
3.
Transcribing
If the interviews are taped, the tapes used should be transcribed verbatim or in
summarized form depending upon the purpose of the study and the experience of the
3-16
person doing the analysis. Afterwards, the points that are important to the study topic
should be underlined. This material should then be reconciled with field notes and
comments of interviewers.
3.27.
STEP 7:
Analyze the Data
Data analysis begins with the field note-taking of the interviewers. As a first step, therefore, the
study coordinator must ensure that all field data including notes, comments, and recordings (if
any) are recovered from the interviewers.
The analysis can be done by hand or by computer depending upon your skill and the resources
available to you. Most in-depth studies can easily be analyzed by hand though there are various
computer programs that have been developed to assist this process. The assistance of an
experienced resource person is especially important during data analysis.
a.
Analyzing the Data
Many different strategies have been developed for analyzing the data from a series of in-depth
interviews. A simple way of approaching the analysis involves the following steps:
1.
Categorize interview material into various sub-topics.
This is commonly described as the cut and paste process, and involves sorting out notes
and transcriptions into the broad topics or sub-topics used in the guide, or adding any new
themes from the interviews. For example, suppose during an interview with a prescriber
the question is asked "How do you usually treat severe respiratory infection in a child?"
Besides talking about drugs, the prescriber may mention problems mothers have in
paying for treatment. Such information can be "cut and pasted" under a sub-topic,
"Affordability of Treatment." This procedure ensures that "scattered pieces of
information" on the same sub-topic are put together for a complete review.
2.
Label each category using appropriate headings.
For example, under reasons for prescribing antibiotics, responses may include delays in
reporting for treatment due to inability to pay, multiple health problems, difficulty in
monitoring patient compliance, patient expectation, and a pill for every illness. These
categories of response can be assigned labels such as economic, social-cultural, and so
on. For example, "patient expectation" and "a pill for every illness" can be put under
socio-cultural reasons. This step is very useful for intervention design.
3.
Describe and interpret the major findings
3-17
Analysis consists of considering responses in each topic as group, and drawing
interpretive conclusions about commonly held beliefs, attitudes, or opinions.
Implications for interventions should always be considered. You can also report findings
by the proportion of various sub-groups interviewed giving their reasons under each
category, the apparent strength with which certain attitudes are held, or issues on which
there is substantial difference of opinion..
b.
Using a Data Sheet for the Analysis
Sometimes a data sheet can be used to organize the analysis. A data sheet lists the major topics
and sub-topics of the interview guide in order to record responses in a logical manner. A data
sheet for a health provider=s interview, for example, may contain the following categories:
!
Personal Data of Informant: i.e., sex, age, education, etc;
!
Common Presenting Complaints at Out-Patient Clinics;
!
Drugs Used in Treating ARI;
!
Factors Influencing the Decision to Use Antibiotics;
!
Cost of Treatment;
!
Dispensing Process;
!
Other Comments, Suggestions, etc.
For each of the sub-topics mentioned, responses of each informant are recorded from the cut and
pasted material assembled from transcriptions, interviewers' notes, comments, and observations.
The data sheets from the individual interviews can then be combined in an overall analysis as
described above.
3.28.
STEP 8:
Write a Report and Recommend Interventions
By the time the data analysis steps have been completed, the major findings of the study should
be apparent. It will become clear which data should go into a final report. The responsibility for
the report writing rests with the principal investigator(s), but if a resource person is involved, his
or her skills are also most valuable at this stage.
a.
Outline of Report
The first step in report writing is to develop an outline, bearing in mind the objectives of the
study. Such an outline might contain the following sections:
3-18
!
title of study;
!
objectives and methods, including data analysis;
!
major findings in line with significant broad topics of the guide;
!
discussion;
!
conclusions;
!
recommendations for interventions.
All material from the field should be reviewed together and findings organized by topic and in
conformity with the report outline.
You should bear in mind that the results of a qualitative study using only a few in-depth
interviews are difficult to generalize because of their restricted scope. However, some form of
generalization can still be made, depend ing on the type and number of respondents. Hypotheses
can also be formulated on the basis of the major findings, which can then be validated by use of
other more quantitative methods such as structured questionnaires.
3-19
CHAPTER FOUR
FOCUS GROUP DISCUSSION METHOD
This chapter describes the Focus Group Discussion (FGD) method
and indicates how it can be used to collect information in drug use
studies. It begins with a brief overview of the method and the
areas in which it can be used to study drug use problems. The
major part of the chapter is devoted to the main steps involved in
conducting focus groups.
4.10.
Overview
4.11.
What Is A Focus Group Discussion?
A focus group discussion (FGD) is an in-depth field method that brings together a small
homogeneous group (usually six to twelve persons) to discuss topics on a study agenda. The
purpose of this discussion is to use the social dynamics of the group, with the help of a
moderator/ facilitator, to stimulate participants to reveal underlying opinions, attitudes, and
reasons for their behaviour. In short, a well- facilitated group can be helpful in finding out the
"hows" and "whys" of human behavior.
The technique is borrowed from social marketing where it was used to ascertain consumer
satisfaction. The discussion is conducted in a relaxed atmosphere to enable participants to
express themselves without any personal inhibitions. Participants usually share a common
characteristic such as age, sex, or socio-economic status that defines them as a member of a
target subgroup. This encourages a group to speak more freely about the subject without fear of
being judged by others thought to be superior.
The discussion is led by a trained moderator/facilitator (preferably experienced), assisted by an
observer who takes notes and arranges any tape recording. The moderator uses a prepared guide
to ask very general questions of the group. Usually more than one group session is needed to
assure good coverage of responses to a set of topics. Each session usually lasts between one and
two hours but ideally 60 to 90 minutes.
4.12.
Use of FGDs in Drug Use Studies
The method can be used in drug use studies in several ways. The following gives some ideas of
ways to apply FGDs in the field.
4-1
a.
Explore a topic about which little is known. For example, to begin the process of
understanding cultural meanings of drugs in a community.
b.
Generate research questions if employed at the early stages of a multi- method study.
c.
Develop appropriate language to be used in a questionnaire.
d.
Complement other data in explaining people's actual thoughts, feelings, beliefs, and
perceptions obtained from other methods.
e.
Develop appropriate materials and messages for educational interventions.
4.20. Key Steps in Conducting Focus Group Discussions (FGD)
The steps in using FGDs to study a drug use problem are summarized below, followed by
detailed discussion of each step. The extent to which these steps must be followed varies,
however, depending on the training and experience of those involved in the data collection.
TABLE 4.1: Key Steps in Conducting a FGD
Step 1:
Plan the entire FGD study
Step 2:
Decide what types of groups are needed
Step 3:
Select moderator and field team
Step 4:
Develop facilitator's guide and format for recording responses
Step 5:
Train field team and pretest instruments
Step 6:
Prepare for individual FGDs
Step 7:
Conduct FGDs
Step 8:
Analyze and interpret FGD results
4-2
4.21.
STEP 1: Plan the Entire FGD Study
Once the decision to use focus group method is made, you will need to plan how to carry out the
study. Planning is critical because it is the area where major decisions regarding the study are
made.
a.
What Activities Need to be Planned?
Planning decisions will involve the study design, selection and training of field team, collection
of data, analysis, and report writing as well as planning for interventions. Other essential
supporting materials and logistics such as an office for meetings by the field team, equipment for
data processing, and transport and incentives for the field team must also be planned.
b.
Is There Need for a Resource Person?
One important decision is to determine whether a resource person is needed to assist in planning
and implementing subsequent stages of the study. This decision will depend on a number of
factors. These include the size of the project, the resources available to you and your own
experience with focus groups. If you are not quite confident with the method or the study is
large, relying on a resource person to assist at this stage can help to ensure that subsequent stages
of your study proceed smoothly. Otherwise, the services of a colleague familiar with FGDs
could be all that you need.
c.
Role of Resource Person in Training Field Staff
One of the principal roles of the resource person is training of the FGD Moderators and
assistants. If the field staff have no experience in applying the technique and have been involved
in only clinical aspects of health, they will need considerable training. On the other hand, if staff
have had some previous experience in similar studies, the task of the trainer is likely to be
minimal. (See discussion of resource persons in chapter 2.)
4.22.
STEP 2: Decide What Types of Groups Are Needed
After developing an overall plan, you must decide the specific types of groups which will be
used for your study. The following are some guiding principles:
a.
Identifying Target Groups
Since broad generalizations are not usually made from the data obtained from FGDs alone, the
common method for selecting participants for focus groups is by purposive (non-probability)
sampling. An investigator selects those who, in his or her estimation, can provide the needed
information. This depends on the target groups of concern to the study.
4-3
For example, consider a study to determine the attitude of prescribers and mothers in public
health facilities towards the use of antibiotics in the treatment of Acute Respiratory Infection
(ARI) in children. The two overall target groups will be prescribers in public health facilities
and mothers who attend these clinics with their children. In selecting prescribers for a focus
group discussion the study coordinator may decide to talk to prescribers working in hospital
outpatient departments and health centers in separate sessions, if differences in their training or
work setting might have an effect on their attitudes or behavior. This will be an example of
quota sampling. On the other hand, in recruiting mothers for a similar discussion he/she may
decide to draw participants from mothers in one or a few villages rather than from many villages
in the district. This is a typical case of convenience sampling and, as its name implies, it is more
convenient than a random sample of mothers drawn from all villages. Mothers may be further
grouped into those living in villages near the district hospital and those living in remote villages,
if ease of access is seen as an important determinant of behavior.
When selecting participants, target those population segments likely to provide the most
meaningful information, especially where differences might affect the way you design an
intervention. Nevertheless, be sure that the group is representative of the larger population,
though this does not imply that the results can be generalized.
b.
Composition of Groups
Recruiting participants can require a great deal of effort if you need specific target groups. There
are no rigid rules to follow, but one of the guiding principles in forming groups is that
participants should have something to say about the topic of concern, and they should feel
comfortable saying it to one another. For example, a group that includes both para- medics and
health center officers-in-charge might not be very successful since the para-medics might be
reluctant to speak in the presence of their "superiors." Forming two groups, one with paramedics and one with officers- in-charge, would more likely generate more free and open
discussion.
In order to separate participants into groups a screening process is sometimes required. This
involves using a predetermined list and a very short questionnaire to select those who qualify and
are interested in participating. Qualifying questions may include demographic characteristics,
personality factors, or other variables related to the purpose of the study. Table 4.2 is an
example of a screening questionnaire used in a study of family planning in Ghana.
4-4
Table 4.2: Example of a Screening Questionnaire
1.
Do you have any children?
Yes ............................. No ................................ Reject ...............................
2.
Name: ..........................................................................
3. Age: ................................
4.
Number of children: ................ 5. Number of boys: ............. 6. Number of girls: ...............
7.
Marital Status: ............................................................................................................................
8.
Educational level: .......................................................................................................................
9.
Occupation: .................................................................................................................................
10. Religion: ......................................................................................................................................
11. Number of years of residence in village/town: .........................................................................
12. Do you practice family planning?: ............................................................................................
13. What contraceptive do you use?: ...............................................................................................
Selecting the Group and Conducting the Sessions
A screening form was used in selecting participants for contraceptive user or non-user groups. A
woman qualified if she had at least one child. For the user group, the women were, in addition:
(a) Married, single, or divorced
(b) current users of any modern contraceptive
(c) resident in the village for a considerable length of time.
Women for non-user groups had the same characteristics as the users except that they had either
never used contraceptives or were not using them at present.
c.
Number of Groups
Practically, the number of focus groups you conduct will depend on the purpose of the study.
Thus, more sessions may be needed, for example, to explore the reasons for the use of antibiotics
in the treatment of ARI, in contrast to a simpler exploratory goal of discovering the terms people
use to refer to antibiotics for the purpose of designing a questionnaire.
4-5
In general, however, the more similar the study population in terms of social characteristics, the
fewer groups that will be needed. If there are several distinct target subgroups in the study
population, you should run separate FGDs for each, e.g., groups composed entirely of doctors
run separately from those of pharmacists, or groups with men run separately from those with
women.
One useful strategy is to conduct as many FGDs as are necessary to provide an adequate ans wer
to the study questions. A minimum of two FGDs should be planned with each target subgroup.
After these two sessions with each subgroup, if results are consistent, there may not be a need for
any more FGDs in this subgroup. However, if important inconsistencies emerge, additional
FGDs should be conducted until the reasons for the inconsistencies are explained. One focus
group discussion for any meaningful topic in a particular target group is certainly never
enough.
d.
Group Size
Practically, the size of the group should facilitate a dynamic interaction between the participants.
Having a too small or too large group would make this difficult. The best size is at least six
members, but not more than twelve. Groups of less than four or more than twelve are difficult to
manage, and the benefits of group dynamics that make FGDs effective are usually lost.
e.
Contacting and Informing Participants
The initial contacting of participants may occur by mail, telephone, or in person. Personal
contact may be the most feasible way in most developing countries. Recruiting can be done at a
clinic, the market, or by going from house to house in the community. When you enter a
community or institution to recruit, it is advisable to contact the head of the community, or the
person in charge of the institution, to obtain permission. These people can help you with vital
information about particular cultural practices and habits of the local population or community,
as well as identifying participants who meet the target criteria..
Provide prospective participants with information about the study but restrict this to a general
description, including the fact that it will involve a group discussion. If any form of incentive is
to be provided, such as refreshments or transport, this should be indicated along with when and
how it will be provided. Invited participants should be notified a few days before the discussion.
4.23.
STEP 3: Select Moderator and Field Team
The selection of the personnel who will be invo lved in the study is essential since the success of
FGDs depends on the calibre of staff.
4-6
a.
Field Staff Requirements
The usual staff requirements for focus group discussion are:
1.
A Moderator/Facilitator who has a very demanding role as the discussio n leader of the
group. This involves the following:
!
directing the discussion and not taking over the group;
!
encouraging participants to express their feelings and opinions and communicate
among themselves during the discussion;
!
building rapport to gain the confidence and trust of the participants and thereby
probe beneath the surface of comments and responses;
!
maintaining flexibility and being as neutral as possible: if the discussion wanders
away from the topic, he or she subtly directs it back without offending
participants;
!
controlling the time allotted to each topic and to the entire discussion.
In view of the high leadership and communication skills required of FGD moderators, you need
to select them carefully. Generally, educational background such as sociology, mass
communication, or psychology, as well as experience in moderating focus groups, are useful.
These requirements are, however, not essential, nor are they enough. The key qualification is an
appropriate personality, since the procedures for moderating a group can be learned during
training. Key personality traits include: sensitivity, willingness to listen, tolerance for different
views, ability to focus a discussion, and assertiveness in supporting as well as cutting off the
expression of opinions. Experience has shown that nurses, teachers, community leaders among
others have proved very skillful as moderators.
2.
An Observer/Recorder is also present, mainly to observe the session and take notes. The
observer/recorder is responsible for the use and care of any tape recorder or other
equipment. It is good to have the note taker trained in how to be objective in recording
discussions and observing non- verbal expressions.
Participants must be informed of the presence and role of the observer at the beginning of
the session. He or she should be seated away from the group.
Even though the observer/recorder is not expected to take part in the discussion, he or she
may do so in a few exceptional cases, for example:
4-7
3.
!
if the moderator overlooks a useful point raised by a participant;
!
to suggest a new question or topic relevant to the study;
!
if the moderator has missed a an important topic in the guide.
Other Staff
Depending on need, other staff may sometimes be recruited to assist in running the
discussion, but they do not necessarily constitute part of the group.
4.24.
!
Assistants: useful for sessions where interference from crowds and children has to
be controlled.
!
Translators: sometimes necessary where the moderator is not fluent in a local
language.
STEP 4: Develop Moderator's Guide and Format for Recording Responses
The main purpose of the guide is to provide direction for the group discussion. To ensure that all
related issues are covered in the study, it is recommended that all parties involved in the study
have an input or consult in its preparation.
a.
Structure and Sequence of Topics
Discussion guides will differ depending upon the topic under investigation and the target
populations (e.g., physicians, pharmacists, mothers of children under five). Nevertheless, the
general categories of questions in a guide for focus group discussions include:
b.
!
General questions which are designed to open the discussion and to allow
participants to reveal common perceptions and attitudes. The sequence of
questions on a given topic should proceed from the general to the specific.
!
Specific questions designed to reveal key information and show the feelings and
attitudes of participants.
!
Probe questions designed to reveal more in-depth information or to clarify earlier
statements or responses.
Wording of Guide
Questions in FGDs are generally less structured in order to elicit flexible response. The guide
must be phrased in simple language. Avoid long and complex statements and make sure that the
meanings are clear.
4-8
Do not word questions to make people feel guilty or embarrassed. For example, instead of
asking: "Why don't you go to the health center when your child has a serious cough?," the same
question might be phrased: "What do you think might happen if you go to the health center when
your child has a cough?”
The questions must be framed in an "open-ended" style to enable participants to respond freely.
Example (to prescribers at health centers): "How do you feel about treating cough with
antibiotics?"
This question allows respondents to discuss their satisfaction or dissatisfaction with antibiotics.
It does not, however, place a judgment on antibiotic treatment, limit them to any specific
antibiotic, nor indicate what other drugs may be used in addition to antibiotics.
Questions should never imply what is acceptable and what is not. Suppose you are interested in
knowing what other drugs are combined with antibiotics in the treatment of cough. This will
require a question to encourage participants to speak about a range of other drugs. You would
not want to ask a question like:
Bad Example: ADo you think drugs besides antibiotics are needed for cough?@
This question can be answered yes or no, and it also suggests that other drugs are not needed, and
participants may be reluctant to talk about what they actually do. It would be better to ask:
Example: AI would like us to talk about drugs that are used for cough. Can you tell me
about some of the drugs that are commonly used?”
This questions allows the respondents to answer in any way they choose, but it also suggests to
them that there is a range of drugs that can be used for cough.
It is important to avoid questions that have a yes/no answer. Occasionally it is possible to get a
quick "Yes" or "No" answer which can then be further explored, but generally it is not a good
way of questioning since such answers do not encourage lively discussion.
c.
Number of Topics
Most FGD guides consist of fewer than a dozen topics, though the moderator may frequently
probe responses and add new topics as the actual interview progresses. It is recommended that
the guide be written with just one hour in mind to allow time for additions to be made in the
field. Table 4.3. is an example of a list of questions in an FGD Guide on the overuse of
antibiotics in the treatment of cough (ARI).
4-9
Table 4.3: Example of FGD Guide on Overuse of Antibiotics in Treatment of Cough
1.
Introduction
[Narrative welcoming participants, describing reasons for discussion, and setting up the
general ground rules for the session]
Ground Rules
1. 60-90 minutes (tape recorded -- observer and note taker)
2. Speak clearly/one at a time
3. Conversation/all participate
4. No right/wrong answers
5. Assurance of anonymity and confidentiality
2.
Diagnosis
Can we talk about when your child gets a cough (ARI)? In your own experience, how do
doctors find out what is wrong with the child at these times?
Probe: Do they depend mostly on symptoms or lab tests? What are some of the tests for?
What are the common reasons for cough?
3. Treatment of Cough
Let us talk now about the treatment of cough at the health centers. Can you tell me the
common drugs that are prescribed for cough at the health centers?
4. Patient Expectation
I would like to know more about how you feel about the treatment your child receives for
cough. Do you usually come to the health centers with any expectations about the treatment
you will receive?
Probe: Do you prefer certain kinds of treatment? What do you do if your expectations are not
met? Do you try to convince doctors to give you the treatment you prefer?
5. Attitude towards Antibiotics
Can you tell me something about how you feel about antibiotics as a treatment for cough?
Probe:
Do you know the names of specific antibiotics that you think are good? Do you
prefer pills or injections? Do they
use other remedies/drugs for treating
cough? What are some of these?
Why do you use these
remedies/drugs?
4-10
4.25.
STEP 5: Train Field Team and Conduct Pilot Test
The field team's ability to perform well depends on their previous experience, and on how they
are trained for a particular study. Training is a very important part in ensuring the success of the
study.
a.
Training Hints
Before you begin the training, you need to make sufficient preparations to ensure that all aspects
are covered and everything proceeds smoothly. The following are useful hints to assist in the
training.
!
Choose a comfortable location for the training.
!
Keep all training sessions as simple as possible.
!
Use simple language: complex language may make the tasks and concepts
difficult to understand.
!
Allow regular practice through role plays in order for team members to gain
confidence in their abilities.
!
Allow sufficient time for field practice or rehearsals.
b.
Training Package
1.
Theory Sessions
Depending upon previous experience of the field team with focus groups, the training
package should involve several or all of the following theory sessions:
!
!
Introduction to Focus Groups
!
What are focus groups?
!
How helpful are focus groups in drug use studies?
What information will we be collecting?
!
What specific drug use problem(s) are we investigating?
!
What are the objectives and rationale for the study?
4-11
!
!
!
2.
Preparing for the Individual FGDs
!
Becoming familiar with the FGD guide
!
Reason for role plays
Conducting the FGD
!
Roles of the field team members
!
Activities before the session: pre-arrangements and visits; checklist for
FGD
!
Activities during the session: reception/refreshment; opening the
meeting/introduction;
conducting and recording the session/group
dynamic tips; closing.
!
Activities after the session:
field debriefing;
transcribing and expanding field notes.
office debriefing;
Analysis and report writing of FGD results:
!
Data analysis: Individual session reports; combined analysis.
!
Report writing
Practice Sessions
Role playing involves a mock discussion in which members of the field team assume roles as
moderator, observer and participants as a way of practicing the technique. While the session is
going on, other members of the field team observe and give their objective feedback after the
role play. More than one trial should be held with field team members while changing roles each
time.
Pilot testing is essential because it provides:
!
an opportunity to determine if the wording in the guide is appropriate for eliciting
discussion, i.e., whether it is understood as intended;
!
a way of checking the effectiveness of training of field team members;
!
much needed field practice for the staff to develop confidence;
!
a means to identify potential problems likely to be encountered in the actual
study.
4-12
c.
On-going Revision of FGD Guide
Results of pilot tests will provide more information or new insights that are important for the
study and interesting to participants. Each new focus group may lead to changes in the guide. In
consultation with moderator(s) and other study investigators, the field coordinator should be able
to modify the guide while the study is in progress.
4.2.6. STEP 6:
Prepare for the Individual FGDs
Between training field staff and starting the actual field work, an important link is preparing for
the individual FGDs. This includes the following:
a.
Site Selection and Location for FGD
Visit the project site(s) together with the field team and locate a place for the group meeting
some days before the scheduled time. This will enable you to familiarize yourself with available
logistics.
The site for the discussion must be easily accessible to participants and convenient to the field
team. The selected site must also be neutral (usually not a health facility) and large enough to
accommodate all the participants and the field team.
b.
Date and Time
For most focus groups in communities the ideal time is evening, while for those involving health
staff late afternoon is often the best time, when the daily office routine is over. Make a time
table that will guide how you will proceed with the field work after deciding the site(s), day(s),
and time(s). See an example of a project time table in the annex.
c.
FGD Checklist
Ensure that all equipment is ready before the field work. A checklist may include the following:
(a) Arrange
Transport
Chairs, Mats, etc.
Refreshments
Other incentives, if any
(b) Bring to the Field
Tape Recorder
Microphone (if needed)
3 blank 60 minute cassettes
Batteries (plus extra)
Moderator's guide
Recording forms
Test all recording materials a day before you go to the field to ensure that they are in working
condition.
4-13
4.27.
STEP 7: Conduct the FGD
The climax of all the preparations made for the study is the actual FGD. On the day of the
discussion a host, usually the moderator, and other members of the field team should be present
at the venue before participants arrive. Snacks or drinks may be served to welcome the
participants and put them at ease.
a.
Conducting the Discussion
In general, the session proceeds in the following main stages:
1.
!
Introduction;
!
Warm-up;
!
Discussion;
!
Wrap-Up/Summary.
Introduction
The moderator's brief introduction is aimed at making respondents relaxed, initiating rapport,
and establishing the "ground rules" for the discussion to follow. In it the moderator:
!
speaks in a casual, friendly manner to help respondents relax;
!
introduces himself/herself by giving his/her name and sometimes providing
information about himself/herself;
!
explains the general purpose of the group meeting to foster group feeling;
!
encourages respondents to feel free to give their frank and honest opinions,
explaining that there are no right or wrong answers, and it is okay to have feelings
different from others;
!
establishes neutrality by assuring respondents that he/she (moderator) has no
connection with the subject of discussion that will affect his/her feelings;
!
gives respondents the group rules: speak clearly and one at a time, avoid interrupting
one another, and allow all participants a chance to speak;
!
explains the purpose of any recording equipment that is being used;
!
assures the group of confidentiality.
4-14
2.
Warm-Up
This stage includes self introductions by respondents. They are asked to give their names and
other information about themselves, for example mothers may give age and numbers of children.
The moderator must show interest in what participants have to say, for example, by making eye
contact and attending to each introduction. The moderator must sometimes probe for clarity and
understanding of information. He or she must also confine discussion only to the introductory
formalities to avoid digressions.
3.
Discussion
This part begins the actual discussion of the study topic. At this stage efforts are directed at
understanding the issues surrounding each topic. The moderator's role at this phase is very
demanding. The following are some strategies the moderator can use to generate a healthy
discussion:
4.
!
Maintain a friendly and warm attitude to make participants feel comfortable.
!
Do not behave like an expert.
!
Build rapport by showing sensitivity to the needs and feelings of participants.
!
Pretend to convey a lack of complete understanding sometimes with statements such
as: "I didn't know that. Can you tell me more about it?"
!
Pause when necessary to allow participants to think more or provide additional
information. It is helpful to use incomplete statements like: "I don't know, maybe in
some cases .... and wait for response.
!
Use in-depth probes to clarify responses given by a participant, for example by
asking: "Could you explain further?" or "I don't understand ... " or by repeating the
response as a question: "...It's effective?"
!
Know when to keep quiet and use it to your advantage, and do not let quietness
intimidate you.
!
Encourage participants to communicate among themselves.
Wrap-Up Summary
The last five to ten minutes of the session consists mainly of summarizing and recapping the
identifying themes of the group.
4-15
This is meant to assist the moderator, the recorder, and the respondents in understanding what
has occurred during the session. It also provides an opportunity for respondents to alter or
clarify their positions or add any remaining thoughts they may have.
