WHO How to investigate the use of medicines by consumers

Publication date: 2004

How to investigate the use of medicines by consumers WORLD HEALTH ORGANIZATION UNIVERSITY OF AMSTERDAM HOW TO INVESTIGATE THE USE OF M EDICINES BY CONSUM ERS W HO ROYAL TROPICAL INSTITUTE WHO/EDM/PAR/2004.2 How to investigate the use of medicines by consumers Anita Hardon University of Amsterdam The Netherlands Catherine Hodgkin Royal Tropical Institute The Netherlands Daphne Fresle Formerly of the Department of Essential Drugs and Medicines Policy, WHO © World Health Organization and University of Amsterdam 2004 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization and the University of Amsterdam concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization and the University of Amsterdam in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization and the University of Amsterdam do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Cover illustration by Victoria Francis Designed by minimum graphics Printed in Switzerland iii HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS Contents Acknowledgements iv Preface v 1 Why study medicines use by consumers 1 1.1 Introduction 1 1.2 Common patterns of inappropriate medicines use 2 1.3 From research to action 4 2 What infl uences medicines use by consumers 7 2.1 Introduction 7 2.2 The household level 7 2.3 The community level 10 2.4 The health institution level 11 2.5 The national level 13 2.6 The international level 16 3 How to study medicines use in communities 20 3.1 Introduction 20 3.2 Describing and identifying medicines use problems 20 3.3 Study of documents 22 3.4 Semi-structured interviews 24 3.5 Focus group discussions 28 3.6 Observation techniques 31 3.7 Structured interviews 33 3.8 Weekly illness recalls 36 4 Prioritizing and analysing community medicines use problems 43 4.1 Introduction 43 4.2 Prioritizing problems: the criteria 44 4.3 Rating the problems 45 4.4 Analysing problems and identifying possible solutions 47 5 Sampling 57 5.1 Introduction 57 5.2 Selection of study sites and study units 57 5.3 Purposeful sampling for qualitative studies 58 5.4 Probability sampling methods for quantitative studies 60 5.5 Bias in sampling 63 5.6 Sample size 64 6 Data analysis 67 6.1 Introduction 67 6.2 Sorting and ordering data 68 6.3 Making quality control checks 68 6.4 Processing qualitative data 69 6.5 Analysing qualitative data 70 6.6 Processing quantitative data 71 6.7 Analysing quantitative data 72 6.8 Conclusion 77 7 Monitoring and evaluating rational medicines use interventions in the community 78 7.1 Introduction 78 7.2 Monitoring 79 7.3 Evaluation 79 7.4 Summary guidelines 88 HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS iv Acknowledgements We thank Hans Hogerzeil, Jonathan Quick, Richard Laing, Ane Haaland, Michael Tan, Pimpawun Boonmongkon, Luechai Sringernyuang, Harriet Birungi, Andrew Chetley, Trudie Gerrits, Kathy Holloway and Kath Hurst for their very valuable comments on earlier versions of this manual, and Lisa Greenough and Annelies Dijkstra for their administrative support. We are grateful to Sheila Davey for editing our text. The chapters in this manual have been used as training modules in the Promoting Rational Drug Use in the Community courses. Since 2000 these courses have been co- organized annually by the University of Amsterdam, the Royal Tropical Institute of the Netherlands and the WHO Essential Drugs and Medicines Policy Department, together with various host institutions in developing countries. Feedback from participants has been of great value in improving the manual. We thank our colleagues at the Centre for Health Policy Studies, Mahidol University, Bangkok, Thailand, and the Child Health and Development Centre at Makerere University, Kampala, Uganda, for their help in conducting the courses and evaluating the modules. Chapters 5, on sampling, and 6, on analysis, are based on modules 30, 36 and 39 of the Applied Health Research Manual (Hardon et al. 20011). We thank the publisher, Ben van der Camp at Aksant, for permission to use parts of the modules for this manual. Finally, we wish to express our gratitude to the Department of Essential Drugs and Medicines Policy, the Ministry of Foreign Affairs of the Netherlands, and the University of Amsterdam for their fi nancial support, without which we would not have been able to write and publish this manual. 1 Hardon A et al. 2001. Applied health research: anthropology of health and health care. Aksant, Amsterdam. v Preface In developing countries, medicines may account for 30–40% of health expenditure. Many of these payments are made by individuals purchasing medicines for self- medication and only rarely on prescription. Understanding how and why consumers make the choices they do is the critical fi rst step to intervening to ensure that these precious resources are spent as safely and productively as possible. This manual is a successor to the 1992 WHO publication, How to Investigate Drug Use in Communities, a small but important book that has been reprinted eight times. A year later came How to Investigate Drug Use in Health Facilities. Since then numerous courses have been held and many studies undertaken, with valuable experience gained in understanding the use of medicines in health facilities and communities. This manual’s authors have been leaders in the movement to better understand and improve medicines use in the community. Study methods have been developed and adapted for use in different environments. They are no longer the sole province of social scientists with advanced training but can be used by many different people interested in this subject. The manual aims to bring these methods and approaches to community-based organizations, consumer groups, health workers and health system researchers. By understanding medicine use practices, focused, effective interventions can be designed, implemented and evaluated. To add further impetus, a companion volume is in preparation – How to Improve the Use of Medicines in Communities, describing how to plan and implement such interventions. Since 1992, when the fi rst manual was published, the world of medicines use has changed dramatically. At that time, the major concerns were treatment of acute diseases, misuse of injections and antibiotics, and wasted spending on ineffective tonics and vitamin preparations. In 2004, some of these concerns remain, particularly the misuse of antibiotics, however, injection rates have declined and many consumers are more aware of the issues relating to tonics and vitamins. But today new challenges exist! Chronic diseases such as AIDS and TB need long-term therapy, with all of the diffi culties of ensuring adherence to that therapy. TB programmes have used Directly Observed Therapy (DOT) with variable success in differing environments. Treating AIDS is even more diffi cult, with lifelong therapy to be taken at least twice a day. Understanding what can be done in the community to help patients take all of their medicines will be crucial for ensuring the success of treatment and preventing the emergence of resistance. This manual provides a practical guide to the methods that can be used to: • investigate the use of medicines by consumers to identify problems • design interventions, and • measure changes. Readers are encouraged to “learn by doing”. Health workers are trained to diagnose and treat individual patients. The manual aims to help health workers and many others to go beyond the individual and to study the community as a focus. By understanding why people take medicines as they do, it is possible to design interventions which are sensitive to the particular beliefs, practices and needs of that community. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS vi Although resources and the capacity to do studies are limited in many settings, it is hoped that this book will encourage readers to undertake research on medicines use pratices, if only on a small scale, and to report the results. The editor of the WHO journal the Essential Drugs Monitor is keen to receive such reports with a view to publication. WHO is grateful to the authors who have drafted, fi eld tested and revised this manual. We also appreciate the many comments that we have received from reviewers and from participants in Promoting Rational Drug Use in the Community Courses and the 2nd International Conference on Improving Use of Medicines, who have made suggestions on previous drafts. We welcome further suggestions and examples of instruments used that could be included in future revisions. Please send these to medmail@who.int or to the address below. Dr Richard Laing Medical Offi cer World Health Organization Department of Essential Drugs and Medicines Policy Avenue Appia, 1211 Geneva 27, Switzerland 1 Why study medicines use by consumers 1. WHY STUDY MEDICINES USE BY CONSUMERS 1.1 Introduction Essential medicines are one of the vital tools needed to improve and maintain health. However, for too many people throughout the world medicines are still unaffordable, unavailable, unsafe and improperly used. An estimated one-third of the world’s population lack regular access to essential drugs, with this fi gure rising to over 50% in the poorest parts of Africa and Asia. When available, the medicines are often used incorrectly: around 50% of all medicines are prescribed, dispensed or sold inappropriately, while 50% of patients fail to take their medicines appropriately (WHO 2002). Since the beginning of the 1980s the essential drugs concept has become one of the cornerstones of international and national health policy – infl uencing decision- making in not only developing but also industrialized countries. The selection and rational use of medicines are accepted as key principles of health service quality and management in both the public and private sectors. WHO has vigorously promoted the essential drugs concept and the rational use of drugs – at fi rst through the Action Programme on Essential Drugs, which became a powerful advocate for the new policies. National drug policies were promoted by WHO and others as a guide to action and a key framework within which to coordinate the various policy components needed to guarantee access to and rational use of medicines. For essential medicines to contribute to improved health, countries need to develop national medicines policies, ensure access to these essential drugs, strengthen drug regulation, and improve rational use of drugs in both the public and private sectors, and by both health professionals and consumers. Although much progress has been made in all these areas, health policy-makers have tended to focus more on the provision and regulation of medicines, and on efforts to improve health workers’ prescribing, than on efforts to ensure rational use of drugs by consumers. What is rational use? WHO’s defi nition is, “Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community” (WHO 1985). Rational drug use interventions that focus on health worker prescribing can only partly improve the use of drugs. This is because, as studies on medicines use by consumers have shown, self-medication is the most common form of therapy 1 choice and people often rely on informal drug distribution channels as much as on pharmacies. To address the problem of irrational use of medicines, health planners and administrators need specifi c information on: • the types of irrational use that occur in their country or district, so that strategies can be targeted towards changing specifi c problems • the amount of irrational use, so that the size of the problem is known and the impact of the strategies can be monitored • the reasons why medicines are used irrationally, so that appropriate, effective and feasible strategies can be chosen. People often have very rational reasons for using medicines “irrationally”. 