The steps involved may be ordered as follows:
!
Inform participants that the meeting is closing and ask for any comments; relevant
ones could be explored in depth.
!
Thank the participants and acknowledge that their ideas have been valuable and
will be utilized.
!
Serve refreshments and listen for additional comments as the group breaks up.
!
Provide participants with any information they need but do not feel obliged to
comment on everything that everyone says.
The moderator and recorder need to meet to review and complete their notes after the session,
and to evaluate the success of the discussion.
b.
Debriefing
It is important to hold regular debriefing sessions between the investigator(s) and field team to
discuss progress. In cases where the investigator accompanies the field team to the field, a short
field debrief lasting about fifteen minutes, can be held immediately after the field session. It
should be limited to issues that might be forgotten by the time a full debriefing session is held.
A full debriefing takes place with the entire study team. The session can be used to assess
whether the discussions are providing the information required to meet the study objectives. If
not, necessary changes may be made in the guide and approach. It is advisable to prepare a
meeting agenda to "guide" the debriefing session.
c.
Recording and Managing Information in FGDs
1.
Note-taking
The simplest way to record information in FGDs is note-taking by the observer. It is not
essential for the person to have shorthand skills for this task, but practice in note-taking during
pilot testing will be helpful.
Other non-verbal feedback such as tone of voice, laughter, or posture should be noted, as these
may suggest attitudes useful for the report.
The observer must not inject personal judgments when recording notes. Comment should be put
in brackets. Similarly, direct quotes from participants should be marked with quotation marks.
4-16
After the session, the observer should go back over the notes to add any further detail. (Figure
4.1 is an example of the structure of an FGD observer's notebook.)
4-17
Figure 4.1: Format of Contents of Observers' Notes
The recorder's notes would usually include the following:
1.
Group: (Identification of participating group)
2.
Date: (of group)
3.
Time: (group began and ended)
4.
Name of Community/Group of Professionals: (brief description of it and any other
information that may bear on the activities of the participants (e.g., distance from next
town, conditions of health services))
5.
Meeting Place: (location and brief description (i.e., big, convenient) and how this could
affect the discussion)
6.
Participants: (including number and personal characteristics and other kinds of relevant
information such as presence of children)
7.
Group Dynamics: (general description, level of participation, dormant participants,
interest level, boredom, anxiety, etc.)
8.
Interruptions: (occuring during the session)
9.
Impressions and Observations
10. Seating Diagram of the group. (It is best to have the group seated in a circle.)
11. Running Notes on discussion of various topics.
4-18
2.
Cassette Recordings
Since taking accurate notes on an entire discussion can be difficult, it is ideal if a tape recorder
can be used. Though transcribing tapes is not easy, tapes also serve as permanent records of the
FGD and can be listened to many times to clear up any doubts or confusion. They also make it
easy for an investigator to assess the performance of the field team. The tape recorder must not,
however, be allowed to interfere with a discussion. Asking participants to speak into the tape
recorder, for instance, may disrupt the FGD dynamics as the microphone is passed.
After the session, all tapes used must be transcribed and edited for analysis.
3.
Video Recording
Video is mainly used in developed countries. If a video camera is available, it may be used with
discretion depending upon how much experience your group has had with such technology.
Video recording provides a record of both what participants say and how they say it.
CARTOON-PROVIDE A SKETCH CAPTIONED What happened to group
dynamics at this discussion?
4.28.
STEP 8: Analyze and Interpret FGD Results
Focus group analysis is a process that begins when you enter the field and continues until
completion of the final report. This continuous process avoids the situation of accumulating a
mass of data that may be difficult to cope with at the end of a study.
Since the moderator and the observer/recorder are the key actors in gathering the information the
investigator should work closely with them in analyzing the data.
a.
How much Analysis is Required?
The amount of analysis required in any focus group study will vary with the purpose of the
study, its design, and the extent to which conclusions can be drawn from the data available.
A simple analysis using notes/feedback material of the field team may suffice in exploratory
studies where the conclusions of the study are straightforward. In general, however, analysis of
focus groups involves various activities, each of which is important for producing the final
report. These include:
4-19
1.
Field Notes and Debriefings [Refer to the in-depth interview analysis]
Field notes include written notes and comments on both verbal and non-verbal exchanges during
the FGD compiled by the moderator and the observer. Debriefing notes compiled immediately
after the sessions afford a quick and easy way of summarizing the data while the events of the
FGD are still clearly in the minds of the field staff (see Step 7 above). Taken together, the field
notes and debriefings can give a snapshot of the key findings from each session.
2.
Session Summaries
Within a day or two after the completion of each FGD, the moderator should complete a session
summary. Working with his/her field notes and notes from the field debriefing (if completed)
the moderator should prepare a 2-3 page summary of the session covering the following:
3.
!
number and type of participants
!
place and length of session
!
moderator=s evaluation of how successful the session was in achieving meaningful
interactions among all participants and staying focused
!
key findings from the session for each of the major topics in the moderator=s
guide, including useful non- verbal information
!
unexpected findings and insights, especially regarding factors that may increase
or decrease the success of the intervention.
Transcripts
Transcribing is very demanding. It is therefore recommended that transcript analysis be carried
out as soon as the transcripts become available and not when all the focus groups are completed.
The following guidelines may be followed for analysis of transcripts:
!
First, read through the transcripts with the study questions in mind; note any
impressions and major opinions from the discussion.
!
Second, read the transcripts again, this time looking at each specific topic of
interest or importance defined in the moderator=s guide. Also note any new areas
of interest raised in the session.
!
Third, read through each transcript again and strike out any responses that might
have been forced on participants through poor moderating. Also, you may
remove sections that have been poorly transcribed or that do not make sense.
4-20
4.
!
Begin a coding process by marking the transcripts according to various sub-topics
or areas of interest to indicate what participants are talking about. For instance, in
analysing data concerning the use of antibiotics in the treatment of ARI, every
time a participant mentions antibiotic use, you can mark the section to indicate
this by saying ANTIBU (ANTIBIOTIC USE). At the end of each page, therefore,
your transcripts will have various code words running down the side. This makes
it easier for you to identify areas of interest.
!
Prepare as many code words as necessary to meet your information needs, but try
to keep these simple and short. Note also that not all responses will fall into the
neat categories of information that you hope to obtain. If you come across a new
response that introduces a new idea or topic of importance, code it. You may
need a code book for the exercise.
!
The final task of the analysis involves using the list of information required to
check what information you have actually obtained. This will tell you whether
the objectives of your study are being met or not. Alter your question guide for
the next session if you are not getting close.
Log Book
Some studies use a log book to organize the transcribed analysis. It consists of a table that
enables the investigator to record the responses according to selected topics of interest.
The idea behind the log book is to retain the full range of responses in order to be able to spot
relevant issues. Topics of interest are written on the left column of the page while the right side
is divided into columns for the various FGD sessions. Responses are then tallied under each
column as and where they occur according to sub themes. Approaching the analysis this way
enables the investigator to find out how many times an issue was discussed across all the focus
groups, as well as how many times a response was given.
The approach is very useful when combining FGD results from different discussion groups. (i.e.,
prescribers, paramedics, patients, etc.). This approach is similar to the process of synthesis
across methods. (See Chapter Seven.) An example of a log book for a study on the overuse of
antibiotics is provided in Table 4.4.
4-21
Table 4.4: Example of Log Book on Use of Antibiotics Reasons for Preferring Antibiotics
# of Mentions of Issue by Session
# of participants
3
4
5
6
Pressure from families and peers
Prevention against pneumonia
Appropriate treatment for cold and
coughs
Better/more powerful drugs
Complaints/requests from patients
Fear of losing patients
Severity of symptoms
a.
Writing the Report
If you have used all the methods mentioned so far, the following may be available to you for
your report writing: log book, codes from transcripts, session summaries, field notes, and
debriefing notes.
Your task in report writing involves deciding which responses are important to include in the
report and which can be omitted. Findings are presented according to topics or issues of interest.
Use quotations to illustrate strongly expressed thoughts, beliefs, and emotions by the
participants. Remember to describe the overall consensus of the groups by sub-topics in the
moderator's guide. Majority and minority feelings, as well as apparent differences in feelings by
4-22
characteristics of respondents (e.g., sex and age) should be distinguished. Your final report must
therefore reflect the variety of participants' ways of thinking about the subject of study.
Many focus group reports do not indicate how many participants discussed a certain issue. The
common style is to say: "The majority of participants said ... " or "Few of them, however, felt....."
Depending upon the purpose of the research, such presentations can be sufficient and useful.
Nevertheless, it is sometimes useful to dwell a bit on frequency of occurrence of particular
issues.
b.
Interpretation of Findings
Interpretation involves explaining your findings in terms of the problem or question you want to
answer. In the course of the study, you may have developed some ideas about what the
respondents are saying. This is the time to question yourself about how significant the
information you have gathered is to the problem under investigatio n. As much as possible
involve the rest of the team, particularly the moderators and observers in this exercise since they
had a direct contact with the groups.
Based on the discussion of findings, the investigator may then be in a position to make useful
recommendations for planning and developing an intervention. Any recommendations about
how future studies should be conducted must also be noted.
In general, the format of the focus group report should consist of:
!
title of study
!
objectives and methods, including data analysis
!
major findings in line with significant broad topics of the moderator=s guide
!
discussion
!
conclusions
!
recommendations for interventions.
4-23
CHAPTER SUMMARY
Following is a summary of the main issues discussed in this chapter.
FOCUS GROUP DISCUSSION (FGD) METHOD IN DRUG USE STUDIES
OVERVIEW
What is Focus Group Discussion?
Use of FGDs in Drug Use Studies
KEY STEPS IN CONDUCTING FOCUS GROUP DISCUSSIONS
STEP 1:
Plan the entire FGD
What activities need to be planned?
Is there the need for a resource person
Role of resource person in training field staff
STEP 2:
Decide what types of groups are needed
Method of sampling (selection criteria)
Composition of groups
Number of groups
Group size
Contacting and informing participants
STEP 3:
Select moderator and field team
Field staff requirements
moderator
observer/recorder
other staff
STEP 4:
Develop moderator's guide and format for recording responses
Structure and sequence of topics
Wording of guide
Number of topics
Example of an FGD guide
STEP 5:
Train field team and conduct pilot test
Training hints
Training package
theory sessions
practice sessions
On-going revision of FGD guide
4-24
STEP 6:
Prepare for the individual FGDs
Site selection and location for FGD
Date and time
Plan for supporting materials or FGD checklist
STEP 7:
Conduct the FGD
Conducting the Discussion
Introduction
Warm-up
Discussion
Wrap-up summary
Debriefing
Collecting and managing information in FGD
STEP 8:
Analyze and interpret FGD results
How much analysis is required?
debriefing
notes
transcripts
log book
Writing the report
Interpretation of findings
Example of format of an FGD report
List of Tables
List of Figures
List of Tables
Table 4.1 Key Steps in Conducting FGD
Table 4.2 Example of a Screening Questionnaire
Table 4.3 Format of Contents of Observer's Notes
Table 4.4 Example of a Log Book
Table 4.5 A hypothetical example of an FGD report
List of Figures
Figure 4.1 Example of Format of a Focus Group Moderator's Guide
4-25
CHAPTER FIVE
STRUCTURED OBSERVATION
Structured Observation is potentially one of the most useful field
methods in drug use studies. This chapter is devoted to a brief
overview of the method and a detailed description of the main
steps involved in conducting an observational drug use study.
5.10: Overview
5.11: What is Structured Observation
Observation is a technique that involves directly observing behaviour with the purpose of
describing it. To observe means to examine an object, or an individual, or group of people, or an
event with all of the senses. Recording of observations may take many forms, from simple and
casual to exact and sophisticated. For example, an observer may observe an event and then
complete a checklist on whether or not key behaviours occurred. Or the observer may write
notes on everything that happens in his or her presence. More sophisticated recording may
involve audio-visual devices.
The technique can be classified into participant and non-participant observations. Participant
observation takes place when an observer participates with the people and in the events he or she
is observing. Non-participant observation occurs when an observer observes events without
interacting with the person(s) being observed.
Non-participant observation may further be classified as structured or unstructured. The aim of
unstructured observation is to observe and record behaviour in a holistic way without the use of a
pre-determined guide. Structured observation, on the other hand, refers to a technique in which
an observer observes events using a guide that has been planned in advance. The focus of this
chapter is on structured observation.
Events in structured observation are recorded according to an observation guide. The observer is
not involved in the activities being observed, but records them as inconspicuously as possible.
However, it must be pointed out that the presence of even a "neutral" and non- interacting
observer may influence the behaviors of the person(s) or events being observed.
Although structured observation may seem simple, obtaining useful data requires reliable
observers, an informative observational guide, and the cooperation of those being observed. This
presents the issue of bias in the observation process in both the observer and the person being
5-1
observed. The observer's bias includes his or her subjective judgment regarding events being
observed. For example, if the observer has a positive attitude towards the person being observed,
he or she may record positive observations and ignore negative behaviours. To overcome this
bias, an observer must be trained to be neutral and non-judgmental towards persons being
observed.
From the perspective of the person being observed, bias occurs when the person being observed
alters his or her usual performance of an activity in order to impress the observer. In a diarrhoea
study in one country for example, when prescribers were informed that the observation
concerned diarrhea, they examined infants who had diarrhea longer than they did other patients.
The examination took about 5-7 minutes for diarrhea cases, whereas the examination for other
patients took only 1-2 minutes.
Surrogate Patient Technique
To overcome certain problems of bias, some studies employ the use of surrogate patie nts. In this
technique a client suitably dressed and prepared presents at a health facility or dispensing/drug
sale outlet with a complaint requiring treatment. The complaint may concern the same
individual or the treatment may be for another person, suc h as a child. When combined with
direct interviews, the method affords an investigator the opportunity to contrast what providers
say they do with what they actually do. The reasons for the discrepancies can then be
ascertained using in-depth interviews or focus groups.
5.12: Use of Structured Observation in Drug Use Studies
In drug use studies structured observation can be used independently or as supplement to other
methods. As an independent method, it can be used to observe situations in health facilities. This
will involve part or all the sequence of events commencing when a patient comes to register until
he or she leaves the health center. In general, the goal for using the observational method in drug
use studies involves one or more of the following:
!
To generate research hypotheses in pilot studies where very little is known about
the problem.
!
To collect information not available in any other way, such as communication
patterns during a provider-patient encounter.
!
To supplement other data as part of a multiple assessment approach where
observation may aid in the interpretation of data.
As a supplementary method, structured observation can also be made during focus group
discussions (FGDs), in-depth interviews, or interviews using a structured questionnaire. It can
also be used to supplement quantitative methods of data collection, such as prescribing surveys.
5-2
5.20: Key Steps in Conducting Structured Observations
The steps listed in Table 5.1. can be followed in applying the structured observational method to
study drug use problems. The list is followed by a more detailed discussion of each step.
TABLE 5.1: Key Steps in Conducting Structured Observations
Step 1.
Decide if a resource person is needed.
Step 2.
Determine what is to be observed.
Step 3.
Choose the observers.
Step 4.
Develop observation guides.
Step 5.
Select the setting for the observations.
Step 6.
Train observers and pre test observations.
Step 7.
Conduct the observations.
Step 8.
Analyze and interpret the observational findings.
5.21.
STEP 1: Decide If a Resource Person Is Needed
Use of structured observations in a drug use study requires certain skills which those involved in
the clinical aspects of health may lack. One of the first decisions to make is whether the
assistance of a resource person is needed. The following are some points to consider.
a.
Assessing the Need for a Resource Person
The assistance of a resource person is very helpful, but whether you need one or not will depend
on a number of factors. These include size of the study, the resources available for it, and the
experience of the investigator and others on the study team.
If the study is small, you may rely on the services of someone who can consult for brief periods
when you need his/her services. However, if it is a large study you may need to look for
someone who can devote sufficient time to the study. The use of a resource person can be very
5-3
important to the success of the study, particularly if you have no experience with observational
methods.
b.
Who to consider as a Resource Person
The role of a resource person is to assist in planning the observation protocol and preparing for
subsequent stages of the study. The first choice for a resource person would be a social scientist
who has the knowledge, skills, and actual field experience in using structured observational
methods. Where it is difficult to find a social scientists to assist, others whose jobs are
behaviourally oriented and who have actually done some work using observations such as
colleagues in public health or community development officers, can be equally useful. In any
case, the resource person needs to have knowledge about the health care system and the context
of drug use in the locality.
5.22.
STEP 2: Determine What Is to Be Observed
The beginning of preparing an observation protocol is to determine what behaviours or
encounters will be observed on the field. The following describes some guidelines.
a. Selection Criteria
As with all applied qualitative methods, the purpose of the study will determine who and what is
to be observed. Since structured observation is often used to validate data obtained from other
methods, appropriate sources of information must be identified. For example, suppose the
purpose of an observation encounter is to verify a claim by providers that they give antibiotics to
children who present with ARI because their accompanying parents ask for them. Since you
cannot observe all patients in the targeted population, you will need to develop a method to
select encounters to represent this group.
Most clinic-based observational studies use a convenience sample of patients who happen to be
available at the time of data collection. Thus, all patients who report with cough on a particular
day at a certain health center might be observed. A random sample of patients with cough in the
community during a given period would be impractical to obtain.
b. Sources of Information
An investigator using structured observations must decide beforehand what the target of attention
of the study will be. Pertinent issues to consider before designing the observation protocol
include:
!
Is the emphasis to be on drug prescribing habits, adequate patient care, patient
behaviour, the health system context, or all of these?
5-4
!
Will the focus of attention be the health provider, the patient, or the prescribing
encounter?
!
Will the observation take place in hospitals, health centers, private drug outlets,
or some other place?
!
Will the observation cover the interaction of prescriber and patient, or the whole
situation at the health facility or drug outlet?
!
What are the possible opportunities in the observing environment for the observer
to blend in and become less obtrusive?
!
What is the most appropriate recording system for this situation?
The final decisions must be based upon the aims and goals of the study and the practical aspects
of collecting the data. Remember to narrow attention to data that are useful in designing an
intervention, and not other interesting but possibly unnecessary information.
5.23.
STEP 3: Choose the Observers
In preparing for data collection, you need to select the most appropriate field staff to carry out
the observations. The following are essential prerequisites to consider when recruiting field
staff.
a.
Qualities to Consider When Selecting Observers
The following observer qualities are helpful in ensuring accurate data:
!
Familiarity with the cultural background of the people being observed and ability
to understand their language is a key qualification.
!
Familiarity with pharmaceutical and general medical terms is a benefit, and may
be an absolute prerequisite for certain studies..
!
Knowledge about social research techniques is an advantage.
!
A secondary or high school education may be sufficient if the medical aspects of
the behaviour being observed are not complex..
!
Observers must be able to sit quietly and observe without interfering.
5-5
Ideally, structured observation would use two observers to ensure reliable information.
However, it may not always be possible to have two observers for every situation. Besides, it
may be more difficult for two observers to stay "unnoticed" than one person. With adequate
training, a single observer should be able to produce high-quality and consistent data.
b.
Observer's Role in Structured Observation
In structured observations, the observer watches events unfold without affecting them and
records these events in appropriate categories (on an already prepared checklist). The observer is
like a video recorder. He or she should record as objectively as possible all relevant events,
situations, and behaviours.
To minimize bias, the observer tries to be as unobtrusive as possible so that subjects feel at ease
and comfortable in carrying out their daily activities. The best way is to "sit quietly as a fly on
the wall in the corner" so that the subject forgets that the observer is in the same room. The
observer must maintain interest in the events being observed. Otherwise he or she will carry out
the observation mechanically and risk failing to notice some important events.
5.24.
STEP 4: Develop Observation Guides
The basis for structured observations is the observation guide. A preliminary list of issues to be
observed, and the categories in which to record them, must be prepared in advance based on the
objectives of the study. A list of common items that can be observed during clinical encounters
at a health facility is included in Table 5.2.
a. Who Prepares the Guide?
Usually the investigator(s) and/or the resource person directing the study is/are the appropriate
persons responsible for writing the guide. However, it is advisable and helpful to involve the
observers to enable them have input and familiarize themselves with the study. Useful input
might also be obtained from people who would have special insight into the interactions being
observed (e.g., experienced clinicians, community leaders), or administrators who will be
involved in later interventions.
b. Structure and Contents of Guide
Since it is difficult to predict observable behavior in advance, a draft protocol can initially be
partially structured. More attention should be paid to specific aspects that appear central to the
problem as the study proceeds, and a final observation guide prepared.
The guide should be prepared to suit local situations; the input of the field team is particularly
useful. You may also find it useful to begin with the instruments and protocols presented in the
annex, and adapt them to the local environment and problem of interest.
5-6
Table 5.2
Items That Can Be Observed During Clinical Encounters in a Health Facility
1. REGISTRATION:
! impressions
! payment
2.
!
!
!
SCREENING:
does it occur?
who does it?
content
3.
!
!
!
WAITING:
what do parents and patients do?
any health education opportunities?
how long?
4. CLINICAL CONSULTATION:
! physical environment: private, others present, place for patient to sit, exam. bed,
greeting ritual
! medical history: duration, associated symptoms (fever, chills, chest pain, cough, yellowish
sputum in cough), appetite (eating, drinking), previous treatment
! clinical exam: temperature, pulse, breathing (rate, in-drawing of space between the ribs),
touching, listening to the chest.
! use of instruments(stethoscope, BP machine, etc.)
! interaction: warm, cold, patient encouraged to speak, type of language (technical vs. nontechnical, local vs. non-local)
! explanation of illness: causes, prognosis
! advice: about prevention (environment, hand washing, food storage, clean water, latrines),
! about feeding (fluids, breast feeding), explanation about drugs
! length of time
! how encounter is terminated: prescribing on termination, reassurance, warm, abrupt
! prescriber washes hands after examination.
5. WAIT FOR DRUGS:
! how long?
! what happens during the waiting period?
6.
!
!
!
DISPENSING ENCOUNTER:
physical environment: private, possible to talk with dispenser
how are drugs dispensed: packaging, sterile technique for injection, labeling
communication: instructions about how to take, side effects/precautions, prevention and care,
patient asks questions
5-7
c.
Useful Events to Observe During Clinical Encounters
The most frequent target of observation in drug use studies is the clinical encounter between
health provider and patient. The following are key events that can be observed during the
clinical encounter:
1.
Aspects of Clinical Process
Polypharmacy
The focus of the observation is on how many drugs a provider prescribes for a patient and
why. Observation can take place in a health center, or in clinical examination areas
during a working day. The observer can sit quietly close by the prescriber and record the
drugs being given to the patient and any discussion about reasons for multiple drug
therapy.
Non-pharmaceutical therapy
The focus of the observation is on any instances in which a provider consults with a
patient without prescribing any drugs, and why. In drug use studies, the observation
usually takes place in the consulting room, although observing interactions between
patients and nurses or dispensers may also be informative..
Selection of Drugs
The focus of the observation is on the choice of drugs, and reasons for specific choices.
Many different aspects of the decision- making process can be covered: adequacy of
history taking and examination; discussion of alternatives with patients; patient requests
for particular drugs; the use of generic names; stock availability; and so forth.
Two prescribing choices that have received particular attention are use of antibiotics and
injections. Which antibiotics are being given to patients, and for what diagnoses? What
are the opportunities for laboratory investigation, and are they used appropriately? For
injections, in addition to why they are given and whether they are necessary, observation
can also focus on adequacy of sterile practice.
Information about use, risks, side effects
The focus of the observation is on the information communicated to the patient about
prescribed drugs, on both whether communication takes place at all and whether it is
adequate. Issues addressed can include how and when to take the drugs prescribed,
possible side effects and what to do if they occur, as well as responses to patient
questions or concerns. These interactions can be observed in the consultation room as
well as in the dispensing room.
5-8
2.
Features of provider-patient interaction
In addition to the more clinical aspects of the encounters between patients and health
providers, the observational method can be used to study the nature of the interaction
between them. It is often non-clinical aspects of the encounter that determine the overall
quality of care from the patient=s perspective. The following aspects of the encounter can
be included in the observation guide.
5.25.
!
exchange of greetings between provider and patient;
!
verbal expressions of concern by the provider;
!
conversation between provider and patient;
!
nonverbal expressions such as smile, touch, tone of voice;
!
eye contact between provider and patient;
!
duration of the encounter;
!
language used during the encounter;
!
advice given by the provider;
!
questions posed by the patient;
!
how provider ends the interaction.
STEP 5: Select the Setting for the Observations
Before beginning the field work, you need to decide the sites, days, times, and other related
issues for the observations. The following steps outline the preparations that need to be made.
a.
Site Selection and Permission
Some days or weeks before the field work, the investigator should visit the location of the study
to learn about the setting and people in order to make a final selection of study sites. When this
visit is made, it is possible to obtain permission to carry out the observations from relevant
authorities. The meeting can be used to inform local leaders about the purpose of the study, and
how it is intended to benefit them, and how many observers will be involved.
Before deciding on the specific site, date, and time of the study, discuss the issues with the local
authorities. This could ensure their support and cooperation. Sometimes the places and times
5-9
offered by local authorities require compromise in the intended study plans. Time constraints
can often be overcome by doing the observations over several days, rather than on only one
working day.
b.
Date and Time
The availability of cases for observation depends on local patterns of health service use. The
investigators and the contact personnel at the observation sites must decide the days on which it
is best to collect the data. Remember to schedule observations at the time of day and week when
an appreciable number of cases can be obtained.
For health centres, it is usually best to conduct observations in the morning between 8:00 and
1:00. Attendances are likely to be low at week-ends and holidays. For observations in
households and private retail outlets, early mornings before work and late evenings after work
are optimum in most communities.
c.
Decide on Observation Sites
The number of observation sites will be influenced by the objectives of the study, the number of
available and accessible sites, and the need to adequately represent the target population.
Difference in attendance at various sites must also be considered. The decision about how many
sites to include will therefore vary from place to place. If the study aims to assess practice in a
large group of health facilities, a minimum of 10 randomly selected sites would generally be
needed.
d.
Determine Number of Observations per Site
The number of observations per site is again dependent upon the study objectives, logistics,
attendance, and so forth. Usually observations can be made at the place of registration, the
waiting room, the consultation room or at the dispensary. There is no rule for deciding how many
observations per site, but at least 20-30 would be recommended to adequately describe practices
at each site.
5.26.
STEP 6: Train Observers and Pilot Test Observations
Structured observation may not appear as complicated as other applied qualitative methods such
as FGD and in-depth interview. However, observable behavior may be so complex and rapid
that observers may fail to detect interesting and important aspects if they are not properly trained.
Observers need to be well trained to enable them take note of interesting unforeseen events
which may not be indicated in their guides.
5-10
a.
Useful Hints for the Trainer
The following are some useful hints to guide the training:
b.
!
Find a suitable location for the training that allows participants to be comfortable
and removed from their usual work setting;
!
Involve the entire field team in all aspects of the training;
!
Allot sufficient time for each session, especially the practical sessions like role
plays and pilot observations;
!
Use simple materials for the training;
!
Use appropriate language, i.e., local language, for the training sessions;
!
Set sufficient time aside for discussions, and questions from the trainees;
!
Evaluate the sessions in a formal way to allow improvement over time.
Training Agenda
Theoretical issues that must be covered in the training include the following:
c.
!
What is structured observation and why is the method useful?
!
What are the objectives of the study?
!
Why is structured observation appropriate for the study?
!
How are unstructured observations conducted?
!
How will structured observations be conducted in this study?
!
How are field problems to be dealt with?
!
How will field data be handled and summarized in the daily report?
Practical Aspects of Training
Role play is a very effective practical approach for training observers how to observe. In role
play, the observers play scenes to depict the activities and roles at a health facility. Models could
include registration clerks/nurses, a doctor, a dispenser, other paramedics, and patients. While
5-11
some of the observers act the scene, others observe the activity. They record events according to
items in the guide as well as those that they observe themselves.
During the role play, the trainer observes the observers, and later comments on their
performance. For example: observer busily writing instead of paying close attention to an event.
When beginning training, it can be most useful to start with exercises in unstructured
observation. Create hypothetical events/situations and let trainees describe them. This helps to
bring out the observational strengths and weaknesses of trainees for the trainer. This might be
done by having two trainees observe the same events during a role play, after which they would
each write one paragraph to describe the key aspects of what they observed. Discussing their
descriptions with the trainer and the other observers can help them to focus on important issues.
After they become comfortable with unstructured observation, trainees can be introduced to the
structured observation guide and taught the meaning of each item in the protocol. They can then
role play again, and use the structured form to record data.
After the role play sessions, it is important to pilot test and revise the guide before beginning
actual field work. The uses of the pilot test include the following:
5.27.
!
to check whether the observational guide is suited to actual situations;
!
allows observers to become familiar with the guide;
!
spot which parts of the guide need to be revised.
STEP 7: Conduct the Observations
After pilot testing and revising the guide as needed, you are now ready to begin the field work.
a.
Preparing for Field Work
Ensure that the following are available for use by observers before they move into the field.
!
!
!
!
Latest version of the observation guide and data collection forms
Notebook for making notes
Pens/Pencils
Any other recording equipment such as tape recorder that will be used
It is of utmost importance that observers dress appropriately for the field. Appropriate dress will
vary from group to group and from community to community, but the guiding criterion is that
dress should be chosen to be unobtrusive. For example, an observer wearing a suit to collect
data in a village health post would stand out and interfere with normal activities. On the other
5-12
hand, an observer wearing a lab coat in a consultancy area in a health center can often blend
most easily into the background.
b.
Conduct the Observations
On the day of the observation, observers should arrive early at the health facility to make the
necessary preparations before the health facility commences work. Such preparations will
include locating observation positions. Being in position as patients arrive can help observers
appear more natural. When everything is set the observation can proceed as follows:
1.
Getting Started
It may sometimes be necessary to inform and explain your presence to those being
observed. How this is done depends on the setting and people involved. It is best to have
your host at a health facility (usually the officer in charge) do this introduction. At this
very first stage, display friendliness and show interest.
A prospective observer must gain the trust, confidence and cooperation of subjects.
However, even after achieving this, the observer's presence may sometimes influence
behaviour and events being observed. The observer must be aware of this possibility and
try to prevent it by positioning himself/herself away from the center of activity, and by
writing as inconspicuously as possible. It may also reduce bias if the first few encounters
observed are not included in the sample, giving time for everyone to become used to the
observer=s presence.
2.
Observing
Remain reasonably detached yet attentive. Observers must record observations as
systematically and accurately as possible. The use of observational guides or forms
should enable them to record events easily. It is also important to write notes about
events that are not included in the guides or forms. These qualitative data will add flavor
to the interpretation of the more structured items and could provide unexpected, but
relevant information. For example, the fact that female patients are not touched by male
health workers may not have been captured by the observation protocol, but could be a
key finding for developing an intervention.
Observers may also make sketches of observation situations and note other non-verbal
communication.
5-13
3.
Wrap-Up
At the end of the session remember to thank the health facility staff and your host. In
some situations, it may be appropriate to thank patients or their accompanying person
immediately after the encounter. On the other hand, it is best to wait until the end of a
day's field work before you say thank you to health facility staff. Sort out any problems
you might have encountered with your host if it is within his/her means to help before the
next observations begin.
c.
Regular Review of Data
During the field work, there must be a regular review of the data by the investigator with the
observers. This is very helpful for ensuring the accuracy of recordings especially at the early
stages of the study. Such a review also provides an opportunity for the investigator to discuss
any problems encountered by observers in the field.
d.
Recording Information in Structured Observations
An observation protocol must strike the correct balance between brevity and comprehensiveness
in recording data during the observations. Generally, relying on the observer's memory is ideal
but risky because notes made after the observation can be distorted. However, making extensive
notes during the observation may also distract subjects and cause the observer to miss some
important events while occupied with note taking.
Observation guides with which observers have been familiarized through training are an
effective means of recording data. The observers can check appropriate categories in the guides
and write notes in available space for comments and other observations. Normally, because
events are itemized in the guide, structured observation may not always need extensive
supplementary notes. Nonetheless, notes of unexpected events not included in the guide should
be recorded.
5.28.
STEP 8: Analyze and Interpret the Observational Findings
The final stages of the observational study involve analyzing and interpreting the data from the
field. This can be done manually or with the aid of a computer depending upon local capability,
as well as the objectives and size of the study.
a.
When does Analysis Begin?
The analysis of structured observational data begins the moment the data collection begins. The
exercise involve a number of activities which include;
5-14
b.
!
Routine debriefing sessions involving observers and investigators. This aspect of
data management can improve the quality of the final results.
!
Comparing notes of observers from daily field trips. This makes it possible to
compare the performance of different observers, and to spot and remove
irrelevant parts of their field notes. It also provides an opportunity to add new
themes or topics which are found useful while the data collection lasts.
How much Analysis is Required?
Since structured observation is partly quantitative and partly qualitative, the analysis involves
procedures for both types of data. Whether it is done manually or with the aid of a computer, the
analysis involves the following:
!
Categorization of data: This is the first formal stage of the analysis. The
qualitative part of the data comprising descriptions of behaviours of people,
events, and situations recorded as free text must first be categorized. This begins
by reading through the raw data and placing similar responses in identifiable
categories.
Usually, the data collected with structured observation forms about planned
events are already categorized. If the data are to be analyzed by computer, some
software requires that numeric codes be assigned to different categories (e.g., A0"
assigned to ANo,@ and A1" to AYes@ responses. The qualitative data that has been
categorized previously may also need to be coded with numbers.
!
c.
Summarizing the data: This stage involves analyzing the coded information in
order to describe the frequency of responses for each item or theme. Report
percentages for each response category for pre-planned observations. You may
also describe the qualitative aspects in a narrative style, although certain
qualitative issues could equally be quantified and presented as percentages. The
data summaries should present the key quantitative and qualitative findings from
the observations that would guide the design of an intervention.
Doing Analysis with a Computer
Using a computer to analyze data from structured observation can be more costly and time
consuming than manual analysis. If the data set is small, it is advisable to avoid
comp uterization. If a computer analysis is to be used, the following steps can be followed after
coding the data:
!
Choose appropriate software: Various computer software programs are available;
two of the most popular are Epi Info and dBase. It is suggested you see a
resource person for assistance before you choose a program.
5-15
d.
!
Enter the data: Before entering data, you need to develop a data entry format to
allow transfer of coded data into the computer. Data entry needs to be validated,
often by entering data twice and comparing the entries. Data entry errors must be
thoroughly edited out before analyzing the data. .
!
Run the analysis: After editing the data, you are now ready to run the desired
analyses. You can analyze the contents of each response under various subthemes using frequency distributions, and compare responses in different
categories of the target population using two-way or three-way tables..
Writing the Report
Writing the report is the responsibility of the investigators, but involving the entire study team
will ensure that all important aspects are covered. Discussion of findings by the team will often
trigger unexpected insights about the reasons for problems or ways of improving them. The
report should focus on recommendations for policy changes or specific interventions to solve the
problem being studied.
The major sections of the report of an observational study are:
Introduction:
Statement of problem, research objectives, rationale, scope, operational
definition, outline of the chapter.
Methodology:
Research approach and method, instruments, study setting, sampling,
personnel, field work organization and supervision, mode of data analysis.
Findings:
This embodies tabulating and deascribing the study results.
Discussion:
Underlying reasons and explanations of the main findings.
Conclusion and
Recommendations: Inferences, suggestions, and likely follow-up interventions.
Interpreting the findings involves drawing conclusions about intervention design based on both
quantitative summaries and the qualitative data analysis. Other data which can help in
interpreting findings include observers= notes from the field, existing research findings, as well as
educated opinion on the subject. The conclusions and recommendations should stay primarily
focused on the issues that will contribute to the design of an intervention.
5-16
CHAPTER SIX
STRUCTURED QUESTIONNAIRES
This chapter focuses on structured questionnaires and how they
can be used in drug use studies. It begins with a brief overview of
the questionnaire method and indicates the types of study questions
for which it is most suited. The greater part of the chapter is
devoted to a discussion of the steps involved in using the method
to study a particular drug use problem.
6.10: Overview
6.11: What is a Structured Questionnaire?
A questionnaire is a group or sequence of questions designed to elicit information from an
informant or respondent when asked by an interviewer or completed unaided by the respondent.
When an interviewer is involved, the questionnaire is sometimes referred to as an interview.
An unstructured questionnaire is an instrument or guide used by an interviewer who asks
questions about a particular topic or issue. Although a question guide is provided for the
interviewer to direct the interview, the specific questions and the sequence in which they are
asked are not precisely determined in advance.
A structured questionnaire, on the other hand, is one in which the questions asked are precisely
decided in advance. When used as an interviewing method, the questions are asked exactly as
they are written, in the same sequence, using the same style, for all interviews. Nonetheless, the
structured questionnaire can sometimes be left a bit open for the interviewer to amend to suit a
specific context.
A semi-structured questionnaire is a mix of unstructured and structured questionnaires. Some
of the questions and their sequence are determined in advance, while others evolve as the
interview proceeds.
The focus of this chapter is on structured questionnaires.
The list of questions that make up a structured questionnaire may be open ended or close ended,
depending on how the questions are framed and asked An open-ended question is one in which
possible responses are not supplied in advance. Each respondent=s statements should be recorded
as fully as possible and in the respondent's own words. Open-ended questions are very useful for
exploring sensitive issues and investigating topics concerning beliefs, attitudes, and practices.
6-1
A close-ended question usually provides a set of responses or options from which a respondent
indicates his/her choice. Where the study topic concerns factual issues, or is a familiar one with
a limited range of responses, close-ended questions are particularly useful.
6.12: Use of Structured Questionnaire in Drug Use Studies
The structured questionnaire method can be used to study various aspects of drug use behavior
involving providers and consumers. The method is appropriate to use where the study is aimed
at:
!
Estimating the prevalence of existing beliefs or attitudes as a means of
confirming data obtained with either unstructured interview or other qualitative
methods.
!
Finding out more information to complement or follow up a previous
exploratory study. The purpose of this may be to check the validity of previously
collected data or observations to enrich the overall results of a study.
!
Comparing responses in subgroups of a large population, such as knowledge
about different drugs, the type of drugs used, how much they cost, and so on.
6.20: Steps for Using Structured Questionnaires
Drug use studies that employ the structured questionnaire method share some of the
characteristics of other methods. Several steps are involved; these are outlined and described
below.
6-2
Table 6.1:
Key Steps in Using a Structured Questionnaire in Drug Use Studies
Step 1:
Plan how to carry out the study.
Step 2:
Define and identify the target group for the study.
Step 3:
Develop the questionnaire(s) and guides.
Step 4:
Select interviewers and other field team personnel.
Step 5:
Train field personnel and pilot test the questionnaire.
Step 6:
Prepare and conduct the field work.
Step 7:
Analyze and interpret the data.
6.21.
STEP 1: Plan How to Carry out the Study
a.
Why is Planning Necessary?
When planning a questionnaire study, you must first make a number of decisions regarding
various aspects of the study and how it will proceed. These decisions will all have a major
impact on the implementation and success of the study.
During the planning you must decide which target group will answer your questionnaire, how to
select a sample, design the questionnaire, and select and train interviewers.
In addition, you need to plan study logistics and equipment. These include stationery, forms,
transport and whether incentives will be offered to respondents. Field allowance for interviewers
must also be decided at this stage. These issues are addressed in the rest of this chapter.
b.
Is there the Need for a Resource Person?
Planning and implementing a questionnaire study is an interesting but demanding task. Whether
or not it is necessary to find a resource person to assist in planning and implementing the study
will depend upon factors such as the scope of the study, available resources, and your own
experience and confidence in applying the technique.
6-3
Of all the methods described in this manual, questionnaires are the most familiar to many health
professionals, and the one technique with which many people have had experience. An
investigator with some experience may be able to manage a small study by merely following the
steps described here, since the skills required to design and implement a structured questionnaire
are not as demanding as other methods. For a large study, you may consider the assistance of a
social scientist who is experienced in questionnaire design and survey research.
6.22.
STEP 2: Identify the Target Group
One important decision is to identify the study population (the target groups of respondents who
can best provide the information you need). The following steps provide a guide to the issue of
sampling.
a.
Determine Type of Sampling
Probability sampling methods are most commonly used in structured questionnaire studies. The
purpose for using the questionnaire method usually involves confirming a hypothesis or
generalizing the results of a study so relatively larger samples selected by probability methods
are appropriate. The common probability sampling methods include:
!
simple random sampling
!
systematic sampling
!
stratified sampling
!
cluster sampling
!
multi-stage sampling
These methods are described briefly in Annex A.
The basic principle underlying probability sampling is that the selection of any respondent or
unit in the study population is based on a known (usually equal) probability. The most
appropriate method for a particular study depends on the size of the target population, what lists
of members are available, and whether the population is organized in natural clusters like
villages or health centers. [See also How to investigate drug use in health facilities: selected
drug use indicators (WHO/DAP/93.1) for a more detailed discussion on sampling procedures.]
Sometimes, because of logistical constraints, the sample for studies of the knowledge, attitudes,
or satisfaction of patients attending health facilities, or of patients with specific health problems,
will not be selected randomly, but in the order in whic h they present for treatment (a
convenience sample). In such samples, we must assume that patients in general, or patients with
specific problems, present Arandomly@ from the underlying pool in the community, and that
6-4
generalization to the larger underlying population is justified. Sometimes surveys will avoid
sampling patients who attend early in the morning (more likely to be emergencies), or those who
attend on market days (more likely to have no specific complaint) in order to avoid bias.
b.
Who should be Selected?
The target population for a questionnaire survey will be chosen based on the drug use problem,
the study objectives, and how the results are to be used. For example, you might be interested in
inappropriate diarrhea treatment in the community. Previous research may have shown that most
patients are treated without prescription in private pharmacies and drug retail outlets. A
questionnaire survey of provider knowledge and beliefs may target all counter attendants in
licensed pharmacies if that is an identifiable group for whom an intervention might be mounted.
The most important principle is to ensure that all segments of the target population are well
represented.
Sometimes questionnaire surveys will include Aproxy@ cases; if so, criteria for who can be
included must be clearly specified at the beginning. For example, in studying the use of
antibiotics for treating ARI, an investigator is likely to talk to mothers with children who report
with an episode of ARI. In cases where patients are accompanied by other relatives such as an
aunt or neighbor, instead of the mother, the study should specify whether these persons can be
interviewed or not.
c.
Number to Interview
Sample size depends upon the aim of your study, and in particular how precise the sample
estimates must be. Using the antibiotic example, if the purpose is simply to explore beliefs and
attitudes about antibiotics in the treatment of cough in children, a small sample may be
sufficient. However, if the purpose of a study is to estimate specific knowledge deficits in a
population of paramedics in order to design a curriculum, a larger sample might be necessary.
Generally, if the goal of the study is to test a hypothesis or generalize the findings to a large
population, then an adequate representative sample -- usually a large one -- must be taken to
achieve a reliable result.
d.
Contacting Respondents
Respondents to a study may be contacted by mail, telephone, or personal contact; the latter is
usually the most feasib le in developing countries.
It is wise to contact the community or institution where the sample will be drawn in advance of
the study. Depending on the focus of the study, contact people may include the chief or
community head, health center officer- in-charge, or local government representative. Such
influential people can later assist with field organization and logistics, and especially with
providing an up-to-date list of the members of the target population (a sample frame).
6-5
During the initial contact, the aim of the study, when and for how long it will take place, and
how it will benefit them should be explained to the agencies involved. Such information may
encourage greater cooperation.
6.23.
STEP 3: Develop the Questionnaire(s) and Guides
The design of a questionnaire and how questions are worded can greatly influence the reliability
of the data collected. Developing a structured questionnaire is a relatively familiar activity, since
questionnaires are so commonly used. Despite this, creating a good questionnaire is not a simple
task, but one which requires careful testing and retesting. The suggested sequence of steps to
assemble a questionnaire is:
a.
1.
Determine the contents of the questionnaire.
2.
Formulate the questions.
3.
Order the questions.
4.
Arrange the questionnaire.
5.
Translate the questionnaire (if necessary).
Determine the Contents of the Questionnaire
The first task is to determine which topics the questionnaire will cover and how it will be
administered. The number of topics will depend on the objectives of the study, and on the length
of time it is reasonable to expect respondents to cooperate. Remember that the information
collected should be relevant to the design of an intervention. The most frequent problem in
questionnaire design is asking too many questions that are not directly useful or relevant. You
can organize your work as follows:
!
Outline the most important objectives of the study.
!
List under each objective the types of information directly relevant and necessary
in meeting these objectives.
!
Rearrange and organize the lists into separate sub-themes or sections of the
questionnaire.
!
Decide how the questionnaire will be administered; i.e., whether it will be filled in
by respondents themselves or by an interviewer (which is more common in
developing countries).
6-6
b.
Formulate the Questions
After identifying the sections of the questionnaire, you must formulate individual questions to
gather the specific pieces of information needed.
Wording questions so that they are uniformly understood and tap into the desired category of
response requires patience, practice, and, above all, pre-testing. Some general guidelines on
good question formulation include:
1.
Each question must be clear, simple, and specific
For example, a question such as "Where do you normally seek treatment when your child falls
ill?" may be perceived differently by different respondents. AIllness@ can include many different
types of health problems, and varying degrees of severity. AWhere@ can be interpreted as a
physical location or a type of practitioner. ANormally@ is an imprecise word that means different
things to different people. ASeek treatment@ may exclude self- medication in the minds of some
respondents.
To overcome this problem, it is best to specify questions in clear, short and simple language.
You may for instance break the question into pieces to assist respondents, for example, by asking
specifically about ARI. Further limiting the duration to the last two weeks preceding the study
or the last episode of illness will also enhance recall of respondent. You can further ask them to
mention specifically the various actions they took since the illness was noticed. These may
involve the following questions:
Has your child been ill with cough within the past two weeks?
(If the answer is yes): Did you visit anyone for advice or treatment? Did you give the
child any medicines?
(If the respondent indicates medicine(s) were given): Would you please list any
medication(s) that the child has used since the illness started?
2.
Each question must measure one thing at a time
Questions which measure two or more different things should be avoided. For example, the
question "How do you and your staff normally treat children who present with cough?" should
be divided into several questions to enable the respondent to give separate answers for different
types of prescribers in the facility, since they may each have a preferred way of treating cough.
3.
Questions should not be biased
Leading questions can lead to biased responses. A leading question is one which suggests the
expected answer. For example, the question: "When a child presents with ARI, do you prescribe
6-7
an antibiotic?" is a leading one because it mentions antibiotic. An alternative would be to ask
"What do you do when a child presents with ARI?"
Leading questions may also arise when presumptions are made about the respondents. For
example, the question: "What additional fluids did you give your child when he was last ill with
cough?" is biased because of the presumption that when the child has had an attack of cough, the
respondent would give the child extra fluids.
A better set of questions might be: "Has your child had cough within the last two weeks?" (If
yes): "Did you take any action?" (If yes): "What action did you take?"
4.
Questions must be free from ambiguity
Words which are vaguely defined or have double meanings should be avoided. The question:
"What kind of patient was he?" may lead to different types of responses such as `"poor" or
"rich," "simple" or "complex," "cooperative" or "un-cooperative," and so on.
Also, "double barreled" questions, such as: "Do you think ampicillin and tetracycline are
effective for treating cough?" are not good questions since a respondent could like one and not
the other. In this case, a Yes or No response would not truly reflect the respondent's opinion.
Divide such questions into two, each containing a single idea.
c.
Sequence the Questions
After framing the questions, they must be organized in a sequence that is helpful for respondents.
Following is a useful approach:
!
Ensure a logical order of topics, and of questions within a topic. Ideas should
flow smoothly from one question to another, moving from more general questions
to more specific ones within each topic.
!
Begin with relatively non-controversial and interesting questions, e.g., How many
years have you worked at this health post?"
!
Place sensitive questions concerning personal information such as age, education,
occupation, and income at the end of the questionnaire since respondents may be
unwilling to answer them if they are asked early, before a relationship of trust has
been established.
!
If the response to one question is likely to influence the response to another
question, these questions should be separated.
6-8
!
d.
Any instructions for skipping one or more questions should be clearly indicated
and, if possible, written in a different font or typeface.
Arrange the Questionnaire
Finalizing the draft questionnaire involves planning the layout to make it both "consumer" and
"user" friendly. This involves the following:
e.
!
Provide necessary headings and spaces for labeling and identifying all
questionnaires, ie., identifying information for respondent, date and place of
interview, as well as name of interviewer.
!
Provide necessary instructions at the start of each section of the questionnaire.
Give guidance and reminders at relevant sections to the interviewers.
!
Provide sufficient space between questions.
!
Be consistent with codes or boxes for pre-categorized answers.
!
Provide enough space for writing down answers to open-ended questions.
Translate the Questionnaire (if necessary)
Most interviews involving patients in developing countries are conducted in local languages. To
ensure consistency in the use of words and meanings, questionnaires must be thoroughly
translated before the field work begins.
One effective way of checking the accuracy of translations is to have a different translator do a
back translation into the original language in which the questionnaire was written. The two
versions can then be compared to iron out any differences. Table 6.2. is an example of a
questionnaire.
6-9
Table 6.2.:
Example of A Structured Questionnaire
DRUG USE STUDIES IN ACUTE RESPIRATORY INFECTION (ARI)
Client Intercept Questionnaire
Name of District..........................................................................
Date of Interview..............................................
Name of Town.............................................................................
Name of Interviewer.........................................
Name of Facility..........................................................................
Name of Patient...........................................................................
DIAGNOSIS
1.
Can you tell me in your own words what the problem is with your child?
2.
Why did you choose to come to this facility today for treatment?
3.
Have you ever been to this facility before?
Yes________
No________
4.
Did you try any other kind of treatment before you came here?
Yes________
No________
If yes: What kind of treatment was that?
DRUG USE
5.
Could you please show me the drugs you were given here today? Examine drugs to be able to later fill
in the questions on drug labeling on the dispensing form.
Did anyone here tell you how to use these drugs?
Yes________
No________
Did you understand what they explained to you?
Yes________
No________
b. The drugs you were given?
No________
If yes: Who was it that explained this to you?
Table 6.2.
6.
Yes
(Continued)
Could you please explain the use of each drug to me? Hold each drug in turn for the adult to see.
Drug
Described Use
a.
6-10
b.
c.
d.
e.
SATISFACTION WITH CARE
7.
Are you satisfied with the treatment obtained?
Yes________
No________
The way the child was examined?
Yes________
No________
The drugs you were given?
Yes________
No________
8.
If you could change one thing about the care here to make it better, what would that b e?
9.
If your child=s cough does not improve after taking these drugs, what do you plan to do?
SOCIO-DEMOGRAPHIC CHARACTERISTICS
10.
Sex of Respondent
Male_______
11.
Highest level of education (Check one):
Female________
Primary
______________________
Other Tertiary
Secondary
______________________
Other (Specialties)____________________
University
______________________
No formal education __________________
6-11
____________________
6.24.
STEP 4: Select Field Personnel
The calibre of field personnel who administer the questionnaire have a great influence on the
quality of data. In structured questionnaire interviews, the field team personnel usually include
interviewers and supervisors.
a.
Selecting Interviewers
The interviewer is the one who "sells" the aims, objectives, and intended use of the information
to the respondents. The following are qualities to consider when recruiting interviewers.
1.
Educational qualifications
Administering a structured questionnaire does not necessarily require high qualifications.
Usually people with high school or second cycle education who can read and write well would
be appropriate. In fact, using personnel with high qualifications may even prove risky since such
people have a greater tendency to get bored with repetitive work.
2.
Personal qualities
The following are useful personal qualities in an interviewer:
!
ability to develop rapport with people;
!
ability to speak all la nguages, if multiple languages are being used;
!
fluency in local language where this is essential;
!
ability to work alone and under difficult conditions;
!
honest and with a strong motivation to work;
!
previous experience in conducting interviews;
!
good communication skills.
Someone who is shy, aggressive, or has an unpleasant appearance
is not likely to be a good interviewer
6-12
b.