1.2 Common patterns of inappropriate medicines use Not using the medicine in the way intended by the prescriber This is the problem which health workers tend to stress and which has been the focus of many drug use studies (Homedes and Ugalde, 1993). These studies, though suffering from methodological limitations, give a general view of low levels of adherence to medical regimes.1 People tend to forget the details of the advice given, or fail to purchase all the drugs that are prescribed, because they lack the fi nancial means to do so. Patients sometimes stop taking the prescribed drugs or take the wrong dosage. Homedes and Ugalde identify four types of patients who request medical advice but do not follow it: • those who are motivated to comply but do not know, or have forgotten, all or part of the recommendations • those who are knowledgeable but insuffi ciently motivated to follow them • those who may not be able to adhere because of poverty, inaccessibility to medication or other external constraints • those who change their minds and for a variety of reasons decide not to follow the recommendations. Homedes and Ugalde argue that poor consumer adherence to medical regimes is problematic but they also argue that adherence should be viewed in the light of the quality of health workers’ prescribing practices. Interventions to improve adherence only make sense if health workers’ prescribing practices are appropriate and rational. Self-medication with prescription drugs Another problem is that in many countries people can purchase drugs over-the- counter that legally should only be sold on prescription. In the Philippines, Hardon (1991) found that people keep copies of prescriptions to re-use. Doctors’ consultations are expensive and repeated use of prescriptions is a way to economize. Self-medication with prescription drugs is especially a problem in developing countries where pharmacies freely supply medicines over-the-counter, as do informal drug shops and small groceries. Sometimes people even self-medicate with prescription drugs on the advice of traditional healers. People keep stocks of leftover medicines in their homes, and re-use them or give them to neighbours or relatives who request them. These practices also occur in countries where dispensing of medicines is regulated more strictly. The possibility of buying medicines through the Internet 1 NB: Compliance and adherence are words used to describe whether a consumer takes a medicine in the way intended by the health professional who prescribed it or according to the instructions on the packaging. Some people prefer not to use the word compliance because it implies a normative view that the consumer should obey/comply with instructions. The word concordance may also be encountered in this context. It refers to a consultation process between the health professional and the consumer, who reach agreement about the best course of treatment in a way which values the perceptions and opinion of both parties. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 2 means that drugs available only on prescription in one country can be obtained by post from a country where regulation is less strict. Immigration and people’s increased mobility mean that more people buy medicines where it is easy to obtain them – or obtain them through family and friends. For example, immigrants, used to the free availability of “prescription drugs” in their countries of origin, may still obtain these medicines from visiting friends and family members. Misuse of antibiotics Antibiotics are important drugs, but they are over-prescribed and overused in self- medication for the treatment of minor disorders such as simple diarrhoea, coughs and colds. When antibiotics are used too often in sub-optimal dosages, bacteria become resistant to them. This is a serious concern to public health policy-makers. The result is treatment failure when patients suffering from serious infections take antibiotics. People buy sub-optimal dosages because they cannot afford the full course prescribed, or because they are not aware of the need to complete antibiotic courses. Even in industrialized countries where antibiotic dispensing is better regulated, non-compliance with the prescribed regime is a common problem. People who have not understood the need to complete the course stop using antibiotics when the symptoms disappear, while others take an overdose as they think that this will lead to faster recovery. Studies by Lansang et al. (1990, 1991) and others highlight some of the problems with antibiotic use in the Philippines. Surveying 59 drug stores in Makati, Metro Manila, the authors found that two-thirds of 1608 antibiotic transactions were made without prescriptions. They also found that for each antibiotic prescribed the customers purchased only 10 units (tablets or capsules) or less. In a rural setting in the Philippines, the authors found that 57% of 6404 antibiotic transactions were without a prescription. The median number of antibiotics dispensed in a single visit was six tablets or capsules. These fi ndings indicate widespread sub-optimal use of antibiotics in self-medication in the Philippines. Another interesting study by Boomongkon and colleagues (1999), reveals how concerned women are about chronic and recurrent uterus-related problems in Northeast Thailand. Women refer to symptoms, ranging from abdominal and lower back pain to vaginal discharge, itching, odour and rash, using the term pen mot luuk (literally “it’s the uterus”). They fear that these problems will turn into cervical cancer if not treated, a perception inadvertently perpetuated by the cervical cancer education and screening programmes. Eighty percent of women surveyed (n = 1028) reported self-medicating the last time they experienced symptoms. Two-thirds of them bought antibiotics, specifi cally under-dosages of two brands of tetracycline, Gaano and Hero. Tetracycline is medically inappropriate for many of the problems that women classify as mot luuk, but the manufacturer of Gaano appears to endorse its use by having a picture of a uterus on the package. Overuse of injections Health workers and patients in many countries believe that injections are more effective than tablets. This not only leads to unnecessary expenditure (in many cases tablets are a cheaper form of therapy), it also leads to unnecessary health risks when the injections are administered in unhygienic conditions or syringes and needles are re-used without being sterilized. A WHO study on injection practices in developing countries found that in Uganda around 60% of patients bring along their own syringe and needle when they visit health facilities for treatment. The instruments have generally not been sterilized properly. People keep the injections at home because they do not trust the injections provided in the health facilities (Van Staa and Hardon, 1996). 1. WHY STUDY MEDICINES USE BY CONSUMERS 3 Overuse of relatively safe medicines In many countries people believe that they need a “pill for every ill”. At the onset of all kinds of minor disorders they immediately take drugs. Vitamins and analgesics such as multivitamins, acetylsalicylic acid and paracetamol, though relatively safe, are the most commonly used drugs in many countries. This practice is not without risks. Aspirin can cause stomach bleeding and paracetamol, if taken in excess, can cause death. In a community study in Thailand, Sringernyuang (2000) describes the overuse of analgesics in rural Thai communities. People are addicted to analgesics for pain relief, related to hard agricultural labour. For the agricultural labourers a painkiller a day is essential. It allows them to continue work and have a regular income. Health workers recognize that the practice is unsafe, as it can lead to stomach bleeding, a commonly reported health problem in Thailand. Unsafe use of herbal medicines In developing countries people use herbal medicines routinely in self-care. In many countries programmes exist that test the safety and effi cacy of these medicines, and some of them are selected for inclusion in national health programmes. The production of herbal medicines is commercialized in countries, such as China, India and Thailand, and marketing is similar to that for modern pharmaceuticals. In industrialized countries the use of herbal medicines is also increasing. People believe that they are more natural than modern pharmaceuticals. Some herbal medicines are potent, and their safety is not as evident as people think. Also they can be dangerous when taken in combination with modern pharmaceuticals. For example, the antidepressant herb St John’s Wort cannot be used in combination with Selective Serotonin Re-uptake Inhibitors (SSRIs). Use of non-essential combination drugs When suffering from coughs and colds, people tend to take all kinds of cough and cold remedies that contain more than one active ingredient. Sometimes these drugs even contain substances that counteract each other: one substance to suppress a cough and another to encourage it. Hardon (1991) notes that the most popular cough and cold remedies in the communities where she conducted her study combine substances that counteract each other. Such remedies do not contribute to a cure and are a waste of money. People should take the active ingredient that they need, and if they need two drugs then they can take two different preparations. Use of needlessly expensive medicines In many countries people rely on brand name drugs when choosing therapies. Branded products are often more expensive than the same products under generic name. Also people do not realise that two different brand name drugs may contain exactly the same substance. The price of medicines is an important concern for consumers. 1.3 From research to action Organizations working with medicines programmes need to pay more attention to educating consumers on the appropriate use of medicines. Interventions directed towards consumers are most relevant if they focus on common patterns of irrational medicines use, and examine medicines use problems that consumers consider to be important. Policy-makers need to be involved in research into drug use interventions to facilitate the process of translating evidence into action. Drug use studies should be an integral part of the process by which we develop interventions to enhance more HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 4 appropriate drug use by consumers. An overview of the process is given in fi gure 1. Research is an integral part of this intervention cycle. It is the main activity in all steps, except 4 and 6 that concern the actual selection and implementation of interventions. Step 1: Identify medicines use problems. To identify drug use problems you fi rst need to describe common drug use practices and assess to what extent these are rational, and to describe what people in the communities and health workers consider to be drug use problems. In this step you aim to get an overview of community drug use problems. You can use existing (secondary) data, and if resources are available new data on drug use by consumers can be collected. In this phase drug use studies should focus on what people do with drugs and what they consider to be problems in drug use, not on why they take drugs the way they do. Step 2: Prioritize medicines use problems. The overview of problems identifi ed in step 1 forms the basis for step 2, in which problems are prioritized and selected as the focus of your intervention. Step 3: Analyse medicines use problems and identify possible solutions. In this step you analyse the factors that contribute to and cause the selected problem and identify possible solutions. Research in this step aims to describe the core-problem(s) in more detail and analyse why the problems occur. In conducting such an analysis you need to consider the various layers of infl uence, as discussed in Chapter 2 of this manual. These layers include the family, the community, the health institution, the state, and the global environment. Such analysis helps you develop an appropriate intervention aimed at changing the inappropriate medicines use practices. The analysis is done in consultation with key stakeholders. They also help to identify possible solutions. 1. WHY STUDY MEDICINES USE BY CONSUMERS Figure 1. Steps in developing an effective intervention aimed at enhancing rational drug use by consumers 5 Step 4: Select and develop interventions. How to select and develop rational drug use interventions is dealt with in the forthcoming companion manual, How to Improve the Use of Medicines in Communities. This guide will provide information on how to develop and use printed materials, folk and mass media, and video, as well as giving information on how to work with journalists, and advocate for better health and medicines policies. The intervention methods presented in the manual can be used to change individual behaviour and to convince health policy-makers and politicians that they need to change health and medicines policies. Step 5: Pretest interventions. Once an intervention has been developed you will need to pretest it. Pretesting involves trying out the intervention and/or educational materials to be used in the intervention with a small group of the target audience. The group’s feedback and the results are used to fi ne-tune the intervention and the evaluation and monitoring activities. Step 6: Implement interventions. Pretesting can lead to changes in the way the selected intervention is implemented. Once the intervention has been optimized, it can be implemented. Step 7: Monitor and evaluate interventions. Research plays a role in monitoring and evaluating interventions. Evaluation results serve to improve an intervention, and help in sharing successes and failures with others. References Boonmongkon P, Pylpa J, Nichter M (1999). Emerging fears of cervical cancer in the Northeast of Thailand. Anthropology and Medicine, 6(3):359–380. Hardon A (1991). Confronting ill health: medicines, self-care and the poor in Manila. Quezon City, Health Action Information Network. Hardon A, Le Grand A (1993). Pharmaceuticals in communities. Practices, public health consequences and intervention strategies. Bulletin 330. Amsterdam, Royal Tropical Institute. Homedes N, Ugalde A (1993). Patients’ compliance with medical treatments in the Third World. What do we know? Health Policy and Planning, 8(4):291–314. Lansang MA et al. (1990). Purchase of antibiotics without prescription in Manila, the Philippines. Inappropriate choices and doses. Journal of Clinical Epidemiology, 43(1):61–67. Lansang, MA et al. (1991). A drugstore survey of antibiotic use in a rural community in the Philippines. Philippine Journal of Microbiology and Infectious Diseases, 20(2):54–58. Sringernyuang L (2000). Availability and use of medicines in rural Thailand. Amsterdam, Academisch Proefschrift, University of Amsterdam. Ugalde A, Homedes N, Collado J (1986). Do patients understand their physicians? Prescription compliance in a rural area in the Dominican Republic. Health Policy and Planning, 1(3): 250–259. Van Staa A, Hardon A (1996). Injection practices in the developing world: a comparative review of fi eld studies in Uganda and Indonesia. Geneva, World Health Organization. WHO/DAP/96.4. WHO (2002). Promoting rational use of medicines: core components. WHO Policy Perspectives on Medicines, No.5. Geneva, World Health Organization. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 6 2 What infl uences medicines use by consumers 2. WHAT INFLUENCES MEDICINES USE BY CONSUMERS 2.1 Introduction This chapter discusses the various factors that infl uence medicines use by consumers. It provides a framework which links individual drug use behaviour to the multi-layered environment which shapes it. This includes the: • household level • community level • health service institution level • national level • international level. The framework described provides a basis for the analysis of medicines use problems. It can also assist in the development of interventions aimed at changing behaviour and the environment in which medicines use takes place, in order to bring about more appropriate use. The framework helps to identify why medicines are used irrationally, so that appropriate, effective and feasible strategies can be chosen to confront the drug use problems. 2.2 The household level The way medicines are used is infl uenced by individual beliefs about them, which in turn may have been shaped by members of the immediate family and those in extended family networks. Important factors at this level are outlined below. Perceived need for medicines Evidence suggests that people have lost their trust in the body’s ability to fi ght disorders without the ‘help’ of medicines, even for self-limiting disorders, such as colds and diarrhoea. Studies on drug use by consumers show that people think that they should take medicines immediately at the onset of illness to prevent it from becoming worse. People take medicines not only to treat symptoms of ill health but because they believe that medicines are also needed to stay healthy. Preventive use of drugs is a 7 topic often neglected in discussions on appropriate medicines use. However, drug sales increasingly tend to involve products such as vitamins, which are commonly taken because people think they will prevent illness. Ideas about effi cacy and safety People use medicines according to their own ideas about drug safety and effi cacy. Anthropological studies reveal that people believe that the safety and effi cacy of medicines are determined by a number of factors including: • the colour and shape of medicines. In Sierra Leone, for example, red medicines are thought to be good for the blood (Bledoe and Goubaud, 1985) • the method of administration. In Uganda, for instance, people believe that medicine injected into the bloodstream does not leave the body as quickly as that administered orally. Oral medicine is compared to food, which enters the digestive system and eventually leaves the body through defecation (Birungi, 1994) • compatibility between the medicine and the person taking it. A medicine that is effective for one person may not be effective for another. In the Philippines, people use the concept hiyang to explain why a medicine did not work for a particular patient. In Indonesia and Thailand similar concepts exist • whether a medicine was effective in the past. If so, they are likely to use it again • the “newness” of a medicine (new medicines are believed to be more effective). People’s choice of medicine usually also depends on the cause that they attribute to the illness and its perceived severity. In Ghana, for example, people consider heat to be the main cause of measles. Heat also causes constipation and stomach sores in children. To treat measles people use Septrin (cotrimoxazole) syrup, multivitamin syrup, calamine lotion, akpeteshie (local gin) and a herbal concoction given as an enema to ‘fl ush out’ the heat (Senah, 1997). If illnesses are thought to be caused by witchcraft, it is likely that a traditional healer will be used rather than medicines bought at a local shop. However, if the illness is believed to be caused by bodily imbalance related, for example, to hot-cold notions, it is likely to be treated with medicines. More severe disorders may be brought to the attention of health workers or traditional healers, depending on what the cause of illness is believed to be. Finally, people’s ideas about a medicine can actually affect its effi cacy. This has been documented in numerous studies on the psychological and physiological effects of placebos (harmless substances that look like the actual medicine but contain no active ingredient). In double-blind trials on new drugs, for example, approximately one-third of the participants respond to a placebo. Uncertainty resulting in poly-therapy People are often uncertain about the cause of disorders as well as the most effective treatment. As a result, they tend to use several therapies at the same time, often BOX 1. MEDICINE BELIEFS AMONG RURAL VILLAGERS IN PAKISTAN “Medicine is needed for every illness. If medicine is not used, the illness will become serious.” “All illnesses need medicine. No illness will be cured without medicine.” “Medicine is to the sick, what water is to the thirsty.” “If we don’t get medicine, how will we get cured?” Rasmussen ZA et al. (1996). Enhancing appropriate medicine use in the Karakoram Mountains. Community drug use studies. Amsterdam, Het Spinhuis. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 8 combining modern and traditional remedies. If the condition is serious they may consult a variety of modern and traditional health providers. Drug consumption roles Drug use is not only defi ned by people’s ideas about medicines but is also determined by the role people play within families in the process of buying, administering and deciding about medicine use (see box below). 2. WHAT INFLUENCES MEDICINES USE BY CONSUMERS The cost of medicines Cost is a major factor shaping drug use at the family level in developing countries and among those patients in industrialized countries who are not covered by insurance schemes. When presenting a prescription for several different medications at a pharmacy, consumers have to decide which medicines they can afford to buy. In developing countries, 50%–90% of medicines are paid for ‘out-of-pocket’. In parts of Africa, Asia and Eastern Europe, drugs account for up to 80% of household health expenditures. People frequently waste money on drugs. Often they are unaware that cheaper, generic alternatives exist or they do not realize that many medicines are ineffective. Public health workers are sometimes surprised that people pay for medicines in the private sector when they could obtain them free of charge at public health centres. Studies show that people are willing to pay for what they consider to be good and effective remedies. Moreover, people often believe that more expensive medicines (usually brand name products) are more effective than cheaper ones. Interventions which enable people to fi nd cheaper alternatives for medicines, by teaching them how to identify the active component of a drug, and how to compare prices, can draw on strong community interest. This is because such interventions help to deal with the high cost of medicines, an important day-to-day concern for people who are poor.1 Literacy levels of consumers Literacy determines the extent to which people have access to written information on medicines, such as package inserts or educational posters with a written message. However, people who cannot read sometimes ask others, including their children, to explain what is written on or inside medicine packages. BOX 2. CULTURAL INFLUENCES ON THE SELECTION AND USE OF MEDICINES In the Philippines, (Hardon, 1991) mothers decide whether or not they should buy and give medicines to their children. Men are usually not involved in decision-making on the treatment of common childhood illnesses. Instead, women consult with neighbours and relatives on treatment options. Married women in this country manage household expenses and the family’s income, and do not have to consult their husbands about the cost of medicines. Husbands take a more active role only when a health problem becomes severe. In contrast, in Pakistan, (Rasmussen et al., 1996) women are constrained in their efforts to treat children’s health problems. They cannot go to the bazaar or hospital in town to obtain drugs, as cultural norms forbid such mobility for women. Because male family members must buy medicines, men are more closely involved in decisions about children’s treatment. They often receive information on a medicine’s use at the bazaar or health facility and pass this on to their wives who actually administer the drugs. 1 WHO and HAI (2003) have developed a new approach to measuring medicine prices, see references. 9 The “power” of medicines At the family level, medicines use is also infl uenced by the pharmaceutical effi cacy of medicines. Analgesics are popular because they relieve pain; cough syrups because they stop the cough; antibiotics because they cure infections. Some medicines, such as tranquillizers, are even more “powerful” and may cause dependencies. 2.3 The community level The community is the immediate context in which individuals and families deal with their health problems. People talk to each other about therapies, creating and reinforcing existing drug use cultures, and they rely on local sources of drugs. Factors that infl uence medicines use at the community level include: Medicines use cultures Drug use studies often fi nd a clear, local drug use culture in communities. A set of medicines is used routinely to treat the most common health problems. People know what medicines are needed for these problems and they obtain them at local drug stores, general shops or the market. For example, in Uganda, most people use chloro quine as fi rst-line treatment for malaria and buy it at general stores. Medicines supply systems The community drug supply system plays an important role in drug use by consumers. Public health managers often assume that people get medicines at public health facilities, such as local primary health centres, which stock essential medicines. However, this is usually not the case. Most studies on community drug use show that people tend to rely on informal and private channels for their drug needs, using these outlets to buy medicines without a prescription. An additional advantage is that purchases can also be made at convenient times, as these private and informal channels have long hours and open at the weekend. Consumers’ decisions on where to obtain their medicines, or whether to obtain any at all may be infl uenced by previous experience, distance and transportation costs, the stigma attached to visiting formal health outlets, work or family demands or similar considerations. Figure 2 shows the drug supply channels used by consumers in a poor urban community in the Philippines. It reveals that 75% of medicines are obtained from the private sector, either directly from town pharmacies or through sari-sari (neighbourhood) stores. Information channels Information on medicines is a valued commodity which also shapes drug use. Drugs bought at the pharmacy rarely include package inserts and the brand name is often the only information available to consumers. Other possible information sources include: • radio and television programmes • educational sessions organized as part of primary health care programmes • community health workers • drug sellers in small shops or markets • traditional healers who have incorporated pharmaceuticals into their thera peutic regimes • magazines, newspapers and comics, re-used prescriptions and popular health books • advertisements. Primary health care programmes that aim to enhance appropriate use of medicines HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 10 often ignore the messages relayed to consumers through mass media drug promotion by manufacturers. In the Philippines, Hardon (1991) found that the most commonly used medicines in self-care were those promoted most frequently on the local radio station during times when women listened while performing household chores. The station aired three to four of these advertisements per hour. 2.4 The health institution level Health facilities, including health centres and hospitals in the private and public sectors, infl uence consumers’ medicines use. Consulting health workers Household drug use studies in developing countries suggest that most medicines are taken without advice from health workers. Of particular importance are the fi ndings of community-based studies conducted in Thailand, the Philippines, Pakistan and Ghana (Hardon and Le Grand, 1993). In these studies, researchers visited families at regular intervals to record the occurrence of common health problems, such as cough and diarrhoea, and the chosen therapy. The fi ndings suggest that a large proportion of common health problems are treated by family members without fi rst seeking health worker advice. Roughly half of the self-care cases were treated with modern pharmaceuticals (Hardon and Le Grand, 1993; Rasmussen, 1996). Quality of prescribing The quality of health workers’ prescribing is a major determinant of how consumers use medicines. This is true, even if in terms of volume, most medicines are taken without health worker advice. The quality of prescribing plays a crucial role in the treatment of serious health conditions when people do tend to consult health workers. It also affects the treatment of less severe conditions, as people tend to remember the advice given and use it in later episodes of self-medication. In the Philippines it was observed that people keep prescriptions in their homes for re-use (Hardon, 1991). 