Selecting Supervisors
A supervisor is responsible for seeing that the field work is done properly. In addition to the
personal qualities listed under Interviewer (above), the role of the supervisor demands the
following additional qualities:
!
ability to work with an motivate people;
!
highly motivated and intelligent;
!
considerable field experience is most preferable;
In general the duties of a supervisor include:
!
consulting relevant authorities when a team enters a community or an institution
for the necessary permission;
!
checking the progress of the interviewers in the field;
!
acting as point of contact between interviewers in the field;
!
maintaining schedules and coordinating work in the field;
!
solving any problems or difficulties that need to be resolved in the field;
!
reviewing and editing completed interview schedules on a daily basis to avoid or
minimize any problems during the analysis;
!
re-interviewing small samples of respondents on important aspects of the
interview to provide some measure of quality control in the data obtained.
You may decide to select your personnel through interview, or written test (for language
competency). It is advisable to make the selection provisional, subject to good performance
during training and field testing.
6.25.
STEP 5: Train Field Personnel and Pilot-test Questionnaire
The purpose of training is to impart the needed skills to the field team before they embark upon
the field work. The training curriculum must cover both the technical aspects of questionnaire
surveys, as well as practical training in how to implement them effectively.
6-13
a.
Technical Background on Structured Questionnaires
Provide interviewers with adequate background knowledge on structured questionnaires and the
survey process. This theoretical aspect of the training must include the following:
b.
!
an overview of structured questionnaires;
!
how questionnaires will be used in this drug use study;
!
the role of field personnel, including interviewers and supervisors;
!
how to sample and locate respondents in the field;
!
how to gain rapport with respondents and conduct a successful interview;
!
how to record, process, or edit data in the field;
!
how the data will be analyzed.
Relevant Background Knowledge about the Study
Inform the team about the problem, purpose and objectives of the stud y so that they can
understand it in context. Provide information about the study community and target population.
Discuss the possible problems that could be encountered with respondents on the field. Explain
any anticipated sensitivities on the part of community leaders, facility administrators, or
respondents. This is especially important if it is possible that the questionnaire is seen as
evaluating or judging knowledge or performance.
c.
Instructions for Recording Responses
Much of a structured questionnaire is completed by an interviewer marking or circling the
appropriate response. In order to avoid inconcsistency, it should be made clear exactly how the
interviewer is to complete each item. For multiple response lists, indicate whether the
interviewer is to read the list to respondents, and also whether multiple responses are possible. If
the interviewer makes a mistake filling in a question, explain how the mistake is to be corrected (
e.g., by blocking out, erasing, circling with an X, etc.).
Each respondent has to answer open-ended questions in his or her own way. The interviewer
therefore needs to be cautious in recording open-ended responses. Such responses should be
written in full. However sometimes this is impractical, and interviewers must learn to extract the
key information. The respondent can be asked politely to repeat a response if it is not well
understood.
6-14
Interviewers must not spend a lot of time writing since this can interrupt the flow of the
session. Abbreviations are very useful, but interviewers should avoid those that are difficult to
read later. Introducing a common set of abbreviations for vocabulary that will be frequently
used is very helpful.
d.
Role Play Sessions
The practical sessions of training consist of two parts. First are the role plays in which
interviewers and other field staff practice among themselves in artificially created situations.
Interviews should play the part of both interviewers and respondents.
The trainer and other experienced interviewers can observe and comment on the performance of
interviewers in order to improve both the interviewers' style and the questionnaire.
e.
Pilot Tests
As with all applied qualitative methods, it is important to pilot test the questionnaire and the field
procedures. This involves trying out the prepared questionnaire in a group and an environment
similar to that expected in the actual study situation. It affords interviewers the opportunity to
practice all the activities that they are expected to carry out in the field. Functionally, pilot tests
serve to:
6.26.
!
assist interviewers in becoming familiar with the questionnaire;
!
help improve and sharpen interviewing skills;
!
afford a means of checking, revising, and finalizing the questionnaire by
improving the clarity and order of questions and removing ambiguous and
unnecessary questions;
!
enable the investigator to learn about possible problems that lie ahead, thereby
providing an opportunity to make changes in the study organization before
embarking on the field work.
STEP 6: Prepare for the Field Work
Once the training and pilot testing and over, you are almost ready to move into the field.
Preliminary preparations do, however, need to be made to ensure that the field work proceeds
successfully.
6-15
a.
Review and Revise the Questionnaire
After the pilot test, review and revise the questionnaire and the guidelines for the actual field
work. This review should take into account all issues related to the successful administration of
the questionnaire. These will include the following:
!
interviewer's approach to respondents;
!
target response rates;
!
what to do about partial or irrelevant responses;
!
mistakes in following instructions on the questionnaires;
!
time required for completing the interview.
Before printing the final questionnaire, have it thoroughly proof read to correct any hidden
mistakes.
b.
Prepare a Work Plan
As part of your preparation for the field work, you need a work plan and a time-table of how you
will proceed with the field interviews. Particularly if the study is a large one with several
interviewers and other staff, your work schedule will involve:
c.
!
composition of various teams of interviewers and supervisors;
!
assignment of teams to specific locations or delineated areas;
!
transportation and accommodation arrangements;
!
schedule of work.
Plan for Supporting Materials
Before you finally move into the field, ensure that instruments and other interviewing materials
and logistics for the field work are ready. Your checklist should include:
!
introductory letters;
!
sufficient questionnaires for the interviews;
!
waterproof folders for the questionnaires in case of rain (if needed);
6-16
!
instruction list for interviewers and supervisors;
!
pens/pencils and note books for interviewers and supervisors;
!
bags for carrying interviews and materials.
6.27.
STEP 7: Administer the Questionnaire
a.
The Interview Process
Interviews are best conducted with respondents alone in a place that offers reasonable comfort
and privacy. Providers and patients/clients may be interviewed in a health facility or drug retail
outlet. Community members can also be interviewed in their homes which is where they are
most likely to stock and take their medicines.
The interview session can be divided in three stages: introduction and rapport building;
interviewing; and closing the interview.
1.
Introduction and Rapport Building
The opening part of the interview is aimed at introducing the respondent to the topic and making
him/her relaxed for the interview. The interviewer seeks to do the following:
.
2.
!
greet the respondent, keeping with local custom;
!
introduce himself/herself;
!
briefly explain the purpose of the interview;
!
assure respondent that responses will be anonymous and confidential;
!
politely ask respondent to introduce himself/herself;
!
seek respondent's consent to start interview
Interviewing
After establishing rapport, the most important aspect of the interview is asking questions in a
standardized way. Following are interviewing techniques to guide the interviewer:
!
Questions should be asked without changing the wording, order, or emphasis.
Rationale: All respondents should be given the same information and asked the
same questions, under similar conditions.
6-17
3.
!
Instructions which introduce sections of the questionnaire must be read out clearly
and distinctly.
Rationale: These instructions help respondents think about and prepare their
answers.
!
Interviewers must read out questions at a reasonable pace.
Rationale: If the interview is rushed, respondents may give answers that tend to
come to mind first instead of thinking about questions; if the pace is too slow, the
interview can drag along and tire respondents.
!
If a question is not understood, the interviewer must repeat the question in the
same words, with the same emphasis and the same instructions.
Rationale: Putting questions in different words can easily change the meaning
and emphasis.
!
Interviewers must avoid returning to questions which could previously not be
answered.
Rationale: Repeating questions this way can expose the intent and influence the
responses.
!
The interviewer must show neutrality as much as possible.
Rationale: Certain reactions by an interviewer can change the attitude of a
respondent.
Examples are: frowning or irritated voice, smiling or laughing suspiciously,
winking an eye, or raising eyebrows.
Closing the Interview
Before the interview is brought to an end, the interviewer must politely thank the respondent,
explain that the interview is now completed, and ask if the respondent has any comments or
questions. It is a good idea to ask respondents if they felt that the interview captured all of their
opinions about the subject matter. Often respondents will offer useful opinions that may not
have been covered in any of the questions.
In the final wrap- up, the interviewer must remember to:
!
repeat the value placed on the respondent=s opinions and their likely bene fits;
!
reassure the respondent of confidentiality;
!
express goodwill or polite farewell.
6-18
Remember: the interview does not end until the interviewer has
said Athank you@ to the respondent.
b. Anticipating and Managing Possible Problems
There are some problems that are commonly encountered during interview surveys. Sometimes
these can be anticipated and prevented. Common problems and suggested ways to deal with
them include:
!
A respondent refuses an interview altogether:
The best way to guard against refusals is by polite introduction, explaining the
intended benefits of the study, and assuring the potential respondent that the
interview will be brief. When refusals occur, note any reasons for the refusal and
leave the respondent.
!
A respondent abandons the interview halfway:
Keeping interviews on track and moving along at a good pace will decrease
abandoned interviews. Well-designed questionnaires also help by maintaining
the respondent=s interest. When interviews are abandoned, record any comments
as to why this occurred.
!
Respondent gives careless answers:
Well-trained interviewers are always alert for respondents who do not seem to be
responding seriously or thoughtfully. Sometimes the respondent is temporarily
distracted or hurried, and the interview can be re-scheduled for completion at
another time. In any case, record any doubts and suspicions, and indicate
obviously suspicious answers.
!
Noisy environment:
Queues of patients, curious onlookers, and young children can all distract
respondents. Finding a more private place for the interview is the best solution.
If this is impossible, carry on as best as you can; find out from the respondent
whether something can be done about the problem.
!
Others present try to intrude in respondent's answers:
Any unusual activity in a health facility or home tends to attract interest.
Onlookers can bias responses not only by directly answering questions, but also
because respondents may not be able to give honest answers in their presence.
Politely ask helpful onlookers to stop; at the extreme, suspend and re-schedule the
interview with the consent of the respondent.
6-19
!
6.28.
Aggressive and other unacceptable behavior change in respondents:
Sometimes a particular question or simply an overly lengthy interview can trigger
hostility in a respondent. In these situations, end the interview with a polite
excuse; record the actual details of the closure on the questionnaire.
STEP 8: Analyze and Interpret the Data
After the field work, data from the questionnaires must be processed, analyzed, and presented in
the form of a report. The process involves the following activities:
a.
Processing Questionnaire Data
1.
Check and Edit Questionnaires
For purposes of easy identification, all questionnaires must be numbered separately after they
have been completed. Field supervisors should maintain a log of the number of completed
questionnaires received from interviewers each day. This helps to prevent lost questionnaires,
and also can be used to check interviewer productivity.
Interviewers should routinely edit questionnaires under the supervision of the field supervisor to
correct errors, omissions, or logical inconsistencies in filling them. The process is particularly
useful at the early stages of data collection, as it allows errors to be fed back to the interviewers
in order to avoid further mistakes.
Before the data process begins, a complete re-check and editing is necessary to clean the data.
2.
Categorize Responses
The first stage of data processing involves categorizing the responses. This is the process of
listing all responses to a question under clearly defined options. In structured questionnaire,
categorization is necessary for open-ended questions. For example, an answer to the question:
"Why did you choose to come here today for treatment?" , could contain possible categories such
as "accessibility", "faith in treatment", "treatment is scientific", and "referred".
The process begins by first examining the raw data to draw up a list of clearly defined responses
for each question. Each category should be precisely described in a few words. Again, the list
of categories for each question should not be too long as this can make the analysis difficult. For
each question, place similar responses under one category. The process takes the analysis a step
on to coding.
6-20
3.
Code Data
Coding involves assigning symbols to categories. Commonly, numbers are used. Coding makes
data processing easier, particularly where the ana lysis involves the use of a computer. Codes are
written on each questionnaire next to the responses. It is ideal to maintain consistency in coding
by writing the codes on one side, i.e., either left or right margin of the questionnaire, since this
facilitates speed and helps minimize errors in data entry.
For each question, if the number of categories does not exceed 9, which may be the case in most
situations, assign A1" to the first category, A2" to the second category, and so on. If the number
of categories exceeds 9, assign "01" to the first group, "02" to the second group, "03" to the third
group, and so on.
When developing a coding list, it is advisable to give the same code to common responses,
irrespective of the question, to minimize mistakes by coders.
Example:
No = ?
Yes = 1
There are no common types of missing values that must be assigned codes. Sometimes a
response is missing because the respondent did not know the answer; this is sometimes assigned
the code A8" or A88" in numerically coded questions or ADK@ in categorical systems. A response
can also be missing if the respondent refuses to answer, the interview was not finished, the item
was skipped, or for other reasons; these missing values are after assigned A9" or A99" codes in
numeric systems, or ANA@ if categories are used. When you have finished developing your
codes, compile them into a code book and ensure that there are enough copies for all coders.
During coding a supervisor must periodically review a sample of each coder's work to ensure
that coding is being done correctly.
4.
Analyzing Data
After coding, the stages of analysis will vary depending upon whether it is manual or involves a
computer. If the analysis is manual, the use of dummy tables or a master sheet is very helpful.
1.
Using data master sheets
When data are to be analyzed manually, you will need tools for organizing the coded data from
the questionnaires and aggregating them into summary tables. The data master sheet is one tool
for organizing data. This technique is particularly helpful for small samples. Basically, it is a
sheet containing the various coded responses on the questionnaire that makes it easier to tally the
individual responses by hand.
6-21
The advantage of using a master sheet is that direct counts can be done easily for coded
responses, e.g., for socio-economic and other background characteristics. It may not be feasible
to use master sheets if the questionnaire involves many open-ended responses. In such cases,
hand compilation may be more useful in order to capture the whole range of responses. Table
6.3. is an example of part of a master sheet.
Table 6.3. Example of a Data Master Sheet
Respondent ID
Sex
Age
Diagnosis
Prescriber
Drugs
No. Prescribed
Satisfaction
Antibiotic?
Inject ion?
With
drugs
Knowledge
With
care
About
diagnosis
About
drugs
1
2
3
Etc.
TOTAL
2.
Using Tally Sheets
After data have been organized on master sheets, it is easier to compute totals for individual
variables. However, the other advantage is that more complex data presentations can be
developed easily from the master sheets, such as two-way and three-way tables.
To develop a complex data presentation, it is first necessary to lay out a dummy table that will
contrast totals within categories. An example of a dummy table contrasting level of satisfaction
for patients who received or did not receive an injection by diagnosis is shown in Table 6.4.
Table 6.4. Example of a Dummy Table
Received Injection
Satisfied
No Injection
Not satisfied
ARI
Diarrhea
Malaria
Other Diagnoses
6-22
Satisfied
Not Satisfied
Once a dummy table has been laid down, each respondent=s data from the master sheet can be
recorded as a tick mark in the appropriate cell of the table. After all respondents= data are
entered, tallying the tick marks gives the totals for the sample as a whole.
3.
Using a microcomputer for analysis
If a study involves a large volume of data, it is generally easier if a computer is used for the
analysis. This will, however, also depend upon the resources available. The following steps
provide guidance on how computerized analysis would be conducted.
4.
Choose appropriate software
Various computer software programs are available for use in processing data. For most drug use
studies some of the common ones include the following:
!
Epi Info version 5 or 6.
!
spreadsheet LOTUS 123 program
!
dBase or other database management program
!
Statistical Package for Social Sciences (SPSS) or other statistical package
Before you decide on what program to use, however, it is advisable to consult an expert in the
area. In fact such a person ought to be consulted at the planning stage of writing the
questionnaire in order to pre-plan how questions should be framed, and what kind of analysis
could be done. This has the adva ntage of preventing or minimizing difficulties in analysis.
5.
Enter data
For the data to be entered into a computer, a data entry format must first be developed. This is a
screen containing the questions in the questionnaire with a space provided for entering
appropriate responses. Epi Info 6 is especially well-suited for developing data entry routines
directly from the wordprocessing files used to print the questionnaire. When this has been done,
the data are then entered into the computer in their coded form. It is fastest to have specially
trained data entry clerks do the data entry.
6.
Edit data
After all data have been entered into the computer, a verification must be done to correct errors
and omissions made in the process. Examples of such obvious mistakes may involve wrong
codes such as entering 6 as code for sex when the allowable codes for sex in most cases are 0 or
1, and so on.
6-23
To avoid or minimize such mistakes, it is sometimes possible to build checks into the program to
detect and refuse such data entry mistakes. Another option is to enter data twice and have the
computer check the equivalence of both entries.
7.
Carry Out Analyses
The great advantage of using a computer lies in its ability to do several kinds of analysis in a
relatively short time. After the data have been cleaned, you can run the analysis to obtain the
needed output. Results can be produced in the form of graphs, tables, charts, and a range of
statistical tests. You need to decide the most appropriate and useful but also interesting way of
making this presentation.
c.
Presenting and Interpreting Data
Two basic approaches are involved in the presentation and interpretation of data from structured
questionnaires. The approach is determined by the nature of the questions asked; ie., whether
they are close-ended or open-ended.
The analysis of close-ended questions, which are more or less quantitative, involves:
!
First summarizing the information in a tabular or statistical form, and then
!
Describing in words or text the information presented.
The presentation can be descriptive or analytical depending upon the purpose of the study and
the intended use of the results. Simple statistical procedures that are used in most studies include
calculating averages, percentages, proportions and ratios. As already mentioned, presentations
can be in the form of tables, graphs, pie charts and several others as best as the investigator can
manage.
Open-ended questions may also be reported as percentages if categorized and coded, but the
content of each response or categories of any particular question may also be analyzed in more
depth. As much as possible, responses that ask for knowledge, attitudes, and practices should be
described as well as quantified.
The last stage of the data presentation is interpretation. It involves explaining the underlying
reasons for the findings, and drawing implications from them. The discussion can highlight the
significance of the main findings by contrasting them with other studie s on the subject.
Based on the findings and discussion, recommendations for further action can be made. This
may involve the introduction of interventions such as health education, targeted at the
community people, or policy changes to streamline the managerial capacity of the institution(s)
involved.
6-24
d.
Writing the Report
Findings from a questionnaire study are presented in the form of a report. An outline of the final
report should ideally be developed at the initial stage of the study and reviewed after the pilot
test. The components of the final report should consist of the following:
Introduction:
Statement of problem, research objectives, rationale, scope, operational
definition, outline of the chapter.
Methodology: Research approach and method, instruments, study setting, sampling, personnel,
field work organization and supervision, mode of data analysis.
Findings :
This embodies tabulating and describing the study results.
Discussion:
Underlying reasons and explanations of the main findings.
Conclusion and
Recommendations: Inferences, suggestions, and likely follow-up interventions.
6-25
SYNTHESIZING DATA AND DESIGNING INTERVENTIONS
Chapter 7:
Synthesizing Data to Prepare for Interventions
Chapter 8:
Using the Study Results to Design Interventions
CHAPTER SEVEN
SUMMARIZING DATA TO PREPARE FOR INTERVENTIONS
The primary focus of this chapter is on how data from applied
qualitative methods may be summarized to prepare for an
intervention, especially in studies that have used multiple methods.
Following a discussion on the use of multiple methods, the chapter
describes a structured process for organizing and summarizing
data.
7.10: Using Multiple Methods
The applied qualitative methods described in this manual can be used to enrich our
understanding of the factors causing a drug use problem and of the potential barriers to
correcting it before we attempt to design and implement an appropriate intervention. Frequently
we use several methods together in a coordinated way to achieve the best understanding and to
design the strongest intervention.
As described in previous chapters, each applied qualitative method is well-suited to answer
different types of questions. In planning a study, we must decide which me thod is likely to
contribute useful information to answering each of the study questions we have identified. Often
the best results are obtained by using more than one method; the issues explored by different
methods will usually overlap or complement each other.
For example, to learn about the reasons for a high rate of antibiotic use in treating acute
respiratory infections, we decide to combine exit interviews with patients, questionnaires and
focus groups with health workers, and structured observations of clinical consultations. The
questionnaires and focus groups may both be used to look at prescriber preferences for drugs to
treat ARI, with the questionnaires aimed at understanding levels of knowledge and the
prevalence of different opinions about drugs, while the focus groups look more at underlying
reasons and beliefs. The structured observations might gather data on the adequacy of diagnosis,
treatment choice, and patient-prescriber communication, while the patient exit interviews
examine prior expectations, satisfaction with treatment, and understanding of prescribed drugs.
One way to think about summarizing the data from multiple methods is in terms of taking
photographs of objects, such as houses in a given town. Photographs can be taken from front or
back; from far away to see the houses in their setting, or from close- up to get more detail; in
7-1
daytime or at night. All the photos are true and objective pictures of the houses, but none gives
the whole story; each photo provides a piece of the truth. Only when the photos are considered
as a composite will our perception be complete. Even then we may still need to infer details
about the houses that appear in none of the photos from the features that do.
Similarly, each quantitative and qualitative method is like an individual photo. Quantitative
methods tend to take pictures from a distance, and use the same camera, held the same way, with
the same film, and the same shutter speed; qualitative methods are more concerned with close-up
and detail, and they generally give more freedom to the photographer to be inventive in his/her
use of the camera. Collecting and putting together our different research photos gives us the
most complete picture of the problem and its causes. Viewing the problem from a number of
different angles helps to increase the appropriateness and potential impact of an intervention.
Each applied qualitative method generates its own type of data, as well as its own separate
findings and conclusions. The team which implements each method may or may not know about
the findings from other methods; in fact, there may be an advantage to obtaining several
independent viewpoints by having different people implement each method. However, the use
of multiple methods results in a large volume of data, and the findings are not necessarily
compatible. It can be difficult to sort through, combine, and summarize data from individual
methods in order to draw conclusions about an optimal intervention.
There are a number of different strategies that researchers use for combining and summarizing
data from multiple studies -- there is no correct way of approaching this task. This chapter will
describe one strategy for summarizing data that is based on a process of structured interaction
among all the individuals who have been involved in planning or implementing the individual
methods. This process is organized around the set of questions you developed when the study
was first planned. If you (or the resource person assisting in this study) are familiar with another
strategy for integrating data from multiple methods, you should certainly feel free to vary the
process described here, or to use an alternate process. However, the key features of whatever
process you choose should be taking account of all the available data and staying focused on the
implications of the data for intervention.
7.20: Summarizing the data
Typically, a drug use problem is first defined in quantitative terms, e.g., overuse of antibiotics to
treat acute respiratory infections in certain health facilities, or low rates of compliance with
treatment for tuberculosis in a given region. An applied qualitative study can help us understand
in greater depth why and under what circumstances an identified problem occurs, and how we
might be able to correct it. Each applied qualitative method adds additional pieces of
information to our understanding. However, when multiple methods have been used, it can be
difficult to integrate all this information into a comprehensive overview of what we know about
a problem and its possible solutions. It helps to have an efficient process for combining and
summarizing findings; the following steps describe one process for achieving this.
7-2
a.
Hold a Data Summary Meeting
Often health managers or investigators leading a study will not actually implement the field
work. Separate individuals or teams may be commissioned to carry out each method and prepare
a report analyzing the findings. Sometimes there will be very little communication during the
field work phase between the study leaders and the implementors of each method.
One strategy for summarizing the data and findings from a multi- method study is to hold a joint
meeting of everyone involved in the study, called a data summary meeting. Such a meeting can
last from one to three days, depending on the number, scope, and complexity of the studies that
were carried out. The structure and content of the data summary meeting are reviewed below.
b.
Report Each Method Separately
To be sure that everyone at the meeting is familiar with each of the studies, the first activity
should be a presentation of separate reports by each study team. These reports can be presented
according to the format in which they have been prepared. However, each study report should
cover at a minimum: the specific study questions addressed; details of the methodology; a review
of results; and a brief discussion of conclusions. Brief written summaries of the findings, tables,
or graphs should be distributed to all participants.
It is best to limit group discussion after each individual report to clarification about methods or
results. Detailed discussion of specific findings or of their implications for intervention design
should be limited until all groups have had a chance to present their separate reports.
Sometimes findings will suggest important issues to be considered during the later discussion
about interventions. Each of these issues should be listed in a visible place (e.g., on a white
board or poster paper) as it is raised, but not discussed at length. By compiling such a list, you
can be sure that all relevant issues will be covered in the integrated discussion that will follow.
c.
List All Data Relevant to Each Study Question
You began your study by formulating a set of questions you felt needed to be answered in order
to design an intervention (see Chapter 2). Each applied qualitative method was chosen to
address a specific subset of these questions. Usually no single method can provide answers to
all the questions asked. On the other hand, many of the questions will have been addressed by
more than one method, each of which examines the question from a different viewpoint.
After individual methods and results have been presented, the next step in the data summary
process is to gather together all the data that are relevant to each individual study question.
These lists of data items will then be used to develop a unified answer to each question.
7-3
Return to the list of questions you originally prepared. Proceeding one by one through the
subtopics and the individual questions, try to assemble all of the data that seem relevant from all
of the available sources. Additional topics that were raised during the individual presentations
should be considered as separate questions within the topic where they fit best.
As each question is asked, it should be discussed at length. Everyone in the data summary
meeting is free to contribute:
!
specific findings from one or more of the qualitative studies or facts, as
represented by a quantitative result, a table, a graph;
!
quotations or anecdotes, which seem to crystallize an insight about the question
from one of the methods;
!
opinions, either personal or expressed by one or more of the respondents in a
qualitative study.
Each contribution should be written in summary form on the white board or on poster paper as it
is made, along with the source for the data (e.g., prescribing survey, focus group with physicians,
patient exit interviews, etc.). Order is not important. An example showing the data relevant to
the first study question in the Pelotas diarrhea study is presented in Table 7.1.
d.
Develop a Summary Answer to Each Study Question
When there are no more contributions of data for a question, the group should try to develop a
summary answer that reflects all the known information. As far as possible, the summary
answers should be a series of simple descriptive statements. A summary answer for the Pelotas
data presented above about differences in treatment across institutional setting is shown in Table
7.2.
Of course, it may not be possible to create a simple summary answer for every question. Often
the findings about a particular question will be complementary, but sometimes results will
contradict each other. For example, prescribers or patients may respond in a certain way to
interviewers= questions about their practices, yet an observer may see the same people acting in a
way which contradicts their responses. Contradictory findings can be useful, since they may
point to areas that need particular attention during an intervention. Such areas of conflicting or
ambiguous results should be clearly noted.
When the summary answers for all questions have been completed, you will have an organized
and compact presentation of the data in your study. You should now have a good idea whether
an intervention will be feasible, and be ready to make decisions about how this intervention
should look. However, before designing the intervention, you should familiarize yourself with
the general information on interventions presented in the next chapter.