2. WHAT INFLUENCES MEDICINES USE BY CONSUMERS Figure 2. Community drug distribution channels: an example from the Philippines Source: Hardon, AP. (1991). Confronting ill health: medicines, self-care and the poor in Manila. Quezon City, Health Action Information Network. 11 Studies conducted by members of the International Network for Rational Use of Drugs (INRUD) document how health workers practice poly-pharmacy. A study conducted in Indonesia found that the average number of drugs used to treat illnesses presented to the health worker was 3.8, both for children under fi ve and for the fi ve and over age group. Patients seemed to receive a similar mix of vitamins, analgesics and antibiotics irrespective of their disorders. The way in which health workers prescribe multiple medicines reinforces consumer beliefs that they need “a pill for every ill”; and that a cure is unlikely without using medicines. In some countries, professional organizations have been created to inform health workers about rational prescribing and rational drug use. Health institutions can also adopt an essential medicines list and standard treatment guidelines in order to increase rational use of medicines. Quality of the consultation Numerous studies on adherence (Homedes and Ugalde, 1993) suggest that people rarely take medicines as prescribed. Some obvious examples include the use of antibiotics and antituberculosis medications in inadequate dosages. People also follow irregular drug regimes for chronic conditions such as hypertension and diabetes. It has been estimated that half of the medicines prescribed for chronic conditions are not taken (Haynes et al., 1996). Non-adherence can be related to the health worker – consumer interaction. If the health worker does not explain the need to complete treatments, the dosages required, and ways to handle side-effects, then adherence to the prescribed regime is less likely. In a study of 69 hypertensive and diabetic patients in Zimbabwe, Nyazema (1984) found that 60% of the patients did not understand their diagnosis and how to take the prescribed drugs. A study of 119 patients in the Dominican Republic found that 50% could not recall the dosage, frequency or interval of recom mended use (Ugalde et al., 1986). This was particularly problematic among the elderly, those with minimal literacy skills and when multiple prescriptions were given. While non-adherence generally has a negative connotation, Conrad (1985) points out its positive aspects. Children with asthma, for example, have been reported to keep their medicines as their own property, and adjust the frequency and intensity BOX 3. CONSUMERS’ ADVICE-SEEKING BEHAVIOUR Researchers conducted a household survey in four Thai villages covered by a primary health care (PHC) programme that promoted the use of herbal medicines in self-care. One hundred and twenty families participated in the two-month study in which a total of 1,755 cases of illness were recorded. The study found that people in the four villages only consulted a health professional in 7% of the illness episodes. Seventy percent of the illnesses were initially treated by self-care. Approximately half of the cases were treated with modern pharmaceuticals and the other half with herbal remedies. Le Grand A, Sringernyuang L (1989). Herbal drugs in primary health care. Amsterdam, Royal Tropical Institute. A household survey was conducted in two villages covered by an NGO primary health care programme (AKHS) and two control communities in Pakistan’s Karakoram Mountains during a period of seven months. A total of 897 illness episodes were recorded. In the PHC communities 44% of the recorded illness episodes were treated without health worker advice; in the control communities this percentage was slightly higher, 52%. Self-care practices included the use of traditional and herbal remedies, the use of modern pharmaceuticals and no treatment. In the PHC communities 16% of the recorded illness episodes were treated with modern pharmaceuticals without health worker advice. This number was 11% for the control communities. Rasmussen ZA et al. (1996). Enhancing appropriate medicine use in the Karakoram Mountains. Community Drug Use Studies. Amsterdam, Het Spinhuis. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 12 2. WHAT INFLUENCES MEDICINES USE BY CONSUMERS of inhalations depending on the severity of their symptoms (Sanz, 2003). Middle-aged patients with multiple health problems have likewise been shown to adopt ´fl exible´ drug use regimes, in response to their experiences of symptoms and side-effects and varying demands of their daily lives. They generally intend to take as few drugs as possible because they hope to maximize the quality of their lives (Hunt et al., 2003). Doctors say that not taking medicines according to the prescription means poorer health outcomes, but patients argue that only they can know what works for them and what does not. To bridge this gap, it has been proposed that concordance is a better concept. It means shared decision-making and arriving at an agreement on the use of medicines that respects the beliefs and experiences of the patient (Jones, 2003). Quality of dispensing Medicine dispensing is strictly regulated in most industrialized countries. Those who dispense drugs must complete certain levels of training depending on the types of medicines they dispense. It is increasingly recognized that pharmacists have an important role to play in providing information on medicines, to complement the information given by doctors. Pharmacies are also important targets for drug promotion campaigns. In developing countries untrained pharmacy workers tend to dispense medicines in shops owned by pharmacists. These workers have little background knowledge about medicines. However, they are important sources of information on a wide range of medicines (including prescription-only drugs). Medicines are often dispensed in small sachets with little information about their content, use and precautions. Often package inserts meant to inform consumers about a medicine are not given to them when the drug is purchased. Medicines dispensed at markets or informal drug stores usually include no written information at all. Often they are wrapped in newspaper and sold by the tablet. Doctors who also dispense drugs for profi t are likely to prescribe more than non- dispensing doctors. A comparative study in Zimbabwe found that dispensing doctors prescribed on average 2.3 drugs per prescription, while non-dispensing doctors prescribed only 1.7 drugs. Dispensing doctors were also more likely to inject patients, 18.4% versus 9.5% (Trap et al., 2002). Regular supply People judge health centres by whether they have a regular supply of medicines. Often when consulting health workers in developing countries, people fi nd that there are no drugs available. Because consumers know that public health centres often lack medicines, they may go directly to pharmacies and informal drug shops when they or someone in the family become ill. Cost of medicines Often fees for medicines in public health services are relatively low. People pay more in the private sector. They often do so because medicines in the private sector are believed to be more effective. 2.5 The national level In most developing and transitional economies, medicines represent the second largest government health expenditure after personnel costs. Getting the best health care value for such expenditure is vital. Consumer use of medicines is affected by government policies on provision of essential medicines through public health channels and by the regulation of the supply and promotion of medicines by the private sector. 13 Implementing essential medicines policies Today more than 150 countries have an essential medicines list. In 1999, 71 countries reported to WHO that the list guides drug procurement in the public sector (WHO, 2000). However, drug supply in the private sector is generally neither regulated nor guided by the essential medicines policy. This is a problem, as studies show people rely heavily on private and informal sources of medicines. The Philippine market, for example, includes more than 14,000 medicines. Many of these drugs are not essential, expensive, unsafe and ineffective. Most of them can be bought over-the-counter even if they are registered as prescription-only products. It is impossible for rational drug use programmes to inform consumers about all 14,000 medicines on the market. Essential medicines policies tend to emphasize drug procurement and supply, and appropriate prescribing by health workers. Promotion of rational drug use by consumers is not a priority in many countries. Reductions in spending in the public sector make it diffi cult for governments to provide quality health care and the essential medicines that people need. It also becomes more diffi cult to control the way in which drugs are used. The current focus on private/public partnerships makes it much harder for governments (or international agencies) to promote policies which may not be consistent with the interests of major players in the private sector or with ‘free market’ philosophies. Social solidarity and support to the public sector are less of a priority and the solutions to lack of access are increasingly sought in terms of stimulating the private sector and partnership with the industry rather than in strengthening basic services and reallocation of resources. In some countries, particularly in Latin America, the increasing importance of the private sector has been accompanied by reduced government regulatory control of pharmaceuticals. However, as WHO has pointed out, as the role of the private sector increases stronger not weaker central, i.e. government regulatory control, is required. The private sector includes private pharmacies and drug sellers, private not-for- profi t NGOs (for example, the Church is a major provider in many African countries) and the informal or illegal sector (many drugs exchange hands through market stalls or are sold again after being prescribed by a health worker). The private sector is harder to regulate/control and infl uence than the public sector. Improving drug use and implementing the essential drugs concept in the informal and illegal sectors is very hard. Drug promotion Drug promotion creates demand for medicines in various ways. Firstly, it defi nes illness conditions that need treatment. It also promotes the idea that medicines are the best remedy as opposed to non-drug alternatives. Lastly, it tends to emphasize a medicine’s effi cacy while minimizing possible health risks. Companies spend vast amounts of money (an estimated one-third of sales revenues) on marketing. This is often more than double the amount spent on research and development (Mintzes, 1998). Campaigns to promote the rational use of medicines have much less money to spend. In the absence of effective regulation of drug promotion, community interventions to promote rational drug use will have limited impact. Drug promotion to consumers is becoming an increasingly important component of drug companies’ marketing strategies (Mintzes, 1998). In the past, most consumer advertisements promoted over-the-counter medicines. More recently, companies have started promoting prescription drugs to consumers. Direct-to-consumer advertising (DTCA) for prescription drugs is allowed in the United States and New Zealand. It is now under consideration by regulatory authorities elsewhere. The pharmaceutical industry has devised ways to create consumer demand for prescription products even where DTCA for prescription medicines remains illegal (Mintzes, 2002). HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 14 WHO’s Ethical Criteria for Medicinal Drug Promotion (WHO, 1988), adopted at the 1988 World Health Assembly, call for promotion of prescription and over-the-counter