7-4
Table 7.1 Example of Data List to Answer a Study Question
Question:
Are treatment practices the same in health centers managed by the
municipality, the university, and the state government?
Data Source
state prescribing survey
ORS
antibiotic
metronidazole
Data Item
% of cases receiving:
municipality
51%
22%
11%
university
government.
24%
49%
16%
53%
16%
31%
exit interviews
patients at the municipal and state government clinics tend to be of
lower socioeconomic status that those at the university health centers
exit interviews
a similar percentage of patients report being Asatisfied@ or Avery
satisfied@ with the care they have received in all clinics (84% in
municipality; 89% in university; 76% in state government)
patient in-depth
patients see the university physicians more as Aspecialists@ and Aexperts@
compared to other physicians
patient in-depth
patients seem to prefer the drugs they get at the university clinics
(usually brand names) but they generally do not like to go there for
Asimple@ problems like diarrhea because the fees are higher
physician in-depth
university physicians tend to see ORS as Afirst aid@ that patients can
receive at a public clinic, so they often do not bother to prescribe it
physician in-depth
physicians in municipal and state clinics report that they have been
trained in the WHO diarrhea case management protocol, but university
physicians have received no such training
observations
the waiting area and consultation rooms tend to be more crowded,
dirtier, and less comfortable in municipal clinics
observations
examination time is significantly longer in university clinics (4.7 mins)
compared to municipal (2.3 mins) or state government (2.5 mins)
observations
public health nurses were observed carrying out group health education
sessions for patients in some of the municipal and state clinics; no
sessions were observed in the university clinics
7-5
Table 7.2 Example of Summary Statement About a Study Question
Question:
Are treatment practices the same in health centers managed by the
municipality, the university, and the state government?
Summary:
Prescribing for diarrhea in municipal and state government health facilities is quite similar,
except for metronidazole. ORS (given to about half of patients) appears to be underused,
while antibiotics (about 20% of patients) are slightly overused. In state facilities, there is
considerable overuse of metronidazole (31% of patients), but the reasons for this are not
known. Examination time is very short in both settings (less than 2.5 minutes).
In university clinics, there is considerably more room for improvement in prescribing, since
many more patients receive antibiotics (49%), while many fewer receive ORS (24%). Doctors
in these clinics have not yet been trained in the WHO case management protocol. However,
there may be resistance to such a standard protocol, since doctors seem to feel they have more
advanced practices.
Patients are generally satisfied with treatment in all clinics. However, when they can afford
the fees, patients seem to prefer university clinics. Possible reasons for this include: they are
seen by the doctor for a much longer time; the staff are seen to be more Aexpert@; they receive
brand name drugs, including antibiotics; the general clinic facility is more comfortable.
Any intervention that would include a patient education component seems quite feasible.
There is already patient education taking place in the waiting area in municipal and state
facilities, delivered by public health nurses. Staff is actually more available in university
clinics, but they are not yet being used for this purpose.
7-6
CHAPTER EIGHT
USING STUDY RESULTS TO DESIGN INTERVENTIONS
This chapter deals with selecting and designing interventions.
Decisions about intervention design should be influenced by what
you know about the effectiveness of different types of intervention,
together with what you have learned about the specific problem
you are addressing and the context in which it occurs. After a brief
overview of interventions, the chapter provides guidance about
using the information you collected to design interventions.
8.10: Intervention Strategies
The ultimate objective of the applied qualitative studies described in this manual is to design an
intervention to improve an identified drug use problem. To assist in this process, you carried out
targeted studies to answer a series of questions aimed at learning more about the underlying
causes of the problem, the motivations of prescribers and consumers, and possible constraints to
changing their behaviors. Armed with this new information, you are now ready to design an
intervention that you feel will be most likely to stimulate change.
8.11: Type of Interventions
When designing interventions, there are many options to choose from and a range of factors to
consider. Before launching into the design process, it is help ful to have an overview of the kinds
of interventions that have been tried in other settings. Interventions can be broadly grouped into
three categories: educational, administrative, and regulatory. Although it helps to organize our
thinking about interventions to group them in this way, it is important to note that the most
effective interventions combine elements from all three types of intervention.
1.
Educational Approaches
Educational approaches are based on communicating information and persuading health
providers or consumers to behave in a different way. They are most helpful when knowledge
deficits, mistaken beliefs, or access to biased information are contributing causes of the observed
problem. Because the behavior and opinions of peers can be very persuasive in stimulating a
8-1
change in behavior, educational interventions are also very promising when it is possible to
facilitate learning in peer groups of health providers or patients.
Examples of commonly- used forms of education include:
!
!
!
!
2.
printed materials -- clinical literature, newsletters, advertisements, etc.
training programs -- basic, post- graduate, and in-service
face-to-face persuasive approaches, either one-on-one or in small groups
media-oriented approaches, e.g., posters, radio, tele vision
Administrative Approaches
Administrative (or managerial) approaches use processes and tools designed to guide decisionmaking by health providers or consumers. Administrative approaches can work either through
supportive processes that make it easier to perform a preferred behavior, or through barriers
against discouraged practices. These supports or barriers may include:
!
!
!
!
3.
guides for prescribing and dispensing -- limited lists of drugs, standard treatment
guidelines, clinical pathways, standard order forms, etc.
systems for improving the selection, procurement, and distribution of drugs
drug utilization review combined with feedback to providers
financial incentives -- practice budgets, patient cost sharing, drug pricing, etc.
Regulatory Approaches
Regulatory approaches are designed to restrict decision making -- to remove choices about drug
use behavior from the hands of prescribers, dispensers, or consumers and put them in the hands
of policymakers or managers. There are many possible areas of regulatory activity, including:
!
!
!
!
market controls -- banning drugs that are unsafe or of doubtful efficacy, refusing
to register products that are not cost-effective, etc.
licensing restrictions -- enforcing regulations about prescribing by non-physicia n
health workers, or pharmacy dispensing of prescription-only drugs, etc.
prescribing controls -- limiting certain drugs to particular types of prescribers,
changing products from prescription-only to over-the-counter, etc.
dispensing controls -- requiring adequate product labeling, mandated patient
counseling by dispensers, limiting the number of drugs dispensed per patient, etc.
8-2
8.12: Strengths and Weaknesses of Interventions
No intervention approach is equally effective at dealing with every problem or perfect for every
situation. In general, each of the three broad categories of intervention has its own strengths and
weaknesses, and particular interventions in each category may be more or less effective
depending on the circumstances. Table 8.1 summarizes some of the overall strengths and
weaknesses of the three basic intervention approaches.
Table 8.1: Strengths and Weaknesses of Intervention Approaches
Intervention
Strengths
Weaknesses
Educational
Approach
! works best if knowledge deficits
are an underlying problem
! best results if message is clearly
focused on specific issue
! more effective with single
individuals or small groups
! repetition and reinforcement of
messages strengthens results
! knowledge often cannot
overcome system barriers
! disappointing results with broad
messages and large groups
! can be labor intensive if there is
a large target group
! transfer of staff or counterpromotion by drug companies
can dissipate results
Administrative
Approaches
! works best when systems can be
set up to make it easier to
follow recommended behaviors
! can be used to support and
sustain educational programs
! very effective if target group
assesses own practices
! improved supervision can have
positive spin-off effects
! open to abuse if administrative
changes are not accepted by
target group
! formularies, guidelines,
protocols need periodic revision
! information systems may be
hard to establish and maintain
Regulatory
Strategy
! works best if safety is an issue,
and problem behaviors are easy
to isolate and eliminate
! frequently easy to implement
! can give powerful and rapid
results for certain problems
! best if combined with other
approaches
! frequently produces unexpected
negative results
! may be open to abuse
! often difficult to enforce
! impact difficult to measure
8-3
8.13. Caution About Regulatory Approaches
Regulatory interventions often cut with a blunt sword. Although they are frequently easier to
implement than educational or administrative interventions, they can have unintended side
effects. Examples of some of the ways regulations can fail to be effective include:
! prescribers substitute drugs that are clinically worse or more costly than the products
removed by the regulation
! consumers turn to Aunofficial@ health providers or to the black market to gain access to
banned drugs
! problem behavior changes while a regulation is in effect and enforced, but returns to old
patterns as soon as enforcement lessens
! prescribers or dispensers change their record-keeping practices to make regulatory
oversight difficult
One example of an unintended negative effect occurred in a country that banned all antidiarrheal
drugs for children. After the products were removed from the market, there was a reduction in
the use of antidiarrheals, but increases in the use of liquid antibiotic preparations and
metronidazole were also noted. It appears that prescribers had substituted antibiotics and
metronidazole, which they were allowed to use for infective diarrhea, for the antidiarrheals that
they were being educated no t to use.
Implementing a regulations without taking into account the understanding and acceptance of
prescribers and consumers may cause unwanted side effects. For instance, generics prescribing
policies are in place in public health facilities in many countries. When prescribers are not well
informed about the advantage of generics, they may not comply with generic prescribing. They
may also transfer their negative perceptions to patients, which will further jeopardize the
implementation of the policy.
In addition, withdrawing drugs without proper information to the general public can create
confusion and uncertainty for consumers, especially if they use these drugs routinely. For
regulatory actions to be effective, there is usually a need to incorporate information and
education to health providers and consumers.
8.14: Combining Approaches
Interventions are usually much more effective when they combine a number of different
approaches to attack the same problem. Education of prescribers aimed at encouraging a new
approach to treating a certain problem can be combined with posters or pamphlets aimed at
patients and consumers supporting these changes. Administrative systems like formularies,
standard treatment guidelines, or utilization review can be put in place to support the changes
targeted in an education program. Regulations that remove some drugs from the market can be
combined with education for prescribers and consumers to explain why this action was taken and
8-4
to suggest alternatives. Each of the activities in a combined intervention reinforces, sustains, and
extends the overall impacts.
For example, a successful intervention occurred in Mexico City where the treatment of diarrhea
in social security clinics was unsatisfactory. The first component of the intervention was an
educational workshop for clinic staff to develop their own treatment algorithm for this problems.
After the workshop, treatment of children with diarrhea according to the algorithm improved
from 24.5% to 51.2% of cases. For the next six months, the physicians who attended the
workshop monitored their own practice and participated in a process of peer review, which
further improved appropriate case management to 71.6%. After 18 months the improvement had
been maintained. During this period, there were only minor changes in a control group of
prescribers who had not participated in the workshops and peer review.
8.15: Making Intervention Choices
When designing an intervention, the challenge is to choose an approach that will produce the
desired changes for the least cost without any unnecessary negative consequences. Some key
factors to consider in this choice include:
! Likelihood of Success: Choose an approach that is likely to succeed based on experience
elsewhere or on your own analysis of the situation.
! Cultural and Political Feasibility: Choose programs that fit well within your cultural,
political, and bureaucratic environment.
! Technical Feasibility: The availability of technical resources like trainers or data systems
must match the requirements of the intervention.
! Cost: Interventions that require large recurrent expenditures, or where savings on drug
expenditures do not clearly exceed costs, are not likely to be politically acceptable or
financially feasible.
! Potential for Broader Impact: Interventions that can be extended to other members of the
target group, to the rest of the country, or to other drug use problems should receive
higher priority.
! Potential for Negative Impact: Interventions that might result in negative outcomes -e.g., shifts to other expensive or unsafe drugs, increases in use for other services,
diversion of patients to other providers -- should be carefully evaluated before they are
implemented on a widespread basis.
In general, no intervention is final. There is always a need for sustained effort, further
supportive measures, and additional refinements. Interventions that do not succeed immediately
can be strengthened based on information you collect during evaluation. Therefore you may
want to begin with the intervention that is limited, feasible, and relatively simple to implement,
measure its effectiveness, and then extend it in ways that are more complex or demanding.
8-5
8.20: Using Applied Qualitative Data in Intervention Design
The previous chapter described a process for systematically answering a set of questions you had
posed to gain a more in-depth understanding of a problem. From discussions at a synthesis
meeting, you and the other investigators should have a clearer idea about the causes of the
problem and factors that will encourage or discourage change. The specific problem behaviors
should be clearly defined, as should the target groups of prescribers or patients likely to gain the
most from an intervention. You may have ideas about the general style of intervention that
might be effective. However, because until this point you have been exploring the problem
rather than designing an intervention, many details and practical issues may still be unclear.
You must now focus on using the information gained during your applied qualitative study to
design the details of an intervention. If time permits, you can begin this process as the last
activity in a synthesis meeting, so that the individuals involved in the applied qualitative studies
can contribute. However, that setting and group of people included in such a meeting may not
always be appropriate for this task. In addition, some aspects of intervention design may require
additional fact- finding or discussion with others who were not part of the applied qualitative
studies. Depending on your own situation, decide how best to undertake the activity described
below.
Table 8.1 contains a list of issues that you should consider when designing an intervention. For
interventions that will have an educational component, the issues involve: (1) defining target
groups and target behaviors; (2) selecting the best educational approach and materials; and (3)
implementing the educational program. For administrative approaches, the issues to consider
include: (1) the appropriateness of various supportive administrative systems, such as
formularies, clinical guidelines, audit and feedback, reminders, supervisory programs,
incentives, etc.; and (2) strategies for implement ing administrative changes effectively. When
considering regulatory changes, important issues include: (1) strategies for promoting positive
changes following regulation and for minimizing unintended negative impacts; and (2)
implementation monitoring and enforcement. Finally, for all interventions, whatever the mix of
approaches, one key topic to consider during intervention design is monitoring, evaluation, and
dissemination of results.
One way to proceed with the intervention design process is to systematically consider each of the
questions in Table 8.1. These questions address a large number of design decisions ranging from
the early stages of intervention planning through implementation and evaluation. Determine if
each of the issues is relevant to your situation, and if so, how you will account for the issue
during intervention design. Refer throughout this process to the data lists and summary
statements you prepared during the synthesis session, since these should give you concise
answers to many of the major issues to be dealt with during intervention design.
8-6
Table 8.1 Issues to Consider in Designing an Intervention
Type
Educational
Interventions
Questions to Consider
Target Group and Target Behaviors
! Who is the target group for the intervention?
! What behaviors are expected to change and what alternatives will be
recommended?
! What specific knowledge deficits are associated with problem
behaviors?
! Why should target group members adopt the new behaviors?
! How will the members of target group be contacted?
! How will the objectives of the intervention be explained?
Educational Approach and Materials
! What is the best educational format: self- learning, one-on-one, small
groups, seminar?
! How can peer relations or opinion leaders be used to facilitate change?
! What are the main intervention messages?
! How can communication between health workers and patients be
improved?
! What print materials will be used to deliver the educational messages?
! Who will prepare printed materials?
! How and with whom will printed materials be pre-tested?
Implementation
! Who is the most credible sponsor of the educational/training program?
! Who will conduct the actual educational/training activities?
! How will the educators/trainers be trained?
! Who will plan and schedule the educational/training activities?
! Where will the educational/training sessions be carried out?
Administrative
Interventions
Designing Administrative Systems
! Would implementation of formularies, limited drug lists, or clinical
guidelines help to change practice?
! What incentives can encourage health workers to use formularies or
clinical guidelines?
! Do prescribing and dispensing practices very widely among health
workers or facilities?
! Are health workers aware of how their own practices compare with
those of their peers?
8-7
Type
Questions to Consider
! What would be the best way to collect and feed back data to health
providers about comparative practice?
! Are some poor practices due to forgetfulness by prescribers or failure to
consider alternatives?
! How could reminder systems be used, e.g., management information
systems, structured order forms, etc.?
! How can the supervisory system or self- monitoring be used to foster
and sustain improvement?
! How does the system or promotion or evaluation influence practice?
! Are there physical or infrastructural limitations that will prevent
change?
! What is the influence of financial incentives on practice?
! Do consumers have sufficient information about drug pricing to guide
their decision making?
Implementation
! What training will be needed for the prescribers and dispensers who
will be using the new systems?
! What training will be needed for the staff expected to implement and
monitor the planned systems?
! If formularies, drug lists, or clinical guidelines will be used, who will
participate in their development and how will they be kept up to date?
! What supporting printed materials are required?
! How can positive changes in practice be reinforced over time?
Regulatory
Interventions
Impacts of Regulatory Changes
! Are there existing regulations that contribute to problem practices?
! Which specific regulations need to change to improve practice?
! Would limiting access to certain drugs improve their use?
! What would be the impact of removing problem drugs from the
market?
! How are providers and consumers likely to respond to the proposed
changes in regulations?
! If access to certain drugs is restricted, which drugs (or other services)
are likely to be substituted?
! What is the potential for shifts in utilization as a response to regulatory
changes, e.g., more use of traditional providers, increase in sales on the
black market, bypassing of the referral system, etc?
Implementation
8-8
Type
Questions to Consider
! Which educational programs are needed to explain regulatory changes
to health providers and consumers and prevent unintended effects?
! Would active enforcement of regulations improve practice?
! Which staff are available to enforce compliance with regulations?
! How will responses to regulatory changes be monitored?
All
Interventions
8.30.
Monitoring, Evaluation, and Dissemination
! Who will supervise the implementation of the intervention?
! What data systems need to be developed to monitor changes in
practice?
! Who will collect and assess monitoring data?
! Who will be responsible for evaluating the impacts of the
intervention??
! What are the key outcome measures?
! When and how will outcome data be measured?
! What data will be collected to measure implementation cost, efficiency,
and cost-effectiveness?
! When will the target groups be informed about results?
! Who will prepare the report evaluating the intervention, and when?
! How will results of the intervention be disseminated to policymakers?
EVALUATING THE IMPACT OF INTERVENTIONS
Evaluating whether an intervention achieves its desired impact -- i.e., improving use of drugs in a
cost-effective manner -- is often neglected. In many situations, interventions are implemented
without prior field testing to demonstrate their effectiveness in the existing system. This risks a
waste of financial and human resources and may further increase the burden of health care
services. It is wrong to assume that if an intervention takes place, its behavior change objectives
have been accomplished. For example, the fact that clinical guidelines for primary care facilities
are produced does not mean that prescribers will utilize the guidelines, or that prescribing
practices will improve.
Evaluating impacts is an important component of any intervention strategy. The following
points should be considered in designing an evaluation:
!
An evaluation plan should be developed along with the implementation plan.
Before any intervention is disseminated widely, it is imperative to test whether it
can be successfully implemented in the local health care setting.
8-9
!
Impacts of an intervention should be evaluated according to the most relevant
behaviors and messages targeted. Depending on the objectives of the
intervention, evaluation measures may include changes in knowledge or
perceptions about a specific practice, the process of care, the types of drug
prescribed, the cost of prescribing, changes in clinical outcomes, and so forth.
Indicators should also be selected according to their reliability and the feasibility
of collecting the required data.
!
Valid evaluation of impacts requires appropriate methodology. At a minimum,
this usually includes measuring outcomes before and after an intervention, and
comparing changes in a group which receives the intervention with changes
during the same period in a comparison group which does not.
!
Long-term sustainability of the impacts of an intervention is always desirable.
Changes observed immediately after an intervention has taken place often
disappear after a period of time unless there is repetition and reinforcement of the
intervention messages. For this reason, it is useful to measure key outcome
indicators again after a longer period has elapsed (1-2 years) to be sure that
positive changes are sustained.
8-10
ANNEX A:
1.
SAMPLING TECHNIQUES
Non Probability Sampling Methods
There are two common types of non probability sampling, namely convenience or purposive
sampling and quota sampling.
a.
Convenience Sampling
Convenience sampling is that in which the study units that happen to be available at the time of data
collection are selected for purposes of convenience. Most clinic based studies use this method. It
is the common method for selecting participants to a focus group discussion.
b.
Quota Sampling
Quota sampling is used when it is considered that convenience sampling would not provide a
desired balance of study units. For example when assessing patient understanding of how to take
drugs, a quota sample could be used to ensure that both males and females are covered in the
study.
Non probability sampling methods are less representative than probability sampling methods and
thus inappropriate if the objective of a study is to generalize findings. They are often used in
qualitative methods because of their flexibility in adapting to local situations and settings.
2.
Probability Sampling Methods
Probability sampling techniques are those that involve the random selection of study units by
chance. For this to be possible, a sampling frame must exist. There are a number of probability
sampling techniques and any of them could be used in a study depending upon the study problem
and the purpose of the study. These comprise;
Simple Random Sampling (SRS)
a.
Simple Random Sampling (SRS)
This is the simplest form of probability sampling. It involves:
! making a numbered list of all units in the study;
! deciding the size of your sample;
! choosing the number you require.
1
For example, suppose we are faced with a problem of selecting 60 households in a community of 360
households to learn more about their attitudes towards the use of antibiotics in cough. We could proceed
by first giving each household a number. These numbers are then written on small pieces of paper and
placed in a box. Numbers are then picked from the box up to the required total, making sure that that the
box is well shaken each time to ensure the principle of equal and random selection.
b.
Systematic Sampling
The principle involved in using this method is similar to the SRS, but with an added condition that the
selection of units is based on regular intervals starting from a determined point. To use the example above,
we can obtain our interval by dividing 360 by 60 which gives 6. Once the sample interval has been
determined, the first unit is then drawn between 1 and 6.
Afterwards, every sixth case must be drawn until the total sample of 60 has been drawn.
The technique is particularly useful where large numbers are involved such as the sampling of prescription
records. For instance, if we need 30 prescriptions from a register in a health facility which contains 50
pages of 25 lines per page, the sampling interval must be calculated by dividing the product of 50 and 25 by
30 to obtain 41.7. Based on this figure, every 42nd prescription would be selected for the study.
c.
Stratified Sampling
This is an alternative method to systematic sampling and preferable where the sampling frame contains
distinct populations. For example, assuming our antibiotics study covers an entire district, it would be
necessary to ensure that both rural and urban facilities are adequately covered. This would not be possible
using the SRS or systematic sampling techniques.
Alternatively, using a procedure that groups study units who are similar in certain characteristics into strata
ensures that all relevant groups are appropriately covered. In drug use studies stratified sampling could be
used to sort facilities into various levels of care, i.e., community clinics from health centers and both from
district hospitals. When the method is used, the final stage of selecting the units is also based on the
principle of equal selection by chance.
d.
Cluster Sampling
Assuming our district is a large one with a landscape that makes travelling around facilities difficult, then
cluster sampling offers a better alternative. This involves selecting clusters or groups of study participants or
units rather than on individual basis. Clusters may be villages or families or a specified group of patients or
2
providers.
For example, if we want to select two facilities for study in a geographically difficult area, then we could
select a cluster of two facilities by randomly selecting a single facility and then selecting another one close to
it. The method saves time in data collection.
e.
Multi-Stage Sampling
This is a combination of all the methods described above and is very useful if the purpose of the structured
observation method is to generalize study results from diverse populations. As the name implies, it involves
sampling in two or more stages as follows:
1.
2.
3.
4.
Forming clusters and selecting a random sample of these.
Making a separate list of all study units within each of the selected clusters.
Selecting study units separately from each cluster in the sample.
Interviewing selected study units.
For example, if we intend to select 12 health facilities in a district with 36 facilities, we can first group them
into the various clusters or levels of health care such as community clinics, health centers, and hospitals. We
can then randomly select our 12 facilities from the 3 groups. This is two-stage sampling. If we want to
select 30 prescriptions from each facility, we can continue from this stage with the process described in
selecting every 42nd prescription under systematic sampling. This is three-stage sampling.
3
ANNEX B:
BIBLIOGRAPHY
GENERAL
Laing RO., "Rational Drug Use: An Unsolved Problem" Tropical Doctor,Vol ? 1990.
Hudelson PM., Qualitative Research for Health Programmes. 1994, WHO/MNH/PSF/94, Geneva.
Heggenhougen K, Draper A. Medical Anthropology and Primary Health Care. 1990, London School of
Tropical Medicine and Hygiene, London.
Varkevisser CM, Pathmanathan I, Brownlee A, (1993) Designing and Conducting Health Systems
Research Projects. Health Systems Research Training Series, Vol. 2 Part 1, Ottawa
Lutz, W. (1986). Planning and Organizing a Health Survey. International Epidemiological Association,
Switzerland.
4
CHAPTER 3:
IN-DEPTH INTERVIEW
1.
PATH. Developing health and family print materials for low-literate audiences: a guide. PATH,
1988; pp. 17-18.
2.
UNICEF. Baseline data for FGN/UNICEF 1991/95 country program: Manual for rapid
assessment procedures. UNICEF, 1991; pp. 1-5.
3.
World Health Organization. How to investigate drug use in health facilities: selected drug use
indicators. Geneva: World Health Organization, 1993 (WHO/DAP/93.1).
FURTHER READINGS
4.
Scrimshaw SCM, Hurtado Elena, (1987). Rapid Assessment Procedures for Nutrition and
Primary Health Care: Anthropological Approaches to Improving Programme Effectiveness, pp. 1112.
5.
Kashyap P, Young RH. (19??). Rapid Assessment of Community Nutrition Problems: a Case
Study of Parbhani, India, pp. 3-5.
6.
Forcese DP, Richer S. (1973). Social Research Methods. Englewood Cliffs NJ: Prentice-Hall,
Inc., pp. 168-177.
7.
Lockerbie L., Lutz W., (1986) Questionnaire Design, International Epidemiological Association,
Switzerland.
8.
Hepburn W., Lutz W., (1986) Interviewing and Recording, International Epidemiological
Association, Switzerland.
5
CHAPTER 4:
FOCUS GROUP DISCUSSION
Varkevisser CM, Pathmanathan I, Brownlee A, (1993) Designing and Conducting Health Systems
Research Projects. Health Systems Research Training Series, Vol. 2 Part 1, Ottawa
Scrimshaw SCM, Hurtado E. Rapid Assessment Procedures for Nutrition and Primary Health Care. 1987,
University of California Press, Los Angeles
Dawson S, Manderson L, Tallo VL., The Focus Group Manual. 1992, World Health Organization,
Geneva.
Bernard HR. Methods in Cultural Anthropology. 1988, Sage Publications, California.
Stewart DL, Shamdasani PN. Focus Groups, Theory and Practice. 1990, Sage Publications, California.
Folch-Lyon E, Trost JF. "Conducting Focus Group Sessions." Studies in Family Planning Dec. 1981;
12(12):443-448.