drugs to contain reliable claims without misleading or unverifi able statements. The Criteria also state that promotion should not contain omissions that could lead to health risks. They emphasize that promotion should not be disguised as educational or scientifi c activities. Ten years later, WHO reported that the Criteria have only been adopted to a ‘modest’ degree in national drug policies. Criteria for drug promotion are only mentioned in 17 of 42 national medicines policies studied and their implementation remains weak (WHO, 1998). A separate study done in Australia, for example, analysed 140 advertisements to the public and found that only 29% provided warnings or cautions about possible health risks (Watson, 1995). Financing and reimbursement One of the big differences between consumers in industrialized countries and most of those living in developing countries is the payment mechanisms for drugs. In industrialized countries, the cost of prescribed medicines tends to be covered by social security or private insurance schemes. At the national level, insurance companies’ reimbursement policies play an important part in shaping medicine use. In some countries, such as the Netherlands and the United Kingdom, the government decides which medicines will be reimbursed, so ensuring equitable access to essential drugs. In the United Kingdom, the National Institute for Clinical Excellence (NICE) is charged with determining which new drugs should be available in the National Health Service. In developing countries, medicines are sometimes available in public health services. To obtain them, people must often pay a user fee, a cost that is sometimes proportional to the amount of medicine received. However, access to medicines in the public sector is limited. The majority of medicine purchases occur in the private sector in most countries. Drug costs are an important factor in consumers’ decisions on how to treat illness episodes, as we have seen. Consumer advocacy Consumer advocacy can infl uence drug use at the national level of health care. Advocacy initiatives include monitoring implementation of essential medicines policies, informing health workers and consumers about the rational use of medicines, and highlighting unethical drug promotion practices. However, many developing countries, particularly in sub-Saharan Africa and the Western Pacifi c region do not have consumer organizations. Those that do exist may not be powerful enough to infl uence policy. Patient organizations tend to focus on the medicine needs of specifi c patient populations. At times they push governments to allow new drugs on the market and lobby for these drugs to be reimbursed. In such campaigns patient groups are often the allies of pharmaceutical manufacturers. The media The media can play a key role in raising awareness on problems with drugs, publicizing serious health hazards related to drugs, when these are brought to their attention. Also, unethical promotion is an issue that journalists tend to pick up. Media attention can have a positive effect on consumer drug use, but can also sensationalize the discovery and potential effi cacy of new untried and often unregistered drugs. The media are frequently used by the pharmaceutical industry to covertly promote products in the guise of what has come to be known as “advertorials”. Moreover, the pharmaceutical industry is often a signifi cant advertiser and broadcasting companies, newspapers and journals may be hesitant to publish information perceived by the industry to be negative. Pharmaceutical companies attempt to interest mass media journalists in their 2. WHAT INFLUENCES MEDICINES USE BY CONSUMERS 15 medicines. For example, one study reported that even though journalists tend to be sceptical about information from industry sources, in practice they often use industry materials for articles on medicines (van Trigt, 1995). The researcher found that drug manufacturer, GlaxoSmithKline, informed Dutch journalists about its new anti-migraine drug sumatriptan (Immigran) at a scientifi c meeting before the product was offi cially registered. The announcement led to a series of newspaper and magazine articles that reported on the “new drug against migraine, not yet available in the Netherlands” and stated that the “new anti-migraine drug is effective”. This media coverage led to a discussion in the Dutch Parliament on ‘clandestine advertising’. The same debate has taken place in the United Kingdom, with an incontinence campaign initiated by the company Pharmacia and Upjohn as the focus. Television advertisements used in the campaign encouraged women with bladder control problems to see their doctors although DTCA is illegal. In an interesting twist, some of these ‘disease awareness’/ DTCA campaigns are strongly supported by patient groups. This may be linked to the fact that patient groups (both national and international) are increasingly and sometimes solely funded by the pharmaceutical industry (Herxheimer, 2003). Public education on medicines for consumers Few countries have effective public education programmes. Often the programmes are limited in coverage and content, for example, there may be educational programmes on malaria treatment, but not on other diseases. School curricula are often put forward as an ideal medium for public education on medicines, but only a few countries have such curricula. 2.6 The international level Drug use by consumers is also infl uenced by factors at the international level including: Global trade regulation and access to drugs Globalization and the international regulation of trade have important consequences for health policy. Concerns about the consequences of globalization and international trade agreements and what were described as the ‘non-level playing fi eld’ on which they were developed, were fi rst raised at the 1996 World Health Assembly. The lack of fi nancial access to patented HIV/AIDS medicines in developing countries and alliances between health and development groups in both developed and developing countries have brought these issues to the forefront of national and global agendas. The World Trade Organization’s (WTO) Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) obliges all WTO Member States to provide 20 years of patent protection for medicines. Industrialized countries should have implemented TRIPS by 1996, developing countries had to introduce national regulation on intellectual property by the year 2000 and least developed countries have until 2016 to do so. The 2001 meeting of the World Trade Organization in Doha acknowledged that access to medicines should have primacy over commercial interests (see Médecins Sans Frontières, 2003). Donor support Over the past decade there has been a shift in donor support away from vertical programmes, such as essential drugs programmes, and towards health reform and sector-wide approaches. Health reform policies affect local-level implementation of essential drugs programmes. They generally promote collaboration with the private sector, the introduction of user fees and decentralization of health care decision- making, including pharmaceutical procurement and supply. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 16 There have been several recent efforts to mobilize resources in order to increase access to specifi c, greatly needed medicines and vaccines in developing countries. Examples of this trend include the Global Alliance for Vaccines and Immunisation (GAVI), the Medicines for Malaria Venture public-private partnership to enhance malaria drug supply and the Global Fund for HIV, TB and Malaria. These initiatives can potentially increase access in developing countries to urgently needed medical technologies. An interagency committee including a wide range of NGOs and UN agencies has published the second edition of Guidelines for Drug Donations (WHO/EDM/PAR/99.4) which aim to ensure appropriate supply and rational use of donated medicines. Global consumer advocacy As is the case at the national level, consumer advocacy at the global level is vital for rational drug use. Consumer organizations operating in the global arena lobby for rational medicines policies within the formulation of world health policies. They monitor the adoption and implementation of international agreements. Such groups also publicize inappropriate or harmful activities carried out by the pharmaceutical industry. The global advocacy movement also supports national organizations in their campaigns for structural change and rational drug use. The Internet The Internet is a very important source of information on health and medicines for people who can access it. It also serves as a tool for advocacy and networking. However, its lack of borders and regulation also makes it a popular way to promote drugs on industry-sponsored web sites and sites containing material on specifi c health conditions. WHO has published guidelines to help consumers (and health workers) fi nd reliable information on the Internet (WHO, 1999). Table 1 overleaf gives an overview of the main factors infl uencing drug use by consumers, according to their level of infl uence. You can add factors to this list based on local discussions and your own analysis of what infl uences consumers’ drug use in your own country. References Birungi H et al. (1994). Injection use and practices in Uganda. Geneva, World Health Or gan i- zation. WHO/DAP/94.18. Bledsoe CH, Goubaud MF (1985). The reinterpretation of western pharmaceuticals among the Mende of Sierre Leone. Social Science and Medicine 21(3):275–82. Conrad P (1985). The meaning of medications: another look at compliance. Social Sci ence and Medicine 20(1):29–37. Hardon A, Le Grand A (1993). Pharmaceuticals in communities. Practices, public health con- sequences and intervention strategies. Bulletin 330. Amsterdam, Royal Tropical In stitute. Hardon A (1991). Confronting ill health: medicines, self-care and the poor in Manila. Quezon-City, Health Action Information Network. Hardon A (1987). The use of modern pharmaceuticals in a Filipino village: doctor’s pre- scription and self-medication. Social Science and Medicine 25(3):277–292. Haynes RB, McKibbon A, Kanani R (1996). Systematic review of randomised trials of in ter - ven tions to assist patients to follow prescriptions for medications. Lancet 348:383–6. Herxheimer A (2003). Education and debate. Relationships between the pharmaceutical industry and patients’ organisations. British Medical Journal, 326:1208–1210. Homedes N, Ugalde A (1993). Patient’s compliance with medical treatments in the Third World. What do we know? Health Policy and Planning, 8(4):291–314. Jones G (2003). Prescribing and taking medicines, [editorial]. British Medical Journal 327(7419): 819–820. 2. WHAT INFLUENCES MEDICINES USE BY CONSUMERS 17 References continued Le Grand A, Sringernyuang L (1989). Herbal drugs in primary health care. Amsterdam, Royal Tropical Institute. MSF (2003). Doha derailed: a progress report on TRIPS and access to medicines. Médecins Sans Frontières Briefi ng for the 5th World Trade Organization Ministerial Conference, Cancún 2003. Mintzes B (1998). Blurring the boundaries. New trends in drug promotion. Amsterdam, Health Action International Europe. Mintzes B (2002). Women and drug promotion: the essence of womanhood is now in tablet form. WHO Essential Drugs Monitor, 2002, 31:2. Nyazema NZ (1984). Towards better patient drug compliance and comprehension: a chal- lenge to the medical and pharmaceutical services in Zimbabwe. Social Science and Med icine 18(7):551–4. Rasmussen ZA et al. (1996). Enhancing appropriate medicine use in the Karakoram Moun tains. Community drug use studies. Amsterdam, Het Spinhuis. Sanz E (2003). Concordance and children´s use of medicines. British Medical Journal 327: 858–60. Senah KA (1997). The popularity of medicines in a rural Ghanaian community. Com mu nity drug use studies. Amsterdam, Het Spinhuis. Townsend A, Hunt K, Wyke S (2003). Managing multiple morbidity in mid-life: a qual itative study of attitudes to drug use. British Medical Journal 327:837–840. Trap B, Hansen EH, Hogerzeil HV (2002). Prescription habits of dispensing and non- dispensing doctors in Zimbabwe. Health Policy and Planning 17(3):288–95. van der Geest S (1998). Use and misuse of pharmaceuticals: anthropological comments. In: Streefl and P, ed. Problems and potentials in international health: transdisciplinary per spectives. pp. 195–221. Amsterdam, Het Spinhuis. van Trigt AM (1995). Making news about medicines [Ph.D thesis]. University of Groningen, Enschede, Febo. Table 1. Main factors infl uencing drug use by consumers LEVEL OF INFLUENCE FACTORS Household • Perceived need for drugs • Ideas about effi cacy and safety • Uncertainty resulting in poly-pharmacy • Division of drug consumption roles • Cost of medicines • Literacy levels • The power of medicines Community • Drug use culture • Drug supply system • Information channels Health institution • Extent to which health workers are consulted • Quality of health worker prescribing • Quality of the consultation • Quality dispensing • Regular supply • Cost of medicines National • Implementation of essential drugs policy • Drug promotion • Financing and reimbursement • Consumer advocacy • The media • Public education International • Health consequences of global trade agreements • Donor support for essential drugs programmes • Global consumer advocacy • The Internet HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 18 2. WHAT INFLUENCES MEDICINES USE BY CONSUMERS Ugalde A et al. (1986). Do patients understand their physicians? Prescription compliance in a rural area of the Dominican Republic. Health Policy and Planning 1(3):250–259. Watson R (1995). A participatory evaluation of the implementation of the WHO ethical criteria for medicinal drug promotion in multiple countries: Australian results. Mel bourne, La Trobe University. WHO (1988). WHO ethical criteria for medicinal drug promotion. Geneva, World Health Or gan ization. WHO (1998). WHO ethical criteria for medicinal drug promotion: a strategy for review and assessment of effectiveness. Geneva, World Health Organization. WHO/DAP/1998. (Draft document). WHO (1999). Guidelines for drug donations. 