Heggenhougen K, Draper A. Medical Anthropology and Primary Health Care. 1990, London School of
Tropical Medicine and Hygiene, London.
Peelers RF. Methodology of Health Behavior Research. 1989, Esoc. Publication Nr. 19;
Program for Appropriate Technology in Health (PATH). Focus Group Discussion Use in the Preparation
of Materials. [DATE??] Washington DC.
6
CHAPTER FIVE:
STRUCTURED OBSERVATION
OTHER READINGS
Grady KE, Wallston S., Reasearch in Health Care Settings. Newbury Park: Sage, 1991.
Oladepo O, Oyejide CO, Oke EA., "Training Field Workers to observe Hygiene-related behaviour."
World Forum 12, 1991.
Nietzel MT, Bernstien DA, Introduction to Clinical Psychology. Englewood Cliffs, NJ: Prentice Hall, 1987.
Varkevisser CM, Pathmanathan I., Brownlee A., Designing and Conducting Health Systems Reasearch
Projects, Vol. 2, Part 1. Ottawa: IDRC, 1993.
7
CHAPTER SIX:
1.
STRUCTURED QUESTIONNAIRE
World Health Organization (1993). How to Investigate Drug Use in Health Facilities: Selected
Drug Use Indicators. Geneva: (WHO/DAP/93.1).
Additional Readings
Abrahamson, J.H. (1979). Survey Methods in Community Medicine. Churchill Livingstone, Edinburgh,
114-115.
Selltiz, C, Wrightsman, L.S., Cook, S.W. (1976). Research Methods in Social Relations. Holt, Rinehart
and Winston; New York, 542-557.
Denzin, N.K. (1970). The Research Act in Sociology. Aldine Publishing Company, Chicago.
Varkevisser, C.M., Pathmanathan, I., Brownlee, A. (1993). Designing and Conducting Health Systems
Research Projects, Vol. 2, Part 1. International Development Research Centre, Ottawa.
Hepbun, W., Lutz, W. (1986). Interviewing and Recording. International Epidemiological Association,
Switzerland.
Lockerbie, l. Lutz, W. (1986). Questionnaire Design. International Epidemiological Association,
Switzerland.
Lutz, W. (1986). Planning and Organizing a Health Survey. International Epidemiological Association,
Switzerland.
8
ANNEX C:
EXAMPLES OF MODERATOR=S GUIDES FOR IN-DEPTH INTERVIEWS
Example 1:
Bangladesh Diarrhoea Study - In-Depth Interview Guide for Administrators
Example 2:
Bangladesh Diarrhoea Study - In-Depth Interview for Prescribers
Example 3:
Nigeria Malaria Study - In-depth Interview for Prescribers
Example 4:
Nigeria Malaria Study - In-depth Interview for School Teachers
Example 1:
Bangladesh Diarrhea Study - In-depth Interview Guide for Administrators
Introductory Remarks
I am _______________ from _____________________
General purpose of the study
Aims of the interview
How long it will last
Any questions?
Warm Up
How long have you been the administrator of this thana health complex?
Could you please give a brief description of your daily activities?
Probe : Time spent in patient care;
Private practice after hours
Extent of Diarrhoeal Problem and Felt Concern about it
How serious a problem is diarrhoeal disease in your thana (at this time)?
Probe: Severity of the child's condition
Describe a typical case
What proportion needs hospitalization
Criteria for hospitalization
How frequently cases arrive very late
Extent and sources of worry
Mothers Perception of Diarrhoea and Education About Diarrhoea
At what stage of the disease do mothers bring their children here for treatment? How much distress do these mothers
feel when they bring in the child?
Probe: Why they do wait so long?
What do they try at home first?
At home, what can mothers do that would improve the way that diarrhoea is managed?
Probe: Continue breast feeding;
Home made ORS
Early start to management
What activities are currently carried out by this thana health complex to promote/improve diarrhoea management at
home by mothers?
Probe: How do mothers feel about ORS as a main treatment?
Do they like it/Why/Why not?
ANNEX C - 1
Attitudes towards Prescribing for Diarrhoea
What are the main factors that influence the decisions that prescribers make in relation to diarrhoeal diseases?
Probe: Patient's condition?
Previous drugs already started taking?
Whether expect mother to return for follow up?
Mothers demand for specific drugs?
Do you feel that certain patients with diarrhoea need antibiotics for treatment?
Probe: Which ones?
Advantages and disadvantages of antibiotics?
Many M.Os also have a private practice after they finish work at the thana. In what ways does the M.O.s prescribing
practices for private patients influence how they prescribe at the thana?
Probe: What influence do "Medical Reps" have in the M.O.s prescribing practices?
Administrator's Role in Management of Diarrhoeal Cases
For diarrhoea cases, what are the major problems you face in providing effective services at this Thana ?
Probe: How can these major problems be solved?
What do you think are the most effective ways for influencing the way medical officers prescribe for diarrhoeal
cases?
Probe: Do you have discussions with them?
What issues do you discuss with them?
What role do you see for pharmacists?
How can pharmacists give feedback to prescribers?
Comments
Are there any other major influences on prescribing for diarrhoea that we have not talked about? What are those?
CLOSE: Thank administrator for his/her comments.
ANNEX C - 2
Example 2:
Bangladesh Diarrhea Study - In-depth Interview for Prescribers
Introduction
I am _________________________ from ________________________.
General purpose of the study
Aims of the interview
How long it will last
Any questions?
Knowledge About Diseases In The Community
What are the most commo n diseases/illnesses reported by patients in this health facility?
Probe: How about diarrhoeal diseases? (If not mentioned)
How common is it in relation to other common diseases?
Nature Of Diarrhoeal Cases
Can you describe to me the characteristics of patients who usually suffer from diarrhoeal diseases?
Probe: Age, socio-economic status
Housing and water supply
What is the usual condition of children with diarrhoea when they come to see you?
Probe: Some types of diarrhoea more severe than others?
Some types of children worse than others?
Do you have any concerns about this?
Knowledge About Mothers= Perception of Diarrhoea
What do mothers think about diarrhoea when their children get it.
Probes: What are their anxieties?
What feeding practices do they adopt/observe (i.e., breast feeding, home-made fluids)
Do they use medications before seeking treatment?
Capacity for Diarrhoea Case Management
Do you think this facility is adequately equipped for diarrhoeal case management?
Probes: Is there a standard treatment guideline?
Investigation facilities
Sources of obtaining new information on case management
Have you had any special training in diarrhoea management?
Probe: When was the training?
What were the contents of the training?
Any comment on usefulness and adequacy of training?
ANNEX C - 3
Diarrhoea Management Strategies
How do you treat a "typical" diarrhoeal case?
Probe: Do you feel confident treating diarrhoea with only ORS?
Why or why not?
What are some of the drugs you normally use and why do you use them?
Probe: How about antibiotics?
Anything to stop the diarrhoea?
What kinds of things influence you to use other drugs besides ORS in managing diarrhoea?
Probe: Any specific clinical signs?
Length of recovery
Concern for patients expectations?
Does patient load play any part in this?
Staff Functions and Relationships
How do the different members of the staff contribute to patient (curative) care?
Probes: Head of facility
Other prescribers
Pharmacists
Can you think of ways that other staff might contribute more to care for diarrhoea?
Probe: What are some of the shortfalls?
Who has time available to spend with patients?
Promoting ORS
What suggestions do you have for promoting the use of ORS in treating watery diarrhoea?
Probe: Among prescribers
By mothers
By drug sellers
In the community.
Comments
Is there anything else important you can think of about treating diarrhoea that we have not talked about?
CLOSE: Thank health worker for his/her comments.
ANNEX C - 4
Example 3:
Nigeria Malaria Study - In-depth Interview for Prescribers
INTRODUCTORY REMARKS
I am _______________ from _____________________
You are? _________________________________________________________
We=ve been told that malaria is one of the common health problems in this area. We are interested to know more about your view
about malaria and how you manage it. We are also interested in any problems or concerns you might have. We would appreciate
it if you could spend about 20-30 minutes with us discussing malaria treatment. Is this okay with you?
Do you have any questions?
WARM UP
What is your position here?
How long have you been working here?
Do you have a heavy work load? How many patients would you say you see in a week?
On average, about how many patients a week do you end up treating for malaria?
DIAGNOSIS
How do malaria cases usually present here? What kinds of symptoms do patients usually have?
Probe: Any other way they present?
How do you decide that patients presenting this way have malaria?
Probe: Questions asked in history
Physical examination - temperature blood smear
How do you decide if the malaria is mild or severe?
How do you decide about whether a patient needs to be hospitalized?
Probe: Any specific clinical signs?
What percentage of cases need hospitalization?
Do you get cases arriving very late?
TREATMENT AND COST
How do you usually treat mild malaria?
Probe: What would a typical prescription look like How many drugs/injections do you prescribe?
What are they?
ANNEX C - 5
Why do you recommend this treatment/combination of treatments?
Probe: Any concerns about drug resistance?
Preference for injections?
Patient preference
How do you usually treat severe malaria?
Probe: What would a typical prescription look like How many drugs/injections do you prescribe?
What are they?
How much does it cost to treat a typical case of malaria?
Probe: What about a serious case?
Are patients able to afford this cost?
Are patients able to get the drugs they need here most of the time or do they have to go elsewhere?
Probe: Which drugs are not available?
Why are those drugs not available?
Where do patients go to get these drugs?
PATIENT EXPECTATIONS
Do you think that patients expect a specific treatment of malaria from you?
Probe: What kind of treatment?
Any injections expected?
Why do they feel this way?
COMMENTS
Is there anything else that we have not covered that you can tell me about malaria and how you treat it?
CLOSE: Thank you.
ANNEX C - 6
Example 4:
Nigeria Malaria Study - In-depth Interview for School Teachers
INTRODUCTORY REMARKS
I am _______________ from _____________________
You are? _________________________________________________________
We=ve been told that malaria is one of the common health problems in this area. We are interested to know more
about the views of community members about malaria, and your experience with it as a teacher. We are also
interested in any problems or concerns you might have. We would appreciate it if you could spend about 15-20
minutes with us discussing malaria. Is this okay with you?
I would like to go over some of the general rules for our conversation.
There are no correct answers
Want your opinions
Confidentiality
Minimal interruptions
No observers
Do you have any questions?
WARM UP
What is your position here at the school?
How long have you been working here?
Probes: How long living in this area?
Where is your home area?
Do you think that malaria is an important problem in this school and in this area?
COMMUNITY PERCEPTION OF MALARIA
Can you describe to me some of the things that people in this community believe about malaria?
Probes: What do they think causes the disease?
What is your view on this?
How do people in this community know when someone has malaria?
What is your opinion about this?
Do you think most people have a good idea of when they have malaria?
Do people here do anything to try to prevent malaria?
Probes: Do they take any herbs of drugs to prevent getting the disease?
Use bednets?
Use insecticides?
Any environmental sanitation?
ANNEX C - 7
Avoid going out at certain hours?
MALARIA TREATMENT
I am interested in what someone usually does when they think they have malaria. What do people do first?
Probe: What are the reasons for these actions?
Does everyone do that?
What do they do next if that does not work?
How do people treat malaria in this community?
Probes: What type of treatment do people prefer for malaria when they go to the health centres?
Name/colour/taste of tablets preferred.
Do they have any preference between injections and tablets?
Why?
What are some of the home remedies people use in treating malaria?
Probes: Which are the most popular?
Which are the most effective?
When do people use home remedies rather than drugs?
When people go to a government clinic or hospital to treat malaria, what do they expect?
Probes: Are their expectations usually fulfilled?
If not, what would they do?
How about you?
Are people given enough information on how to take medicine when they go to the clinic?
Probes: What are some of the things they are not told?
Who do you think should be telling them these things?
How could this be improved?
COMMENTS
Are there any suggestions or comments about malaria that we haven't yet talked about which you want to discuss?
CLOSE: Thank you.
ANNEX C - 8
ANNEX C1: Example of Interview Guide for Mothers at OPD Assessing Use of Antibiotics in
Treatment of Respiratory Infections
Introduction: As in the interview guide for the prescribers.
General Background: Mother and community.
Interview Start: Could you please tell me what treatments are available in the community for treatment of
colds in young children. What about your educational background, age, number of children alive, marital
status etc. ... Just to tell me a little bit about your status.
Community Perception of Causes of Respiratory Infection: As a care giver to young children and a
member of this commuknity, what do people here believe causes respiratory infections in young children?
What about your own belief? How do you know a child has respiratory infection? What specific signs are
there for each type of respiratory infection?
Treatment Of Respiratory Infections In Children:
What treatments are available in this community for treatment of colds in young children?
Probe: The types of treatment mothers prefer most? What traditional remedies are available in community?
Ask about popular home remedies used by people. At what stage in the course of the ailment do mothers
or care givers take their children to the clinic/hospital or contact modern orthodox health facility?
Probe into:
*
*
*
*
*
*
Types of treatment given by clinic/doctor.
Kinds of drugs/tables or injections given - provide names or descriptions.
Medications given for treatment of mild, severe colds in children.
Perception of mothers on effectiveness of the drugs?
Mothers' expectations from different courses of treatment - what about antibiotics (use
local concepts and terminologies).
Medications mothers prefer for (a) mild (b) severe colds.
Cost of Treatment (Medications) of Colds in Children:
*
*
*
*
How much do you have to pay for a typical treatment of episode of respiratory infection of
your young child? What about payment for (a) antibiotics (b) other drugs.
What about costs of treatment of severe colds for your child? What differences occur in
prices or payment in a government and private clinic?
Are mothers able to afford the costs?
What difficulties are experienced by mothers over payment for medications?
9
Dispensing Process: From your experience, do mothers get prescribed drugs at the clinic pharmacy often
or most of the time?
*
*
*
What sources do mothers rely on most for drug supply when they visit government clinics?
What other sources?
Do mothers get specific instructions on how their children should use prescreibed drugs?
What instructions?
Suggestions: Is there any point you still want to elaborate upon on how children are treated for episodes
of colds? What suggestions do you have for improvement of health care for children in the community, at
clinic? Any other comments?
Close: Expression of appreciation.
Note: The draft interview guides can be discussed with colleagues or preferably proof-read by them
before a training session with interviewers to ensure its test of suitability.
10
ANNEX C2:
The following are draft outlines of protocols for observation of the prescribing and dispensing processes.
Most will come from direct observation. Some will need to be filled in at the end of the visit or end of the
day from the patient record.
CLINICAL PROCESS OBSERVATION FORM
IDENTIFYING INFORMATION
Sequence #:
Health Facility: ___________________________________ Date:
Patient Age:
Provider Type:
<5
5-12
Doctor
over 12
CMO
DIAGNOSTIC COMMUNICATION
Sex:
Nurse
Prescriber
Asks
Length of current problem episode?
Presence of:
fever?
headache?
malaise?
muscle weakness?
loss of appetite?
chills?
vomiting?
bitter taste?
Patient mentions malaria?
Previous treatment for this episode?
Any previous drugs taken this episode?
Last time treated for malaria?
Name of drug used to treat last time?
Patient finished last course of treatment?
Comments
11
Patient
Volunteers
Not
Discussed
EXAMINATION
Yes
Does Not
Apply
No
Temperature measured?
Patient touched for fever?
Pulse felt?
Conjunctivitis/Sclera of eye examined?
Tongue examined?
Listens to chest?
Palpates abdomen?
Comments
TREATMENT
Yes
No
Does Not
Apply
Yes
No
Does Not
Apply
Injection given
(If injection) Sterile technique followed
Advised lab test?
Advised exam at different facility?
Advised return visit if not better?
Comments
COMMUNICATION
Patient asks for:
injection?
chloroquine?
halofantrine?
Provider explains how to use drugs?
Provider offers advice on malaria prevention?
Provider offers nutrition advice?
Comments
12
PROVIDER-PATIENT INTERACTION
Yes
Patient greets prescriber?
Prescriber greets patient?
Friendly conversation?
Provider gives reassurance to patient?
Patient encouraged to describe problem freely?
Doctor listens to responses?
Provider ends encounter abruptly?
Patient appears to want more information?
WRAPUP
Observer: ___________________________
Length of consultation (mins):
Notes:
13
No
Does Not
Apply
DISPENSING OBSERVATION FORM
IDENTIFYING INFORMATION
Sequence #:
Health Facility:
Patient Age:
Date:
<5
5-12
over 12 Sex:
COMMUNICATION
Dispenser
Initiated
Patient
Initiated
Not
Discussed
No
Does Not
Apply
Description of drugs dispensed?
Instructions on how to take drugs?
Cautions, side effects mentioned?
Information about prevention/care?
DISPENSING ACTIONS
Yes
(If injection) Sterile technique followed
Drugs labeled with (Check one or more):
Patient name
Drug name
How to take
No label
Type of package in which drugs dispensed (Check one or more):
Plastic/glass bottle
Folded Paper
Plastic bag
None
WRAPUP
Observer: _____________________________
Length of dispensing process (seconds):
Notes:
14
Envelope
ANNEX C.3:
EXAMPLE OF QUESTIONNAIRE
Study Title:
AN ASSESSMENT OF THE OUTPATIENT CARE PROCESS IN SELECTED HEALTH
CENTERS
Specific Objectives:
1. To estimate the proportion of outpatients adequately during consultation.
2. To assess the dispensing process at the health centers.
3. To identify the main reasons for patients' satisfaction/dissatisfaction with the treatment received.
PATIENT INTERCEPT INTERVIEW
(Introduction)
1.
What is the main complaint/ailment for which you have come here to seek treatment?
2.
Is this your first visit for this ailment?
(1) Yes (Skip to Q.4)
3.
How long ago was your last visit?
.....days
4.
(2) No
.....months before
Did you consult any practitioner for this episode of illness before coming here?
(1) Yes
(2) No (Skip to Q.6)
5.
Whom did you consult? (Probe to specify type of practitioner)
6.
Has the doctor of this facility told you the name of the disease?
15
(1) Yes
(2) No (Skip to Q.8)
7.
What is the disease/diagnosis? (Skip to Q.9)
8.
Did you ask the doctor the name of your disease?
(1) Yes
(2) No
9. Did the doctor physically examine you?
(1) Yes
(2) No
10. Do you feel that physical examination was necessary to diagnose your disease?
(1) Yes
(2) No
11. Did you have the chance to fully describe your illness to the doctor?
(1) Yes
(2) No
12. Did the doctor advise any laboratory test?
(1) Yes
(2) No
13. How many drugs did you receive from this facility?
.......... (Check the patient's prescription)
14. Did the doctor here give you a prescription for a drug that you must buy outside of this facility?
(1) Yes: How many? ........ (Number)
(2) No (Skip to Q.15)
15. Did the pharmacist explain to you how to take the drug?
(1) Yes
(2) No
16
16. Would you please tell me how to take the drugs?
(Look at the prescription and compare patient's answer)
1st Drug
(1) Correctly stated
(2) Not correct
2nd Drug
(1) Correctly stated
(2) Not correct
3rd Drug
(1) Correctly stated
(2) Not correct
17. Would you please rate your satisfaction or dissatisfaction with the treatment you have received?
(1) Highly satisfied (Skip to Q.19)
(2) Satisfied
(Skip to Q.19)
(3) Okay
(Skip to Q.19)
(4) Dissatisfied
(5) Highly dissatisfied
18. What are the main reasons for your dissatisfaction?
(Record maximum three reasons)
(1)
(2)
(3)
19. Will you visit this health facility again in case of sickness?
(1) Yes
(2) No
20. Do you have any specific complaint about any aspect of the health facility?
(1) Yes
(2) No (Skip to Q.22)
21. What is your complaint?
22. Do you have suggestions on how to improve patient care?
17
(1) Yes
(2) No (Skip to Q.24)
18
23. What are these suggestions?
(Record maximum three suggestions)
(1)
(2)
(3)
24. Do you have any other comments on the facility?
(1) Yes
(No) (Stop interview; thank patient)
25. What are your comments?
(1)
(2)
(3)
Stop interview and thank patient.
Name of Interviewer:
Signature:
Date:
19
ANNEX D:
EXAMPLES OF MODERATOR=S GUIDES FOR FOCUS GROUP DISCUSSIONS
Example 1:
Bangladesh Diarrhoea Study - Moderator's Focus Group Guide for Prescribers
Example 2:
Bangladesh Diarrhoea Study - Moderator's Focus Group Guide for Pharmacists
Example 3:
Bangladesh Diarrhoea Study - Moderator's Focus Group Guide for Mothers
Example 4:
Nigeria Malaria Study - Moderator's Focus Group Guide for Nurses
Example 5:
Nigeria Malaria Study - Moderator's Focus Group Guide for Community Members
Example 6:
WHO/CDD Drug Sellers Study - Moderator's Focus Group Guide for Drug Sellers
Example 1:
Bangladesh Diarrhoea Study - Moderator's Focus Group Guide for Prescribers
1.
Introduction
[Narrative welcoming participants, describing the reasons for the discussion, and setting up the general
ground rules for the session].
2.
Diarrhoeal Disease as a Problem
First, I would like to know a bit about the type of diarrhoea cases you commonly see. How would you
describe them?
3.
3.1
Diagnosis and Treatment of Diarrhoea by Prescribers
Can we talk about how you also deal with diarrhoea cases starting with diagnosis. What do you depend on
for diagnosis of diarrhoea?
Probe: Do you depend mostly on clinical features.
What investigations do you think are necessary in these cases?
How often are these done?
3.2
Use of ORS by prescribers
How do you feel about ORS as a way of treating diarrhoea?
Probe: Do you always prescribe ORS?
Why or why not?
For what kinds of cases does ORS work best?
Are there cases when ORS is not enough or not necessary?
Are there times when there is no supply of ORS?
If so, what do you do then?
4.
Use of other Drugs in Diarrhoea Treatment
I would like to talk about other drugs for treating diarrhoea. Can you tell me a bit more about the other drugs
that you sometimes use?
Probe: What are the names of some of these drugs?
Why do you use those particular drugs?
How do you decide when to use them?
When you are treating children, what are the advantages and disadvantages of using:
* antibiotics?
* metronidazole?
* antidiarrhoeals?
* injections? (IV fluid)
Are there any other useful drugs we have not talked about?
What guideline do you follow for prescribing in diarrhoeal cases?
5.
Knowledge of Health Workers about Mothers'
Perceptions of Diarrhoea
I would like to know something about the mothers who come to your clinic to get treatment for diarrhoea for
their children. How do mothers present diarrhoea cases to you?
Probe: At what point in the episode do they usually come for treatment?
What questions do you usually ask them?
Do they usually treat these kinds of cases at home before they come to your clinic?
Could you give me some examples of how?
What do you think about these home treatment?
ANNEX D - 1
6.
Influence of Patient Expectations
I would like to know more about mothers and how they feel about treating diarrhoea in their children. When
they come to see you, do mothers usually come with any expectations about the kind of treatment they will
receive?
Probe: Do they have any prejudices about certain kinds of treatment?
How strongly do they usually feel about that?
Do they ever ask for injections?
What would they do if you ignored their expectations?
Do you ever try to convince them differently?
What usually happens then?
7.
Patients Knowledge and Attitudes Toward ORS
Can you tell me something about what mothers know about ORS?
Probe: How (where/whom) do they usually get to know about ORS?
Do they ever use ORS on their own when their children get diarrhoea?
8.
Promotion of the Use of ORS
What is the reaction of mothers when they are given only ORS when they come for treatment?
Probe: Are they satisfied?
Why or why not?
Could you convince mothers who are not satisfied to accept only ORS as treatment?
How would you do this?
9.
Role of prescribers in Education of Mothers
Do you think that mothers know enough in general about how to prevent diarrhoea, and how to manage it
when their children become sick?
Probe: What else do mothers need to know? (Hint: from doctors experience)
How should this be done?
What role could you play in this?
What things would need to change for this to happen?
10.
Role of Pharmacist
Has the pharmacist in your health complex any role/say in the choice of drugs for patients?
Probe: Do you have discussions with the pharmacis t about drugs used for treatment?
Do you get regular feedback from the pharmacist, about these drugs?
11.
Prescriber Education About Therapeutics
I would like to hear about how you get/learn new information about treatment of health problems and drugs.
Can you tell me something about this?
Probe: What would you do if you had a health problem you had not treated before?
Do you ever have difficulties hearing about new drugs or new information on treatment of
diseases?
Do you have suggestions on how to obtain such information easily?
Have you ever discussed the treatment of diarrhoea with medical representatives (Drug Reps)?
12.
Closing
Finally are there any other major things influencing prescribing for diarrhoea that we have not yet talked
about? What are these?
[Narrative to terminate the discussion, elicit questions and ask participants their impressions about the
conversation, and thank them for their co-operation].
ANNEX D - 2
Example 2:
Bangladesh Diarrhoea Study - Moderator's Focus Group Guide for Pharmacists
1.
Introduction
(Narrative welcoming of participants, describing specific reasons for the discussion, and setting up the
general ground rules for the session)
2.
The Role of Pharmacist in the Health Facilities
First, I would like to know about your position and role in the health facility where you work. I am interested
in what you think and feel about this role.
Probe: Are you also involved in ordering or procurement of drugs to the dispensary?
Do you also maintain an inventory of drugs?
If the prescribed drug is not available, what do you do?
How do prescribers see your role?
How do patients see your role?
What is your feeling about the patient load?
Do you have any suggestions for improving drug procurement and storage?
3.
Diarrhoeal Disease as a Problem
Can we talk about diarrhoeal diseases and their treatment in your health complexes? What are the types of
main outpatient diarrhoea cases that are presented.
Listen to responses, then
Probe: Does it regularly affect all age groups?
How do you feel about it?
4.
Use of ORS What do you think/feel about ORS as a way of treating diarrhoea?
Probe: How often is ORS prescribed?
For what kinds of cases does ORS work best?
Are there instances when ORS alone is not enough for treatment?
Do you think the taste of ORS has any influence in its use for children? How?
Do you have any suggestions about this?
5.
5.1
Use of Other Drugs in Diarrhoea Treatment
I would like you to talk about other drugs that are usually prescribed by doctors for treating diarrhoea.
Probe: What are the names of some of these drugs?
Can you tell me the reasons why these drugs are prescribed?
Do you often dispense those drugs with ORS?
What about these (if not mentioned)
* antibiotics?
* metronidazole?
* antidiarrhoeals ?
* injections?
5.2
Are there any other useful drugs for diarrhoea we have not talked about?
6.
6.1
Drug Prescribing And Dispensing
What is your opinion about prescribing by trade names.
Probe: When the suggested trade name is not available, what do you do?
6.1.1
Do you think the dosage schedule is properly given in the prescription?
Why or why not?
ANNEX D - 3
Probe:
Is there anything you could do about this?
If you know that the dosage schedule is not correct, what do you do?
Do the patients ask you for directions about drugs prescribed for them?
Do you see any other problems related to prescription?
6.1.2
Can we talk about dispensing in your facility. I would like to know specifically about how you actually
dispense different dosage forms.
Probe: How do you dispense two or more types of tablets to patients?
Are you confident that patients will identify and take them (various drugs) properly?
Are there any suggestions to improve the situation?
6.2
Can you tell me what you know about the way doctors in your facility treat diarrhoea?
Does the practice of private doctors/drug outlets influence the way doctors in your
facility prescribe?
If yes, how?
7.
Knowledge of Pharmacists About Mother's perceptions of Diarrhoea
I would like to know about the perception of mothers (who come to the health complexes to get treatment)
about diarrhoea (in their children). How do mothers determine when their children have diarrhoea?
Probe: At what point in the diarrhoeal episode do they usually come for treatment?
Do they normally try some solution before they come for treatment?
Could you give me some examples of these home treatments?
What do you think about these (home treatments)?
8.
Patients Knowledge and attitude Toward ORS
Could you tell me about how mothers get to know/hear about ORS?
Probe: What do they think about it?
Do they ever use ORS on their own when their children get diarrhoea?
Why or why not?
Are mothers able to make "home made solution" on their own?
9.
Promotion of the Use of ORS
Are mothers usually satisfied when their children get only ORS when they come for treatment for diarrhoea?
Probe: Why or why not?
Could you convince mothers who are not satisfied to accept ORS as the only treatment to do so?
How would/could this be done
10.
Role of Pharmacist in Educating Mothers
Do you think that mothers know enough in general about how to manage diarrhoea, when their children
suffer from it?
Probe: Is there anything else that mothers need to know?
How should this be done?
What role could you play in this?
What things need to be changed for this to happen?
11.
Pharmacist Education About Therapeutics
Finally, I would like to hear about how you get new information about new drugs. What are some of the
ways that you learn about these things?
Probe: Do you have difficulties in learning about new drugs?
Are there any suggestions you could make to remedy this situation?
Do you think you need further training?
What type of training do you need?
ANNEX D - 4
How would you benefit from such training?
12.
Closing
Before we close the discussion, is there anything that you would like to add or to give new comments to
what have been discussed before?
(Narrative to terminate the discussion, elicit questions and ask participants their impressions about the
conversation, and thank them for their co-operation).
ANNEX D - 5
Example 3:
Bangladesh Diarrhoea Study - Moderator's Focus Group Guide for Mothers
Introduction
[Narrative welcoming participants, describing the reasons for the discussion and setting up the general ground
subjects for the session]
1.
Perception and Knowledge About Diarrhoea
First, I would like to get some idea from you about diarrhoea. How are you able to tell when your child has
diarrhoea? What are some of the main symptoms you look for to determine that it is diarrhoea?
Probe: Listen to response and probe:
Please tell me beside loose stool what else would you look for in a diarrhoeal child?
What may be the cause of diarrhoea?
Is there a way to prevent your children getting diarrhoea?
Do you think that when you get diarrhoea, the baby may get it from you?
What preventive measures do you take?
2.
Severity or Threat of Diarrhoea
Please tell me if your child is not treated what are the problems the child is likely to undergo.
Probe: Are you worried that the child may be seriously ill?
Why do some child die from diarrhoea? Can you tell me about that?
3.
Management of Diarrhoea by Mothers
I would like to know about what you do when your child gets diarrhoea. What do you do when you
suspect this?
Probe: What else do you do? Do you go to a practitioner?
What type of practitioner do you go?
What happens when your child does not respond to this kind of treatment?
How many days after the onset of diarrhoea do you send/bring your child to the hospital?
4.
Knowledge about ORS
I would like to hear what you know about ORS. Can you tell me please.
Probe: Can you describe what ORS does and how it works?
How and where did you learn about ORS? Can you prepare it yourself, How?
How do you give it and for how long?
Have you used any other kind of fluids to treat diarrhoea before knowing about ORS?
What are those fluids?
Did you like ORS or these fluids when you used them?
Why or why not?
5.
Sources for obtaining ORS
Can you tell me some possible sources for obtaining ORS?
Probe: Do you ever have problems in getting ORS when you want it?
What kind of problem is it? Is the problem due to its cost?
ANNEX D - 6
6.
Attitude Towards ORS
Are you satisfied when you are given only ORS to treat diarrhoea when you go to the health centre? Why
or why not?
Probe: Do you feel that ORS is a good treatment for diarrhoea?
Why or why not?
Do you prefer home made or packed ORS? Why or why not?
When ORS does not cure the diarrhoeal baby, what is your feeling about ORS then?
7.
Educational about Diarrhoea Management
I would like to know about how confident you feel about managing diarrhoea yourself.
Probe: Do you like to know any thing more about the home management of diarrhoea?
Where would you be able to find out about such information you want to know?
Is there any one whose opinions about these things you specially trust?
8.
Feeding and Breast feeding Practice
Can you tell me something about what you think children should eat and drink while they are having
diarrhoea?
Probe: Is this different from what you normally give your child?
Do you increase or decrease certain kinds of food?
Should you continue to breast feed your child during diarrhoea episode?
Why do you prefer the kind of diet when your child has diarrhoea?
9.
Use of Other Drugs to treat Diarrhoea
I would like to hear about some of the other medication besides ORS that your child receives for diarrhoea at
the health centre. Can you describe any other drugs children sometimes receive there to treat diarrhoea?
Probe: Do you like it better when your child get one of these other drugs.
Do you think your child needs these drugs?
What do these drugs do?
Do you insist on the other drugs or the doctor prescribed it himself?
If these drugs are not provided at the thana do you ever go somewhere else to get them?
Where do you go?
Did you get to know of these drugs from any worker at the health centre?
10.
Attitude Towards System
I would like to hear about your views on the health services delivered to you?
What were your expectations when you arrived at the health centre?
Were the expectations fulfilled?
Why or why not? What time did you come to the health centre
If late, why did you come late?
11.
Closing: [Narrative to terminate discussion, elicit questions and ask participants their impression about the
conversation, and thank them for their co-operation].
ANNEX D - 7
Example 4:
Nigeria Malaria Study - Moderator's Focus Group Guide for Nurses
1.
Introduction
I am __________ from _____________, and my colleague who is assisting in this session is
____________.
We have been asked by the Federal Ministry of Health to learn more about the problem of malaria in this
area in order to establish programs to improve the treatment of this important health problem. We would like
to welcome you, and thank you for agreeing to participate in this discussion.
We know that as nurses working in health centres and hospitals, you are on the front-line in dealing with
the problem of malaria. Your insights and opinions will teach us a great deal about the perceptions of
community members about malaria, and how personnel within the public health system are dealing with
malaria treatment.
[Set up the general ground rules for the session.]
i)
90 minutes (tape recorded; observer and note taker)
ii)
Speak clearly/one at a time
iii)
Conversations/all participate
iv)
Want everyone's opinions
v)
No right/wrong answers
vi)
Courage of convictions
2.
Common Health Problems in Community
First, I would like to know more generally about the diseases seen at the health centres in this area. What
are the most common ones? [If malaria is not mentioned, specifically bring it up].
Probe: What proportion of all cases present with malaria?
How does malaria rank in perceived importance to other problems?
On what are they basing their opinion about importance?
Does the community perceive malaria to be an important problem?
3.
Malaria Cases
I would like to hear a bit more about malaria cases.
Probe: a)
Age
b)
Severity
c)
Seasonal variation
d)
Economic status
4.
Knowledge of Nurses about Patients' Perception of Malaria
I would like to know about what patients who come to the health centre for treatment think about malaria as
a disease?
Probe: At what stage after attack do they usually come for treatment?
What questions are they usually asked?
Do they usually use some medications before they come for treatment?
What are some of these?
What do you think about that (self medication and drugs used by patients themselves)?
ANNEX D - 8
5.
Malaria Diagnosis
Can we talk about the diagnosis of malaria? In your own experience, how do health workers arrive at the
diagnosis of malaria?
Probe: Do they depend mostly on clinical features or laboratory investigations? What investigations do
the prescribers request? How often are these done?
6.
Treatment of Malaria
Let us talk now about the actual treatment of malaria at the health centres. Can you tell me the common
drugs that are prescribed for malaria at the health centres?
7.
Patient Expectation
I would like to know more about how patients feel about the treatment they receive for malaria. Do they
usually expect to receive certain kinds of treatment when they come?
Probe: Do they have prejudices about certain kinds of treatment?
What do they do if their expectations are not met?
How do they feel about the treatment they get?
How do you convince them to accept the treatment they are given?
8.
Attitude towards Chloroquine
Can you tell me something about how patients feel about chloroquine as a treatment of malaria?
Probe: What is the attitude of patients towards chloroquine?
Do they use other drugs for treating malaria?
What are some of these other drugs?
Why do you think they use these other drugs?
9.
Polypharmacy
What is your opinion on the use of multiple drugs in the treatment of an episode of malaria?
Probe: For what type of patients is this common?
In your opinion, are these justified?
Why, or why not?
10.
Use of Injections
Let us discuss the use of injection in the treatment of malaria.
Probe: What factor(s) determine when a patient with malaria should get an injection?
How is this decision influenced by patient demand/expectation?
What will happen if expectation (if it exists) is not met or is ignored?
11.
Role of Nurses in Prescribing at Health Centres
What part do you play in patient care/prescribing at the health facilities?
Probe: Are you satisfied with this role?
Why, or why not?
What else can you do?
12.
Role of Nurses in Education on Malaria Prevention
How much do you think the community knows about malaria prevention?
Probe: What else do they need to know?
How should this be done?
What role can you play in this?
13.
Closing
Are there any important issues about treatment of malaria that we have not talked about? What are these?
ANNEX D - 9
Example 5:
Nigeria Malaria Study - Moderator's Focus Group Guide for Community Members
1.
Introduction
I am __________ from _____________, and my colleague who is assisting in this session is
____________.
We have been asked by the Federal Ministry of Health to learn more about the problem of malaria in this
area in order to establish programs to improve the treatment of this important health problem. We would like
to welcome you, and thank you for agreeing to participate in this discussion.
Your opinions will teach us a great deal about the perceptions of community members about malaria, and
how well we are doing in the public health system in coping with this problem.
[Set up the general ground rules for the session.]
i)
90 minutes (tape recorded; observer and note taker)
ii)
Speak clearly/one at a time
iii)
Conversations/all participate
iv)
Want everyone's opinions
v)
No right/wrong answers
vi)
Courage of convictions
2.
Common diseases
Could you tell me please, what are the common illnesses in this community?
Probe: Which is the most common illness?
Which is the most important?
(If malaria is not mentioned:) What about malaria? How important is it?
What do you think is the cause of malaria?
Probe: What makes some people get malaria while others do not?
Are certain people less likely by nature, or is it something that they do?
Are there things people can do to prevent malaria?
Is malaria more common at certain times of year?
3.
Malaria Recognition and Care Seeking
How would you know when has malaria?
Probe: What are the most common symptoms? (Probe until no more are mentioned.)
Are there different kinds of malaria?
Are some cases more severe?
How can you tell what kind of malaria someone has?
Do the symptoms differ in adults and children?
What do people usually do when they think they have malaria?
Probe: Does everyone do that, or do some people behave differently?
Was it different in the past?
What determines how someone will deal with their malaria?
Do people do different things for adults and children?
ANNEX D - 10
How would malaria be treated at a government clinic and how much would it cost?
Probe: By a private doctor
At the traditional healer
At the patent medicine store
What happens if a person goes for treatment and the malaria does not get better?
Probe: Is this common?
Do people always do things in the same order?
Are some drugs better or more powerful than others?
4.
Malaria Treatment at Health Centres
Please explain to me what normally happens when you go to a government health centre with malaria. Start
from the time that you arrive at the clinic until when you leave.
Probe: history, examination, temperature, blood test, treatment, advice, etc.
Is it the same at all health centres
Is it the same for adults and children?
When you go for malaria treatment at a health centre, what kind of drugs do you usually get?
Probe: How many different drugs are given?
What do these drugs do?
Are they all equally important?
What is the best drug?
How do you know that?
When you are given the drugs, what advice are you normally given?
Probe: Who gives you this advice?
Is it helpful?
Are there other things that you wish they would explain?
4.
Use of Injections
What do you think about treating malaria with injections?
Probe: Are injections or tablets are better for treating malaria?
Do you expect to receive and injection for malaria?
Are some doctors more likely to give injections than others?
6
Conclusion
Are there any important issues about treatment of malaria that we have not talked about? What are these?
ANNEX D - 11
Example 6:
WHO/CDD Drug Sellers Study - Moderator's Focus Group Guide for Drug Sellers
INTRODUCTION AND STATEMENT OF PURPOSE
!
Hello, my name is
Health.
!
I would like to talk to you about diarrhoeal disease, the customers who visit your shop to be treated for it,
and the drugs they usually buy.
!
Please feel free to discuss the questions I ask openly and honestly. There are no correct answers to them,
and anything you think or feel will be valuable. We hope to be able to learn a lot from each of you.
!
I will try to make sure that we have time to talk about all we are supposed to, and that you all have a chance
to give your opinions.
!
I would like to introduce
, who also works with the CDD Programme. She will be taking notes
during our discussion, so that we can remember to put everything you discuss into our report.
!
You will see that she is also going to tape our conversation. This will be another way for us to remember
what is said when we are writing our report. The tape will not be used for any other purpose.
. I work with the Diarrhoea Disease Control Programme of the Ministry of
WARM-UP
!
I would like to give you a chance to get to know one another. Could you please tell us your name and
describe a little about the pharmacy/drug shop in which you work?
Go around circle and wait for each person to introduce himself or herself.
!
This is the last time you will be asked to speak one by one. After this, please feel free to jump into the
conversation any time you would like to say something.
TOPICS
Diarrhoeal Disease and Treatment
!
First, I would like to get some impressions from you about diarrhoea? Could you tell me when you think of
diarrhoea, what is the first thing that comes to your mind?
Listen for responses, then probe:
Can you tell me more about that?
Could you give me an example?
How do you feel about that?
!
What do you do for a customer who comes into your shop and asks your help for a case of diarrhoea in her
two-year old child?
What else do you ask?
Do you tell her anything else?
Do you always do the same thing?
Why or why not?
ANNEX D - 12
!
Why do you use drugs to treat diarrhoea in children?
How do you decide when to use drugs?
Which drugs do you prefer?
!
What are the advantages and disadvantages of using ORS? Lomotil syrup? Tetracycline? Streptomagma?
Why is that?
Is it always this way?
!
What would you do to convince your colleagues to sell more ORS to treat diarrhoea?
Who would be most receptive?
Are there reasons why they might not be convinced?
Behaviour of Customers
!
How do customers usually decide on which drugs to purchase for a case of diarrhoea?
Do you help them decide in any way?
Do they buy different drugs for adults and children?
Which drugs are the most popular?
!
What do customers say about ORS?
Do they know what it is for?
Where have they heard about it?
Do they know how to use it?
Are they satisfied with it?
!
How would your customers react if you suggest that they purchase ORS for every case of diarrhoea in a
child?
Do they expect such advice?
Would they follow your advice?
Would they still buy other drugs?
What would convince them?
Role of Information
!
How do you learn about new drugs or new ways to treat health problems?
Any other ways?
How about doctors?
How about other people in the pharmacy profession?
Which way is most important?
Why?
!
What kind of information would you like to have?
Anything else?
Where could you get this information?
Would you have time to read about new ideas?
!
Who would you trust to give you reliable information?
Anyone else?
Why?
How about the Ministry of Health?
The Faculty of Pharmacy?
ANNEX D - 13
Why?
Economic Incentives
!
Do customers ever have a hard time paying for the drugs they need?
How do you know who will have trouble paying?
What do you do?
!
Do customers equate the price of a drug with how well it works?
Is there a price below which customers feel that a drug is not worthwhile?
Are there any exceptions to this?
!
Do customers who can't afford all their drugs ever ask your advice about which drugs to buy?
How often?
What do you do?
Anything else?
!
Are some drugs more profitable to you than others?
Which ones?
Does this ever change?
Why or why not?
!
Would there be reasons why you might actively promote a product that is less profitable?
For what reasons?
Can you think of a case where this happens now?
What is the smallest profit you could accept for such products?
!
Is ORS a profitable drug for your store?
Why is this the case?
Does the cost of ORS affect sales?
Does it compete with any other drugs?
Which ones?
CLOSURE OF GROUP
!
I'm sorry but we seem to have run out of time. May I ask if anyone has any final issues they feel they would
like to bring up? [Allow brief discussion.]
!
I would like to thank each of you for your time and valuable contribution. You have helped us to learn a lot,
and we are most grateful.
ANNEX D - 14
ANNEX E:
EXAMPLES OF STRUCTURED OBSERVATION PROTOCOLS
Example 1:
Bangladesh Diarrhoea Study - Clinical Encounter Observation Form
Example 2:
Bangladesh Diarrhoea Study - Dispensing Process Observation Form
Example 3:
Nigeria Malaria Study - Clinical Process Observation Form
Example 4:
WHO/CDD Drug Sellers Study - Pharmacy Encounter Observation Form
Example 1:
Bangladesh Diarrhea Study - Clinical Encounter Observation Form
IDENTIFYING INFORMATION
Health Facility: _________________________
Visit ID: ______________
Dept:_____________
Date:__________
Time of Visit:__________
Patient Age (yrs,mos): ___________
Sex:___________
Accompanied by: ______________
PRESCRIBER-PATIENT INTERACTION
Length of Clinical Consultation (minutes): ______________
Provider Type: _______________
DIAGNOSTIC COMMUNICATION
Prescriber
Asked
Patient
Volunteered
Not
Discussed
Length of diarrhoea episode
Association of onset with foods eaten
Diarrhoea frequency/volume
Appearance of Stool
Child still eating/drinking/breastfeeding
Previous treatment for this episode
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
EXAMINATION/TREATMENT
Examined
Not
Does
Examined
Temperature (measured or felt)
__________
Pulse
__________
Skin turgor
__________
Fontanelle (if child under 6 months) __________
Diaper examined (if soiled)
__________
Stool culture ordered
__________
Sterile technique followed for injection
__________
COMMUNICATION/ADVICE
Specific drugs/injection desired
Information on drugs prescribed
Eating/feeding/breastfeeding advice
Information about diarrhoea prevention
Prescriber
Initiated
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Initiated
ANNEX E - 1
Not Apply
__________
__________
__________
__________
__________
__________
__________
Patient
Not
Discussed
__________
__________
__________
__________
__________
__________
__________
__________
DESCRIPTION OF CLINICAL ENCOUNTER
1.
Patient greets prescriber
Yes __________
No __________
2.
Prescriber reciprocates greeting
Yes __________
No __________
3.
Friendly conversation
Yes __________
No __________
4.
Reassurance to the child
Yes __________
No __________
5.
Reassurance to the adult
Yes __________
No __________
6.
Friendly eye contact with adult
Yes __________
No __________
7.
Encouraged to describe problem freely
Yes __________
No __________
8.
Doctor ask questions about history,
origins of problem?
Yes __________
No __________
9.
Doctor listens to responses
Yes __________
No __________
10.
Doctor explains exam, treatment
Yes __________
No __________
11.
Doctor uses technical language only
Yes __________
No __________
12.
Clinical encounter ends abruptly
Yes __________
No __________
13.
Adult appears to want more advice
or information
Yes __________
No __________
Adult appears to expect additional
treatment that was not given
Yes __________
No __________
Adult appears to understand child's
disease and treatment after doctor's
explanation
Yes __________
No __________
14.
15.
OBSERVER NOTES AND COMMENTS:
ANNEX E - 2
Example 2:
Bangladesh Diarrhea Study - Dispensing Process Observation Form
IDENTIFYING INFORMATION
Health Facility: _________________________
Visit ID: ______________
Dept:_____________
Date:__________
Time of Visit:__________
Patient Age (yrs,mos): ___________
Sex:___________
Accompanied by: ______________
DISPENSER-PATIENT INTERACTION
Length of dispensing process (seconds): _____________
Dispenser: ___________________________
Type: ______________________________________________________________________
COMMUNICATION
Prescriber
Initiated
__________
__________
__________
__________
Description of the drugs dispensed
Instructions on how to take drugs
Cautions, side effects mentioned
Information about prevention/care
Initiated
Patient
Not
Discussed
__________
__________
__________
__________
__________
__________
__________
__________
DISPENSING ACTIONS
Sterile technique followed
for injection
Yes
No
Does Not Apply
__________
__________
__________
How to take:________
No label: ________
Drugs labeled with (Check one or more):
Patient name:________
Drug name: ________
Type of package in which drugs dispensed (Check one or more):
Plastic/glass bottle: ________
Folded paper: ________
Plastic bag: ________
None: ________
ANNEX E - 3
Envelope: ________
DESCRIPTION OF THE DISPENSING ENCOUNTER
1.
Conversation initiated by dispenser
2.
Conversation initiated by patient/caretaker
Yes
__________
No
__________
3.
Explanation given by dispenser
Yes
__________
No
__________
4.
Questions raised by patient/caretaker
Yes
__________
No
__________
5.
Dispenser answered patient questions
Yes
__________
No
__________
6.
Dispenser explained about drugs
Yes
__________
No
__________
7.
Dispenser used technical language only
Yes
__________
No
__________
8.
Dispenser used local language
Yes
__________
No
__________
9.
Patient/client asked for more drugs
10.
Dispenser marked unavailable drugs
on prescription
Yes
__________
No
__________
Dispenser told patient/client to buy
unavailable drugs at outside store
Yes
__________
No
__________
11.
Yes
Yes
__________
__________
OBSERVER NOTES AND COMMENTS:
ANNEX E - 4
No
No
__________
__________
Example 3:
Nigeria Malaria Study - Clinical Process Observation Form
IDENTIFYING INFORMATION
Health Facility: _________________________
Visit ID: ______________
Dept:_____________
Date:__________
Time of Visit:__________
Patient Age (yrs,mos): ___________
Sex:___________
Accompanied by: ______________
PRESCRIBER - PATIENT INTERACTION
Length of Clinical Consultation (minutes)_____________
Provider Type:___________________
DIAGNOSTIC COMMUNICATION
Prescriber
Asked
Patient
Volunteered
Not
Discussed
Length of current episode?
Patient mentions malaria?
Previous treatment for this episode?
Last time treated for malaria?
Name of drug used to treat last time?
Finished last course of treatment?
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
Risk factors (near river, near
bush, mosquitoes, etc.)?
________
________
________
Communication about presence of:
fever?
________
headache?
________
malaise?
________
muscle weakness?
________
loss of appetite?
________
chills?
________
vomiting?
________
metal taste in mouth?
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
If patient is a child:
Child-vomiting?
Child still eating/drinking?
________
________
________
________
________
________
EXAMINATION/TREATMENT
Examined
Not
Does
Examined
Temperature measured?
Patient touched for fever?
Pulse felt?
Sclera of eyes examined?
Tongue examined?
________
________
________
________
________
________
________
ANNEX E - 5
Not Apply
________
________
________
________
________
________
________
________
Listens to chest?
Palpates abdomen?
________
________
ANNEX E - 6
________
________
________
________
TREATMENT
Yes
No
Injection given?
Sterile technique followed for injection?
Advised lab test?
Advised exam at different facility?
Advised return visit if not better?
________
________
________
________
________
________
________
________
________
________
COMMUNICATION/ADVICE
Prescriber
Initiated
Patient asked for:
injection?
chloroquine?
halfantrine?
other specific drug?
________
Patient
Not
Discussed
Initiated
________
________
________
________
________
Provider explained drugs prescribed?
Provider advised about mosquitoes?
Provider advised about prevention?
Provider advised about nutrition?
Does
Not Apply
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
QUALITY OF PROVIDER-PATIENT INTERACTION
Patient greeted prescriber?
Prescriber greeted patient?
Friendly conversation?
Provider reassured patient?
Patient encouraged to
describe problem freely?
Doctor listened to responses?
Encounter ended abruptly?
Patient appears to want
more information?
Yes
No
________
________
________
________
________
________
________
________
Does Not Apply
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
OBSERVER NOTES AND COMMENTS:
ANNEX E - 7
Example 4:
WHO/CDD Drug Sellers Study - Pharmacy Encounter Observation Form
Age of person with diarrhoea: (1=< 1 year / 2=1-4 years / 3=5 and over):
______
Identity of person visiting shop (1=mother / 2=father / 3=sibling / 4=other):
______
Presence of absence of prescription: (1=came with prescription / 2=no prescription)
______
Sales attendant type (1=Pharmacist / 2=Assistant Pharmacist / 3=Other):
______
1. Which of the following issues were discussed during the visit?
Sales Attendant
Mentioned First
Presence of fever / blood in stool
______
Presence of vomiting / stomach pains
______
Dehydration / loss of fluid
______
Food, fluids, or drugs taken by patient
______
Description of what specific drugs do
______
Use of traditional remedies
______
______
Use of ORS/ORT
______
______
Proper dosage / frequency of drugs
______
Cautions / side effects of drugs
______
2.
3.
Customer
Mentioned First
______
______
______
______
______
______
______
______
______
Not
Discussed
______
______
______
______
______
______
______
Which of the following did the shop attendant recommend?
Visit a doctor if the diarrhoea persists, child vomits, or runs a fever
Continue to give fluids and foods, or increase fluid to prevent dehydration
______
______
If advice was given: What was the customer's reaction to the advice?
(1=Accepted without question / 2=Accepted but asked questions /
3=Accepted after persuasion) / 4=Did not accept)
______
Which products were recommended? Write 'NONE' if none were recommended.