2nd ed. Geneva, World Health Organization. WHO/EDM/PAR/99.4. WHO (1999). Medical products and the Internet. Geneva, World Health Organization. WHO/ EDM/QSM/99.4. WHO (2000). Progress in essential drugs and medicine policy, 1998–1999. Geneva, World Health Organization. WHO/EDM/2000.2. WHO and HAI (2003). Medicine prices: a new approach to measurement. Geneva, World Health Organization and Health Action International. WHO/EDM/PAR/2003.2. 19 3 How to study medicines use in communities 3.1 Introduction The medicine use investigations presented in this manual are intended as a basis for developing an intervention project. Such drug use studies should be: Effi cient: Do not collect more information than needed and do not measure more accurately than needed. Flexible: Learn-as-you-go approach, whereby newly generated information helps to set the agenda for the later stages in the development of interventions. Participatory: Methods which allow for stakeholder participation in data gathering and analysis are preferred. Triangulated: Use more than one, and generally three, methods to cross-check the information. In the community: Learning takes place in the community or population groups which experience the problem, in short, intensive periods of fi eldwork. As explained in Chapter 1, the planning and implementation of community drug use interventions is a step-by-step process (see fi gure 3). In this chapter we focus on step 1, Describe drug use practices and identify problems. The aim in step 1 is to get an overview of the drug use problems in a region or a country. We want to identify the many different kinds of problems that occur. In steps 2 and 3 (see Chapter 4) we prioritize the problem and analyse why it occurs, as a basis for developing an effective intervention. Evaluation studies (step 7) aim to measure whether the intervention has been effective (see Chapter 7). 3.2 Describing and identifying medicines use problems To identify drug use problems, it is best to focus on common health problems and on how these are treated. Examples of common health problems include respiratory infections, diarrhoea, aches and pains, and infectious diseases such as malaria, tuberculosis and AIDS. However, as seen in Chapter 2, people increasingly use medicines such as vitamins and tonics to improve their quality of life as well as to treat illness. So we need to know more about such preventive use of medicines too. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 20 We also need to fi nd out what health workers, women and men in communities, opinion leaders, and essential drugs programme planners consider to be problems with drug use in communities. Key research questions in step one of developing effective communication interventions are: • Where do you go if you or a family member is sick? If you don’t go there what do you do? • What are the common health problems in the community? What do people do if they suffer from them? What medicines, if any, do people use to treat them? To what extent are these drug use practices rational?1 • What are the most common medicines used to promote health? To what extent are these practices rational? • What do people consider to be drug use problems in their communities? • What do health workers believe are drug use problems in the community? Additional questions that can help describe community drug use patterns include: • What medicines do people keep in their homes? What are they used for? • What medicines are commonly sold in community shops and other sources of medicines in the community? What are they used for? How much do they cost? • Where do people go to obtain medicines? What are the advantages and disadvantages of the various sources? 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES Figure 3. Steps in developing an effective intervention aimed at enhancing rational drug use by consumers 1 In chapter 1 rational use was defi ned as: patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community. 21 Various quantitative and qualitative methods can be used to describe and analyse drug use problems. Each method has its own weaknesses and strengths. In the following sections, you will fi nd more details on a selection of methods that are especially useful for collecting data in communities on drug use. Quantitative data are needed to describe how often certain drug use practices occur. They are frequently used when the study’s aim is to obtain a representative picture of the situation amongst a given population. In that case, researchers need to use a so-called probability sample to make sure that the study population has all the important characteristics of the general population from which it is drawn. The size of the sample depends on what you want to measure. We give an overview of sampling methods in Chapter 5. This will help you to take decisions. You should consult a researcher with statistical knowledge to decide on the sample size. Because of the relatively large number of respondents involved, the number of questions to be included in a quantitative study should be limited. You need to defi ne key variables and indicators that will be measured in the study in order to answer the research questions. Qualitative methods are used to fi nd out more about people’s ideas, the reasons why problems occur, what people see as possible solutions and constraints. The emphasis is not on representation but on in-depth understanding. When selecting informants you should choose people who can provide the information you need. Make sure you cover the heterogeneity in the population, as views and ideas may differ between older and younger people, men and women, and people with different religious or social backgrounds. Qualitative studies can also be used to formulate appropriate questions for a quantitative survey, or they can be used to elucidate fi ndings from quantitative studies. The following data collection methods are often used to investigate drug use: a. Study of documents b. Semi-structured interviews c. Focus group discussions d. Observation techniques, including simulated client visits e. Structured interviews, including weekly health recalls For each of these fi ve research methods, we discuss how to use the method, and its relative strengths and weaknesses (see Additional Reading at the end of the chapter, which includes publications covering research methods in more detail).1 3.3 Study of documents In the fi eld of drug use and distribution there are many secondary data sources that researchers can tap. These include: • published studies • reports of agencies involved in the implementation of health care (baseline surveys, health surveys, monitoring reports and evaluations) • sales and consumption fi gures • prescriptions. All these data sources can be used to: • get a global overview of drug consumption, prescription and distribution • get specifi c information on drug use in commonly occurring diseases • identify drug use problems. 1 The methods we discuss can also be used in step 3 of developing an intervention, when we aim to analyse why specifi c problems occur (see Chapter 4). HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 22 How to do document reviews Before conducting fi eldwork on drug use practices, we should ask: What do we know about the problem in the local settings? Have studies on the problem been done in other countries? What reasons for the problem were identifi ed? What sub-problems have been described? What population groups are affected? What can you learn from drug sales statistics in your country? Have studies been done on community members’ perception of the problem in your country? What data are still lacking? There are several websites which help you to fi nd published – and sometimes un- published – information (see box). Increasingly, journals offer their articles online. Articles can be downloaded free of charge, see for example http://bmj.bmjjournals. com. 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES Getting hold of unpublished reports is usually more diffi cult. If possible, it is often best to visit a few well-functioning documentation centres of health-related organizations and institutions. UNICEF national offi ces can be a good source of information. Also, when conducting key informant interviews ask for any relevant reports or data. It is best to ask health workers in the research area what data they or others have collected, and if they can be accessed. It is very important to do this, in order not to bother people in the area with questions and surveys that have already been undertaken by others. A survey of prescriptions can give a very accurate picture of physician prescribing practices. To study prescriptions you need to request permission from health care institutions or pharmacies. However, they may not be systematically collected, for example, patients keep them. In that case, interviews with consumers can include a question on prescriptions kept at home, or you can conduct exit interviews at health facilities. Prescriptions are a good starting point for discussion on (non) compliance. Sales statistics provide useful information and can be obtained from IMS Health affi liates in each country, though this may be expensive. Sales fi gures can be used to describe national drug consumption patterns; one can, for example, identify the 10 most commonly used drugs. A drawback is that the agencies collating sales fi gures often ask researchers to pay for these data; only outdated fi gures are available free of charge. Sales statistics refl ect private sector drug consumption. Procurement data from the ministry of health can provide a good indication of volumes of drug use in the public sector. Ministries of health may also have collated data on medicine provision by type of health facility and region. Strengths and weaknesses of document reviews The strengths of using document reviews are: • they are a cost-effi cient way of doing research • they avoid duplication of efforts. BOX 4. INFORMATION SEARCHES A computerized literature search using key words in Medline (which has abstracts of medical articles) and Popline (which covers family planning and related health issues). A site where you can search these and other health-related databases free of charge is: http://igm.nlm.nih.gov/ The INRUD Drug Use Bibliography, an annotated bibliography of published and unpublished articles, books, reports and other documents related to drug use, with a special focus on developing countries, contains over 4,000 entries and is updated regularly. See: www.inrud.org 23 The weaknesses of document reviews are: • consent is often needed from the “owner” of the data • it is sometimes diffi cult to assess the reliability and accuracy of the data • data are often outdated • data may be costly. 