# of Units
# of Units
Name
Recommended
Purchased
Price
Paid
a.___________________________________
________
________
__________
b.___________________________________
________
________
__________
c.___________________________________
________
________
__________
d.___________________________________
________
________
__________
e.___________________________________
________
________
__________
4. Who seems most responsible for the treatment given: a medical practitioner, the sales attendant, or the customer?
Explain why, and describe any factors you feel influenced the behaviour of the sales attendant or customer.
______________________________________________________________________________________
______________________________________________________________________________________
ANNEX E - 8
______________________________________________________________________________________
ANNEX E - 9
ANNEX F:
EXAMPLES OF STRUCTURED QUESTIONNAIRES
Example 1:
Bangladesh Diarrhoea Study - Patient Intercept Interview
Example 2:
Nigeria Malaria Study - Patient Intercept Interview
Example 3:
Nepal Drug Retailers Study - Retailers= Questionnaire
Example 1:
Bangladesh Diarrhea Study - Patient Intercept Interview
IDENTIFYING INFORMATION
Health Facility: _________________________
Patient Age (yrs,mos): ___________
Date:__________
Sex:___________
Time of Visit:__________ Dept:_____________
Visit ID: ________
Accompanied by: ______________
Total Time: _________________
COMPLAINT AND PREVIOUS TREATMENT
1.
What is the main complaint/ailment for which you have come here to seek treatment?
2.
Have you visited this health facility before today to
treat this specific illness?
Yes ________
No ________ (skip to Q3)
How long ago was your first visit? _________________________________________
3.
Did you consult anyone else to treat this illness
before coming here?
Yes ________
No ________ (skip to Q4)
Whom did you consult? (specify type of practitioner) _______________________________________
INFORMATION ABOUT DIAGNOSIS AND TREATMENT
4.
Has a health worker at this facility told you
the name of your illness?
Yes ________
No ________ (skip to Q5)
What illness did they say you have? ___________________________________________ (skip to Q6)
5.
Did you ask the doctor the name of your illness?
Yes ________
No ________
6.
Did the doctor physically examine you?
Yes ________
No ________
7.
Do you feel you had the chance to fully tell about
your illness to the doctor?
Yes ________
No ________
Did the doctor advise any laboratory tests?
Yes ________
No ________
8.
INFORMATION ABOUT DRUGS
9.
How many drugs did you receive today from this facility? __________
10.
Did the doctor here prescribe any drugs that you
must buy outside of this facility?
Yes ________
No ________ (skip to Q.11)
Yes ________
No ________
How many drugs? ___________
11.
Did the pharmacist explain how to take your drugs?
12.
Would you please tell me how you will take these drugs? (Hold up each drug the patient received one at a
time, and allow patient to describe its use. Patient is allowed to read any information written on the drug
package or the prescription.)
Drug 1:_______________________________
Drug 2:_______________________________
Drug 3:_______________________________
Drug 4:_______________________________
Correctly stated ______
Correctly stated ______
Correctly stated ______
Correctly stated ______
Not correct ______
Not correct ______
Not correct ______
Not correct ______
PATIENT SATISFACTION
13.
How satisfied are you with the treatment you received today? Would you say you were (Read options):
Very satisfied ______
Satisfied ______
Dissatisfied ______
Very dissatisfied ______
14.
What are the main reasons you feel this way?
15.
Would you visit this facility again in case of
another illness?
Yes ________
No ________
Do you have any complaints about anything
at this facility?
Yes ________
No ________ (skip to Q17)
16.
What is the complaint? _________________________________________________
17.
Can you suggest any ways to improve patient care at this facility?
18.
Do you have any other comments about this facility?
.
End interview by thanking the patient.
Example 2:
Nigeria Malaria Study - Patient Intercept Interview
1.
What is the main problem for which you have come here to seek treatment?
______________________________________________________________________________
______________________________________________________________________________
2.
Is this your first visit to this facility for this ailment?
( ) Yes
( ) No
3.
What did you do when you first experienced these symptoms?
______________________________________________________________________________
______________________________________________________________________________
4.
Did you receive treatment from any practitioner for this illness before coming here?
( ) Yes
( ) No (skip to Q5)
(If yes) From whom did you receive care?
______________________________________________________________________________
5.
Were you told the name of your problem today by the doctor?
( ) Yes
( ) No (skip to Q6)
(If yes) What illness did the doctor tell you that you have?
______________________________________________________________________________
6.
Were you physically examined by the doctor?
( ) Yes
( ) No
7.
Did you have a chance to fully explain about your illness to the doctor?
( ) Yes
( ) No
8.
Did the doctor take blood from you for a test?
( ) Yes
( ) No
9.
Which medicines did the doctor recommend for you? Which did you receive today from this facility?
Name of Medicine
Received from facility
____________________________________________
_________
____________________________________________
_________
____________________________________________
_________
____________________________________________
_________
10.
____________________________________________
_________
Were you given a prescription for purchase of drugs outside this facility?
( ) Yes. How many drugs?________
( ) No
15.
Were you given any injection?
Yes ( )
No ( )
16.
Would you please tell me how you will take the drugs your received?
Drug 1:
correctly stated ( )
not correct ( )
Drug 2:
correctly stated ( )
not correct ( )
Drug 3:
correctly stated ( )
not correct ( )
Drug 4:
correctly stated ( )
not correct ( )
17.
Overall, would you say you are very satisfied, satisfied, dis satisfied, or very dissatisfied with your
experience in this facility today?
Very Satisfied ( ) Satisfied ( )
Dissatisfied ( ) Very Dissatisfied ( )
18.
Could you please tell me why you feel this way?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
19.
Would you visit this health facility again in case of another illness?
( ) Yes
( ) No
20.
What are your suggestions for ways we can improve care at this facility?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Example 3:
Nepal Drug Retailers Study - Retailers= Questionnaire
IDENTIFYING INFORMATION
Interviewer _____________________________________
Date _____________________
Retailer sample number __________________________________________________________
District ________________________________
Town/Village ______________________
Development Committee ___________________________________________________________
Ward Number ___________________
Shop Name ________________________________
Owner Name ____________________________________________________________________
INTRODUCTION
(Greet) I am _______________. from Chemists and Druggists Association. We are conducting a study to find out
about the condition of retailers in different parts of the country. Would you mind spending a little time (about one
hour) with us, discussing your work?
Yes
________
No (why) ___________________________________________________________________________
Is this a good time for us to discuss, or could you suggest a time?
Now
_________
Appointment time:
______________________________________________________________
Kept appointment:
______________________________________________________________
Missed appointment:
______________________________________________________________
1.
SHOP CHARACTERISTICS
I would like to ask a little about this shop and your stocks.
1.
What year was this shop was established?
_______________
2.
How long have you been working here?
___________ years
3.
How many other people work here? ___________________________________________________
___________ months
4.
How do you find out about new drugs introduced into the market? (Do not prompt. Check all that are
mentioned)
________ From wholesalers
________ From customers' prescriptions
________ Talking to health providers
________ Drug company representatives
________ Drug company advertisements
________ Other retailers
________ OTHER: __________________________________________________________
II.
CUSTOMER PROFILE
Now I would like to ask some questions about this area and what kind of customers you are getting.
5.
Is there a health post or hospital nearby?
1. Yes ________
2. No ________
6.
About how many customers visited the shop yesterday? _______________________
7.
Was that a usual number, more than usual, or less than usual?
1.
usual ---> Go to part d.
2.
less than usual
3.
more than usual
What would you say is the usual number? __________________________
8.
Of the people who visited your shop yesterday, what number
came with prescriptions?
_________________
9.
What are the 3 most common problems that people come to get medicine for?
(a) ________________________________________________________________________
(b) ________________________________________________________________________
(c) ________________________________________________________________________
10.
I would like to read you a list of illnesses and ask you if in general you have many customers, some, or only
a few coming for each of these illnesses.
worms
pneumonia
cough and cold
fever
weakness of pregnancy
diarrhoea
diarrhoea with blood
skin disease
11.
MANY
1
1
1
1
1
1
1
1
SOME
2
2
2
2
2
2
2
2
FEW
3
3
3
3
3
3
3
3
DON'T KNOW
9
9
9
9
9
9
9
9
Do you find that most people who come ask you for a specific medicine by name, or do you usually
recommend what they should buy? [Check one]
1.
Customer usually asks for medicine by name
2.
Usually recommend
3.
Both are equally common
12.
III.
What do you do to attract customers? (PROMPT: Anything else? Prompt until no more responses.)
(a)
____________________________________________________________________
(b)
____________________________________________________________________
(c)
____________________________________________________________________
DIARRHOEA
Now I would like to talk a little about diarrhoea.
LAST CASE --------------- First I would like to ask you about your last case of a child with diarrhoea.
13.
Was the child brought to you, or did someone come (without the child) to ask for a drug?
1.
2.
Child was brought
Someone came without the child
14.
Do you know how old was the child? _______ years
15.
Do you know, was it a boy or a girl?
1.
2.
3.
16.
17.
________ Don't know
Boy
Girl
Don't know
What were the symptoms described to you?
______ Frequency stools
_____
______ Watery stools
_____
______ Mucous in stool
_____
______ Vomiting
_____
______ Fever
_____
______ Dehydration
_____
[TICK all that are mentioned by the retailer. Do not prompt.]
Loose stools
Blood in stool
Stomach pain
Nausea
Weakness
Sunken fontanelle
______
______
______
Sunken eyes
No urine
Mouth is dry
Not taking liquid drinks
Skin dry
______
OTHER: _______________________________________________________
_____
_____
What did you recommend for that child? [FOR DRUGS ASK: What was the name? What was the quantity
you recommended? What is the unit cost? ]
______ Referred to:_________________________________________________________
______ Drugs recommended -- list below
Brand name
Number of units Unit cost
__________________________________________
_____________ ____________
__________________________________________
__________________________________________
_____________ ____________
_____________
____________
18.
Which product is the best in the list you recommended, and why?
____________________________________________________________________________
____________________________________________________________________________
19.
Was there any reason to believe that the child was dehydrated?
1.
Yes
2.
No--------------------Go to Question III-I.
3.
Don't know
Which of the medicines that you recommended, if any, could be useful to correct dehydration?
Name of Medicine: ________________________________________________________________
20.
Did you offer any other advice to the customer?
1.
Yes
2.
No--------------------Go to Question IV-A.
(If yes:) What advice did you give? [PROMPT UNTIL NO MORE RESPONSES WITH: Any other advice? DO
NOT read list.]
__________ Continue feeding as usual
_____________
Increase feeding
__________ Decrease feeding
_____________
Stop feeding
__________ Continue breast feeding
_____________
Stop breast feeding
__________ Other fluids recommended: _____________________________________________
__________ Other treatment recommended: ___________________________________________
IV.
GENERAL DIARRHOEA QUESTIONS
Now I would like to ask you some general questions about children with diarrhoea.
21.
About how many customers a week do you have coming for diarrhoea at this time of year? _______
22.
About how many of these are for adults with diarrhoea, and how many are for children?
________ Adults
23.
________ Children
_________ Don't know
What time of year -- that is, what months -- do you have the most customers for diarrhoea?
____________________________________________________________________________
24.
In your opinion, what are the characteristics of mild diarrhoea in a child? (Do not prompt)
__________
Frequency stools
___________
Loose stools
__________
Watery stools
___________
Blood in stool
__________
Mucous in stool
___________
Stomach pain
__________
Vomiting
___________
Nausea
__________
Fever
___________
Weakness
__________
Dehydration
OTHER: __________________________________________________________________
25.
In your opinion, what are the characteristics of severe diarrhoea in a child? (Do not prompt)
__________
Frequency stools
___________
Loose stools
__________
Watery stools
___________
Blood in stool
__________
Mucous in stool
___________
Stomach pain
__________
Vomiting
___________
Nausea
__________
Fever
___________
Weakness
__________
Dehydration
OTHER: __________________________________________________________________
26.
How do you know if a child is dehydrated? (Do not prompt)
______ Sunken eyes
______ Sunken fontanelle
______ No urine
______ Not taking liquid drinks
______ Mouth is dry
______ Skin dry
______ Weakness
______ OTHER: __________________________________________________________
27.
(i)
(ii)
In order of frequency, what products do you commonly recommend for a child with diarrhoea?
Can you tell me why you recommend each product? This is, what do each of these products do?
(i) PRODUCT
28.
(ii) REASON FOR RECOMMENDING
When a child is dehydrated do you recommend any other medicines in addition to those you listed?
1.
Yes
2.
No--------------------Go to Question IV-I.
(If yes:) Which medicines?
____________________________________________________________________________
____________________________________________________________________________
29.
Do customers ever demand particular brands?
1.
Yes
2.
No--------------------Go to Question IV-J.
(If yes:) In order of frequency, what do they most often demand?
30.
(a)
____________________________________________________________________
(b)
____________________________________________________________________
(c)
____________________________________________________________________
(d)
____________________________________________________________________
(e)
____________________________________________________________________
Do you ever refer customers with a child who has diarrhoea?
1.
Yes
2.
No -------------------- Skip to Section V.
(If yes:) To whom do you refer customers?
____________________________________________________________________
(If yes:)
___
___
___
___
___
___
___
___
___
For what reasons would you refer a child with diarrhoea? [TICK all that are mentioned. Do not prompt.]
Non-availability of drug at shop
___
Frequency stools
Watery stools
___
Loose stools
Mucous in stool
___
Blood in stool
Stomach pain
___
Vomiting
Nausea
___
Fever
Weakness
___
Dehydration
Sunken fontanelle
___
Sunken eyes
Not taking liquid drinks
___
No urine
Mouth is dry
___
Skin dry
___
OTHER: _______________________________________________________
22.
ORS
31.
Do you have ORS in stock?
Yes ________
No ________
32.
Which brands of ORS do you have in stock? What is the price?
Product
Price
(a) _____________________________________ ____________
(b) _____________________________________ ____________
(c) _____________________________________ ____________
(d) _____________________________________
____________
(e) _____________________________________ ____________
33.
Taking into account the price you can get from wholesalers, which brand gives you the best profit?
___________________________________________________________________________
34.
In your opinion, how does ORS help a child with diarrhoea? [Tick all responses mentioned; do not prompt.]
___
Stops diarrhoea
___
Prevents dehydration
___
Treats dehydration
___
Gives energy
___
35.
OTHER: ___________________________________________________________
Each week, about how many customers buy ORS? How many of these are children and how many are
adults.
Total Sales ____________
Adults ____________
36.
VI.
Children ____________ Don't know age ____________
What do customers think about ORS? What do they tell you? [Tick all responses mentioned; do not
prompt.]
___
___
___
___
___
Is effective
Only for children
Replaces water
Is inexpensive
Stops diarrhoea
___
___
___
___
Is not effective
Only for adults
Provides energy
Is expensive
___
OTHER ____________________________________________________________
ARI
Now I would like to talk a little about respiratory problems.
LAST CASE --------------- First I would like to ask you about your last case of a child with respiratory problems.
37.
Please remember the last child with cough and cold/pneumonia you recommended. Was the child brought to
you, or did someone come (without the child) ask for the drug?
1.
Child was brought
2.
Someone came without the child
38.
Do you know how old was the child?
_______ years
_________ Don't know
39.
Do you know, was it a boy or a girl?
1.
Boy
2.
Girl
3.
Don't know
40.
What were the symptoms described to you? [TICK all that are mentioned by the retailer. Do not prompt.]
41.
42.
___
___
___
___
___
fever
sore throat
cough
indrawn chest
fast breathing
___
___
___
___
___
runny nose
ear pain
noisy breathing
headache
pain in chest or ribs
___
OTHER: ___________________________________________________________________
What products did you recommend for that child? [What was the name? What was the quantity you
recommended? What is the unit cost?]
Brand name
Number of units Unit cost
(a)_______________________________________
___________
____________
(b)_______________________________________
___________
____________
(c)_______________________________________
___________
____________
(d)_______________________________________
___________
____________
Which product is the best of the ones you recommended, and why?
____________________________________________________________________________
____________________________________________________________________________
43.
What other advice, if any, did you offer to the customer? [PROMPT UNTIL NO MORE RESPONSES WITH:
Any other advice? DO NOT read list.]
___
No other advice
___
Feeding advice: ________________________________________________________
___
Breast feeding advice: ___________________________________________________
___
Home remedies suggested: _______________________________________________
VII.
GENERAL QUESTIONS ABOUT ARI
44.
About how many customers a week do you see for respiratory problems at this time of year?
______
____
45.
How many of these are for adults with respiratory problems , and how many are for children?
________ Adults
46.
________ Children
_________ Don't know
What time of year -- that is, what months -- do you have the most customers for respiratory problems ?
____________________________________________________________________________
47.
What are the common respiratory problems in children?
____________________________________________________________________________
____________________________________________________________________________
48.
When customers come about a child with cough or cold, what do they usually tell you? (TICK all symptoms
mentioned. Do NOT prompt.)
___
fever
___
runny nose
___
sore throat
___
ear pain
___
cough
___
noisy breathing
___
indrawn chest
___
headache
___
fast breathing
___
pain in chest or ribs
___
extreme sleepiness
___
weakness
___
49.
50.
OTHER: __________________________________________________________________
How do you know when a child has pneumonia? What symptoms will the child have?
___
fever
___
runny nose
___
sore throat
___
ear pain
___
cough
___
noisy breathing
___
indrawn chest
___
headache
___
fast breathing
___
pain in chest or ribs
___
extreme sleepiness
___
weakness
___
OTHER: __________________________________________________________________
(i)
In order of frequency, what products do you commonly recommend for a child with cough and
cold?
Can you tell me why you recommend each product? This is, what do each of these products do?
(ii)
(i) PRODUCT
(ii) REASON FOR RECOMMENDING
51.
Do customers ever demand particular products?
1.
Yes
2.
No -------------------- Go to Question VII-I.
(If yes:) In order of frequency, which products do they most often demand for cough and cold in a child?
52.
(a)
____________________________________________________________________
(b)
____________________________________________________________________
(c)
____________________________________________________________________
(d)
(e)
____________________________________________________________________
____________________________________________________________________
(f)
____________________________________________________________________
Do you have co-trimoxazole in stock?
1.
Yes
2.
No -------------------- Go to Question VII-K.
(If yes:) Which brands of co-trimoxazole do you have? What is the price?
Product
Price
(a) _____________________________________ ____________
(b) _____________________________________
____________
(c) _____________________________________ ____________
(d) _____________________________________
____________
(e) _____________________________________ ____________
53.
Taking into account your price from wholesalers, which of these brands gives you the best profit?
____________________________________________________________________________
54.
Do you have amoxicillin in stock?
1.
Yes
2.
No -------------------- Go to Question VII-M.
(If yes:) Which brands of amoxicillin do you have? What is the price?
Product
Price
(a) _____________________________________ ____________
(b) _____________________________________
____________
(c) _____________________________________ ____________
(d) _____________________________________
____________
(e) _____________________________________ ____________
55.
Taking into account your price from wholesalers, which of these brands gives you the best profit?
____________________________________________________________________________
56.
Do you ever refer customers with a child who has a respiratory illness?
1.
Yes
2.
No -------------------- Skip to Section VIII.
(If yes:) To whom do you refer customers?
____________________________________________________________________
(If yes:)
retailer.
___
___
___
___
___
___
___
VIII.
For what reasons would you refer a child with respiratory illness? [TICK all that are mentioned by the
Do not prompt.]
fever
___
runny nose
sore throat
___
ear pain
cough
___
noisy breathing
indrawn chest
___
headache
fast breathing
___
pain in chest or ribs
extreme sleepiness ___
weakness
OTHER: __________________________________________________________________
PREGNANCY
Now I would like to talk to you about problems in pregnant women.
LAST CASE -- First I want to ask some questions about your last case of a pregnant women who was pale and weak.
57.
Did the women come herself or did someone else come for her? If someone else, who?
___
Herself
___
Husband
___
Female relative
___
Male relative
___
Friend
___
Other: __________________________________
58.
While asking the medicines, what were the symptoms described to you? [TICK all that are mentioned.]
59.
___
___
___
___
___
___
Weakness
Nausea
Loss of appetite
Bleeding
Leaking of fluid
Fever
___
___
___
___
___
___
Tiredness
Back pain
Dizziness
Vomiting
Problems with last pregnancy
Severe lower abdominal pain
___
OTHER: __________________________________________________________________
Can you tell me what you recommended for that woman?
Non-Drug Recommendations: ________________________________________________________
__________________________________________________________________________
FOR EACH DRUG RECOMMENDED ASK: What was the name? What was the quantity you
recommended? What is the unit cost?
Brand name
Number of units Unit cost
IX.
(a)_______________________________________
___________
____________
(b)_______________________________________
___________
____________
(c)_______________________________________
___________
____________
(d)_______________________________________
___________
____________
(e)_______________________________________
___________
____________
GENERAL PROBLEMS OF PREGNANCY
Now I would like to ask some general questions about pregnancy.
60.
61.
When a customer comes for problems during pregnancy, what kind of problems do they usually tell you
about?
___
___
___
___
___
___
Weakness
Nausea
Loss of appetite
Bleeding
Leaking of fluid
Fever
___
OTHER: ___________________________________________________________________
(i)
In order of frequency, which products do you commonly recommend for a pregnancy case who is
pale and weak?
(ii)
Can you tell me why you recommend each product? This is, what do each of these products do?
PRODUCT
62.
___
___
___
___
___
___
Tiredness
Back pain
Dizziness
Vomiting
Problems with last pregnancy
Severe lower abdominal pain
REASON FOR RECOMMENDING
Do you ever refer a pregnant customer who is pale and weak?
1.
2.
Yes
No -------------------- Go to Question IX-D.
(If yes:) To whom do you refer customers?
____________________________________________________________________
(If yes:) For what reasons would you refer such customers? [TICK all that are mentioned by the retailer. Do not
prompt.]
___
Non-availability of drug
___
Weakness
___
Tiredness
___
Nausea
___
Back pain
___
Loss of appetite
___
Dizziness
___
Bleeding
___
Persistent vomiting
___
Leaking of fluid
___
Problems with last pregnancy
___
Fever
___
Severe lower abdominal pain
___
63.
64.
OTHER: ___________________________________________________________________
In order of frequency, what products do customers usually request for paleness and weakness in
pregnancy?
(a)
____________________________________________________________________
(c)
____________________________________________________________________
(c)
____________________________________________________________________
(d)
____________________________________________________________________
Which of these products do y ou think is the best, and why?
____________________________________________________________________________
____________________________________________________________________________
65.
Do you have FerSolate brand of iron (ferrous sulphate) in stock?
1.
Yes
2.
No
66.
Which other brands of iron do you have in stock? What is the price?
Brand
Price
(a) _____________________________________ ____________
(b) _____________________________________
____________
(c) _____________________________________ ____________
(d) _____________________________________
____________
(e) _____________________________________ ____________
67.
Taking into account the price you can get from wholesalers, which of these brands gives you the best
profit?
____________________________________________________________________________
24.
SOURCES OF INFORMATION
68.
Have you ever been taught how common problems should be managed?
1.
Yes
2.
No----------------Go to Question X-B.
(If yes:) From where have you found out about these therapies?
____________________________________________________________________
69.
How do you generally find out about the use of drugs?
____________________________________________________________________________
____________________________________________________________________________
70.
Do you have books that discuss how common health problems should be managed?
1.
Yes
2.
No ----------- Go to Question X-D.
(If yes, ask the following questions about these sources and record the answers in the table below)
(i)
What are the names of the books?
(ii)
How often have you used each of these books in the last 2 weeks?
(iii)
What do you find most useful about each of the books?
(iv)
Could I see the book?
(i) Name of Book
71.
(ii) Times Used
in 2 weeks
(iii) What is most useful?
(iv) Book in
shop (Y or N)
(If not mentioned in the previous question, ask:) Do you have the Drug Retailer's Handbook?
1.
Yes
2.
No ----------- Go to Question X-E.
(If yes, ask:)
(ii)
How many times in the last two weeks have you used it? ______________ times
(iii)
How useful is it? _________________________________________________________
(iv)
How could it be made more useful for you in your work?
___________________________________________________________________________
___________________________________________________________________________
(v)
Why don't you use the manual more often?
___________________________________________________________________________
___________________________________________________________________________
72.
Does a doctor come here to examine patients?
1.
yes, respondent is a doctor
2.
yes , another doctor comes here
3.
no---------------- Go to Question X-F.
(If yes:)
1.
2.
4.
5.
How often?
Every day
A few times a week
Once a week
Less than once a week
73.
In general, how many doctors are there in the area? _________________________________________
74.
Do you ever discuss with doctors about the types of medicines to be brought?
1.
Yes
2.
No
75.
Do you ever discuss with them the use of drugs for a particular problem?
1.
Yes
2.
No
XI.
TRAINING
76.
May I know if you ever took the Drug Sellers Orientation Course?
1.
Yes
2.
No-----------------Go to Question XI-B
3.
Don't Know -----Go to Question XI-B
(If yes:) About how many years ago was that? __________
Can you remember the year? __________
(If yes:) What would have made the course more useful for you in your work?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
77.
Have you cleared the orientation examination?
1.
2.
3.
4.
Yes, pass
No, fail-------------------------------------Go to Question XI-C.
Never heard from Kathmandu ---------Go to Question XI-C.
Don't remember --------------------------Go to Question XI-C.
(If passed ask:) When did you pass the examination?
1.
Same year took course
2.
Following year
3.
Don't Remember
78.
Are you the owner of this shop
1.
Yes
2.
No
79.
Who else besides you dispenses in this shop?
____________________________________________________________________________
____________________________________________________________________________
80.
Which of them have qualified through the orientation course?
____________________________________________________________________________
____________________________________________________________________________
XII.
OBSERVATION
Sex of respondent
Size of shop
male
female
_________ room(s)
Room 1: ________________________ room length: _____________ by breadth:
___________________
Room 2: ________________________ room length:_____________ by breadth:
_____________________
Room 3: ________________________ room length:_____________ by breadth:
_____________________
Facing of the shop? _____________________________________________________________
Examination place? yes
no
Fridge?
yes
no
Electricity?
yes
no
Fan?
yes
no
Heater Type
Electrical Kerosene Charcoal
Carpet?
yes
no
Curtain?
yes
no