3.4 Semi-structured interviews Semi-structured interviews are based on the use of an interview guide. This is a written list of questions or topics that need to be covered during the interview. These interviews can help you collect information on: • local terms for common health problems and types of medicine used • sources of medicines: where do people go to obtain medicines, and what are the advantages and disadvantages of the various sources, in their view? • sources of advice: where do people commonly go for advice on day-to-day health care problems? • perceived drug use problems: what do people and health workers consider to be drug use problems in their communities? • why people use medicines irrationally • what the possible solutions are. How to conduct semi-structured interviews Semi-structured interviews follow an open and informal interview style. They allow for a listing of health problems using local illness terms and a listing of medicines commonly used, as well as an exploration of problems, the reasons why they occur, and possible solutions. Interviewers can continue to ask questions until they fully understand the situation. Ordinary conversation makes it easier to reassure informants and to win their cooperation and trust. Make sure that you interview different types of people: a variety of key informants (knowledgeable individuals) – men and women, poor and rich people; and those of different ethnic backgrounds. Potential key informants in the community are: • school teachers • community leaders • medicine sellers • nurses, midwives and other health workers who serve the community. You will need to limit the number of interviews, as semi-structured interviews are quite time-consuming to conduct and analyse. The aim is not to get a representative sample of the various categories of informants, but to gather a substantial body of information from them. Try to limit the list of the people you will interview to around 20–30 who are likely to give you most information on the problem and can choose from a variety of perspectives. You usually only need to interview 3–5 people from each of the identifi ed groups (see also Chapter 5). When conducting semi-structured interviews, the interviewer is prepared with a list of questions and topics to be discussed. However, the order of the questions and topics is undefi ned. It depends on the fl ow of the discussion. It is best to start with a topic that is not sensitive and is important to the respondent. Thus, an informal, friendly atmosphere can be created, facilitating a ‘natural’ fl ow of ideas and opinions. The researcher acts as a moderator, guiding the respondent from one topic to another. Conducting such interviews requires a skilled moderator. It is best to do a small pilot study in which the interview guides are pretested, preferably not in the community where the actual study will be done. The best way to HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 24 conduct a semi-structured interview depends on the communication rules that exist in any given society. Generally the guidelines given in box 5 can help you. These interviews should be relatively short. The questions on the checklist should help you fi nd out not only WHAT people do. If you are analysing a specifi c problem you will want to fi nd out the REASONS WHY the drug practices which you have defi ned as problematic occur. Limit the questions. The semi-structured interviews will reveal that the drug use problem which you selected as a priority problem, is in fact a set of related sub-problems, with a variety of causes. How to conduct the prioritization analysis of core problems is presented in more depth in Chapter 4. The recording of in-depth interviews can be done in various ways. The simplest method is to prepare a form which you can use to fi ll in information on the interview topics. Below are examples of two simple forms (A1 and A2) that you can use to fi ll in the common health problems mentioned, the types of treatment used, who generally gives advice on these treatments, the source of the treatments, and the advantages and disadvantages of these sources. 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES BOX 5. GROUND RULES FOR A GOOD INTERVIEW Conducting the interview: • Greet your informant at the beginning of the interview in a culturally appropriate way. • Explain the purpose of the interview and ask the informant for consent. • Explain how the information will be recorded. Ask for permission to tape-record the session if you plan to do so. • Arrange comfortable seating to facilitate communication. • Introduce the people present at the interview. The respondent should be asked for permission for all of them to stay. • Start with a topic that is not sensitive and is important to the respondent. This helps create an informal, friendly atmosphere facilitating a ‘natural’ fl ow of ideas and opinions. • Be an “active” listener; look at your informant’s face (not at your interview guide), and always behave in a culturally sensitive way. • Pick up phrases that the informant uses and use these to phrase your questions. Instruct your translator to do this too. • Avoid giving opinions or judgements about what the informant says, and treat him/her as an equal. • Jokes, or friendly gestures towards any small children present can help break the ice. • Use open-ended questions not closed ones which only allow for ‘yes’ – or – ‘no’ answers. • Avoid asking leading questions. • Follow the fl ow of the discussion, but make sure that all the topics are covered. • Ask ‘probing’ questions to clarify points or to encourage more explanation. • Respond to issues raised by your informants, which are not on your interview guide, and probe on these as well. Thank the informant at the end and give him/her time to ask more questions. Recording the interview: • Use ‘telegram-style’ short notes to record the responses of your interviewee but where (s)he uses important terms or interesting expressions record as much as possible of the responses ‘verbatim’ (using the words the informant used). This should also be done if you are tape-recording the interview (sometimes the quality of the recording turns out to be bad). • Find a balance between taking notes (looking down at the paper) and talking with the respondent; (s)he will feel uncomfortable if you spend too much time writing. If you conduct the interview in pairs, one person can do the interviewing and the other can make notes. Complete the interview record immediately after the interview so you can still recall what was said. • Observe and make notes on non-verbal communication like silences, laughing, worried expressions, etc. 25 A1. Key informant interviews on treatment of common health problems Name: Community: Type of key informant: Interviewer: Date of interview: COMMON HEALTH PROBLEMS TYPES OF WHOSE SOURCES OF TREATMENT ADVICE TREATMENTS HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 26 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES A2. Advantages and disadvantages of various sources of medicines Name: Community: Type of key informant: Interviewer: Date of interview: SOURCE OF MEDICINES ADVANTAGES STATED DISADVANTAGES 27 You should make extended notes of the drug use problems identifi ed by key informants. It is best to capture the informants’ exact words used to describe the problem as far as possible. If you made a recording of the interview, type the whole text verbatim, including the questions asked (see also Chapter 6 on processing and analysis of qualitative data). The results of semi-structured interviews are hard to generalise, as they are based on interviews with a limited number of people. Focus group discussions can be used to further validate to what extent the problems identifi ed refl ect what people in the community perceive to be problems, and to compare the practices and views of different categories of people. Structured interviews can be done to further quantify key fi ndings. Strengths and weaknesses of semi-structured interviews The strengths of semi-structured interviews are: • depth of information • respondent can infl uence the topic, so unexpected issues/topics emerge • researcher can probe to understand perspectives and experiences • topic guide ensures that a core list of questions is asked in each interview • because the order of questions is not fi xed, fl ow and sharing of views are more natural. The weaknesses of semi-structured interviews are: • trained interviewers are needed to probe without being directive or judgemental • analysis of findings is difficult – must be done by people who did the interviews • researcher has to avoid bias in analysis • researcher needs to know something of the local culture to capture the interviewees real meaning • analysis is time-consuming • diffi cult to generalize fi ndings. 3.5 Focus group discussions Focus group discussions (FGDs) can be used to collect information on: • common health problems and medicines used to treat them • sources of medicines • sources of advice • perceived drug use problems • reasons why drug use problems occur • possible solutions. The results from the FGDs complement the fi ndings from the semi-structured interviews. They can be further used to contrast drug use patterns among different groups of respondents and to compare their views on drug problems. How to conduct FGDs Instead of having an interview with one person, a researcher preparing for an FGD invites several people to participate. The selection of group members demands careful planning. When organizing FGDs it is generally advisable to choose ‘homogeneous’ groups in terms of age, sex, socio-economic status, etc. since this facilitates open discussion. In mixed groups considerations of status and hierarchy can affect the discussions. Groups should be relatively small, between six to a maximum of 10 members. Possible groups for a study on drug use include: HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 28 • young men • young women • women who have small children • married men • elderly men • elderly women • people of different ethnic backgrounds, if relevant. It is best to conduct at least two FGDs per category of respondents. Question lists for FGDs should include a limited number of questions. Preparing fi ve or six good and relevant questions is generally more than enough for about one and a half hours discussion with six to 10 people. If more questions are prepared, the facilitator will have to rush through the discussion. One should not forget that in FGDs – contrary to individual interviews – the reaction of one person leads to contributions from others. To encourage lively discussion it is often good to start with a little ´ice- breaker´, for example a game, or a lively way of introducing the participants to each other. The questions should be neutral and open-ended. Often FGDs start with general questions, which everyone responds to, then, in the course of the discussion, more specifi c issues are raised. The moderator’s role The most important requirement for a successful FGD is a skilled moderator. Group discussions, though very effi cient as a data-gathering tool, are not easy to conduct. The moderator does not need to have high academic qualifi cations, but (s)he must understand the aim of the discussion, and must have good communication skills. The moderator’s role is to: • encourage everyone to participate in the discussion • stimulate discussion between participants, particularly when new information is given, or a diverging perspective is put forward • guide the group from one discussion topic to another • not express his or her own opinion – facilitate do not teach • not act as an expert, but retain control over the discussion. The choice of venue for an FGD is important. The place should be viewed as neutral by participants. It is better not to choose the local health centre as a venue, as people may not feel free to express their ideas where health workers are present. Providing small extras such as refreshments can create a friendly, relaxed atmosphere, which encourages discussion. Providing child care may be necessary. The interviewer should be present in the venue before people arrive, to start talking with the participants and to create an informal atmosphere that encourages a group discussion. The discussion’s aim and structure should be explained to the group members. In practice, it is hard to control the composition of the group involved in such a discussion. In public settings, people passing by or those who happen to be in the setting may start observing the discussion. They may even start interfering in it. It is important that the moderator has an appropriate response to such unplanned interference. For example, if men stand by watching a session with mothers, the moderator can inform the men that there will be a separate group discussion for them. The moderator can also prevent such interference by selecting a neutral, relatively secluded place. It may also be helpful to inform people who may interfere about the discussion’s purpose before it takes place and to explain why they were not invited to take part. 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES 29 Recording and reporting Finally, FGDs are usually recorded on tape. These recordings should be done with care. Always ask the participants for their consent before taping. In addition, one observer/researcher should make notes. It is sometimes unclear from the tape which participant is speaking, and in the notes, the observer can also record non-verbal communication. You can also choose not to use a tape recorder. It is then best to ask two observers to make notes, which they consolidate into a single record of the FGD after the session. The results of the group discussion can be analysed and interpreted in the same way as the semi-structured interviews described above. FGDs are ideally combined with semi-structured individual interviews. These interviews can be used to gain understanding of ideas and views that were not expressed in the group. BOX 6. FOCUS GROUP DISCUSSIONS A community-based study conducted in the Philippines The following guide for discussion with mothers of small children was used in a community drug use study in the Philippines. The researchers use focus group discussions to elicit the mothers’ ideas about medicines. These ideas are being used in the development of educational materials. To encourage a lively discussion, the moderator starts the discussion with a sorting game. Twelve popular medications (herbal and pharmaceutical) are put on a table and the participants are asked to sort the medications into piles. (The popular medications have been elicited from key informant interviews done prior to the focus group discussions). The recorder notes the comments made during the sorting. 1. The respondents are then asked why medications have been grouped together and in what way they differ from other medications. 2. The interviewer then asks the participants if they use each of these medicines. They are then asked for its uses and their experiences with it. After this exercise, a different point of departure is taken: the area’s most common illnesses. 3. The interviewer fi rst asks what the common illnesses are in the area. She or he writes the answers on cards; and probes for additional common disorders. 4. For each of the mentioned disorders, (s)he then asks what the mothers do to treat it. The interviewer uses fl ashcards to indicate the disorder that is the subject of discussion. 5. For each type of treatment mentioned, (s)he then asks why the treatment is used and where it is obtained. Strengths and weaknesses of focus group discussions The strengths of FGDs are: • the method is quick and cheap • a greater pool of expertise is tapped than in individual interviews; a more diverse picture of drug use will emerge • the contribution of one person often triggers others to share their views and experiences. The weaknesses of FGDs are: • a skilled moderator is required • the success of a group discussion is a bit unpredictable • in some cases one or more participants dominate; the views of others are not recorded and so are under-represented • the depth of information may be limited. It is hard to probe one person’s ideas, as others also have to be given a chance to speak • analysis of the information gathered is demanding. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 30 3.6 Observation techniques Direct observation produces more reliable information than interviews on actual behaviour. The researcher can see which medicines are being sold, prescribed or used, or are available in medicine cabinets; what information on their use the seller or doctor provides; whether drugs are purchased on prescription, etc. The most common observational techniques to study drug use are: • simulated client visits • inventories of community drug outlets and medicine cabinets. How to conduct simulated client visits Observational research is often done to describe drug distribution patterns in informal drug outlets and pharmacies. However it is diffi cult to carry out because drug sellers may not want to have an onlooker present. They may feel that it will disrupt or even endanger their business, particularly if some transactions are illegal. If they have a researcher present, they may do business in a more ‘correct’ way than they normally would, and they may feel that their professional competence is being tested. This problem can be solved by conducting simulated client visits. A researcher or an assistant can pose as a patient or client. The advantage is obvious; it gives an unbiased picture of normal procedures. Simulated client methods are often used to measure the quality of prescribing and dispensing drugs in health facilities, pharmacies and drug shops. It involves a researcher posing as a client and going to a health centre or pharmacy with a complaint. The objective is to determine how a sample of providers react to the complaint; what treatments they recommend, and what information they give. Posing as a patient or client, however, reduces the amount of information that can be gathered. The researcher can only observe his or her own visit, and in pharmacies at most a few drug purchases while waiting in turn. Furthermore it is diffi cult to pose many questions and make notes, without revealing one’s true identity. To counter this restriction, researchers can combine unobtrusive observation with interviewing. This approach was used by Wolffers (1987), who had assistants visit 28 pharmacies to buy tetracycline over the counter, and then let other assistants interview the pharmacy personnel about tetracycline a few days later. You may also consider using different kinds of ‘clients’, representing the diversity in wealth, gender, age and ethnicity of people visiting the facility. The method is somewhat controversial. One can question how ethical it is to conduct such visits without asking health workers and/or drug sellers for informed consent. The ethical issue can be resolved by asking the respondents or their professional organization for consent before conducting the visits and without giving details on when the visit will take place, to avoid bias. In the fi eldwork it is recom mended to use the simulated client visit to observe what information and advice drug sellers give. If a drug is bought during a visit, funding and accountability measures are needed. An advantage of the simulated client visit is that it is a rapid method. A typical trans action does not last more than fi ve minutes. It can also be used to evaluate the effects of rational drug use interventions, such as to measure information provided on drugs before and after an intervention. Ross-Degnan and colleagues (1996) tested the effects of a face-to-face education outreach intervention in Kenyan and Indonesian pharmacies. Using trained surrogate patients posing as mothers of a child under fi ve with diarrhoea, they measured sales of oral rehydration salts; sales of antidiarrhoeal drugs; and history taking and advice to continue fl uids and foods. Sales of oral rehydration salts in intervention pharmacies increased by an average of 30% in Kenya, and 21% in Indonesia, compared to controls. Discussion of dehydration during pharmacy visits increased signifi cantly in Kenya. 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES 31 When planning to use simulated client visits as a method, you need to take decisions on how to sample the drug outlets and how many observations to do per outlet (see 6.2). It is important to consider the usual opening hours and the volume of transactions each day. For example, on market day pharmacies may be very busy and minimal advice given. The guidelines provided in box 7 will help you to conduct effective simulated client visits. Record the results of the simulated client visits systematically. It is helpful to make a simple form to be fi lled in immediately after the visit. However, as with non- formal interviewing, the researcher has to be alert for the unexpected. The analysis and interpretation of the data depends on the extent to which the observations are structured. In some cases the analysis is quantitative, for example, when reporting in how many cases prescription drugs were sold over-the-counter. In other cases the observation is less structured, for example, focusing on the communication during the drug transaction. The researcher then has to categorize and analyse the fi ndings in much the same way as with semi-structured interviews (see Chapter 6 for more information on analysis). Strengths and weaknesses of simulated client visits The strengths of simulated client visits are : • they can provide more reliable information than interviews • drug use and distribution in its natural context can be observed • if done well, this method gives information on what drug sellers really do • a representative sample of pharmacies/health centres can be observed. • results can be generalized • results can be quantifi ed • they can be used to evaluate effects of training of pharmacy sellers and health workers • they can be used as a participatory method. You can ask people living in the communities that you are studying to act as surrogate clients, and collect data. The weaknesses of simulated client visits are: • data are sometimes hard to interpret • it is diffi cult to do a lifelike simulation, especially if you are playing a type of client you are not so familiar with (female students acting as mothers, for example) BOX 7. GROUND RULES FOR CONDUCTING GOOD SIMULATED CLIENT VISITS • Simulating a client requires insight into how clients usually behave. This can be obtained by conducting unobtrusive observations in pharmacies; or by asking informants during semi-structured interviews how they would ask for medicines and present a complaint at a pharmacy. • Don’t step out of your role. • Consider also the details of the transactions: will the advice be followed and a medication bought? What if the medicine is very expensive? Does the client then ask for a cheaper alternative? • Make a realistic ‘script’. • Make sure the ‘client’ looks like a real client. What will the client wear? On recording: • You cannot record what happens during the visit, as that would be unnatural, but this should be done immediately afterwards. Design a form for this purpose to make sure that all relevant information is covered. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 32 • the observation period is short (the time needed to buy the drug, or consult a health worker) • it is diffi cult to probe on why advice is given • the depth of information collected is limited • the fi ndings need to be complemented by interviews. Inventory of community drug outlets and medicine cabinets Inventories of medicine outlets and medicine cabinets are a second useful obser vation tool. The main aim of this tool is to describe the types of medicines commonly used in the community. The assumption is that commonly used medicines are those that people store in their medicine cabinets, and that storekeepers sell in community drug outlets. This tool can provide information about medicines used to promote health (such as vitamins and tonics) as well as illness-related medicine use. And, it can be used to conduct surveys of drug prices.1 The form overleaf can serve as an aid in collecting the information on medicine cabinets. You need to explain to the respondents how the data will be used, as you do with the other tools. It is also important that you ask for their consent. To conduct the inventory of medicines in community stores, ask a key informant to guide you around the community and introduce you to storekeepers. Explain that you are interested in common drug use practices and why. Say that for this purpose you would like to know what medicines are sold in the general shops and what they are used for. You can make an inventory of the types of medicines, and what they are used for. You can combine this method with (semi-) structured interviews. At the household level the inventories can be used as the basis for semi-structured interviews about drug use practices and perceptions. Strengths and weaknesses of medicine inventories The strengths of medicine inventories are: • they give an accurate picture of medicines commonly used in the community • the medicines inventories are a good starting point for discussion on how medicines are used, and why they are used • they can be a good participatory method – community health workers can help in making the inventories • they can be used to collect data on pricing of drugs in different outlets. The weaknesses of medicine inventories are: • they can be time-consuming if households/shops have large medicine stocks, unless a selected list of medicines is surveyed • sometimes people/sellers do not have the package information – it is hard to validate the types of medicines kept. 3.7 Structured interviews Structured interviews include a number of questions in a pre-defi ned order. They can deal with various aspects of medicines’ provision. Either drug providers or consumers may be interviewed. The most common form of structured interview confronts the provider or consumer of drugs with hypothetical patients: e.g. what would you prescribe/use for complaint x, in patient y? Structured interviews are also used to complement observations that the researcher makes during consultations. Physicians are then asked what they prescribed, and why they chose a certain treatment. 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES 1 See WHO/HAI (2003), Medicine prices: a new approach to measurement. 33 FO RM FO R T HE IN VE NT OR Y O F H OU SE HO LD M ED IC IN E C AB IN ET S N am e of in fo rm an t: D at e: N am e of in te rv ie w er : C om m u n it y: M ED IC IN E C O N T EN T S U SE D F O R W H IC H W H ER E W H O SE N A M E M A N U FA C T U R ER (G EN ER IC N A M ES ) EX PI RY D A T E SY M PT O M S O B TA IN ED ? A D V IC E? HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 34 In EXIT INTERVIEWS, people leaving health facilities, dispensaries or private pharmacies can be asked in a structured way about the consultation, treatment and information given, and the perceived quality of care. Consumers may be interviewed at home, in a hospital, a health centre, and at formal or informal drug outlets. Questions could cover topics such as: • types of medicines available/ being purchased • complaints for which medicines are purchased • prices of the medicines • source of advice on the purchase • treatment taken before buying drugs • ideas about the correct use of the medicines. Consumers can be interviewed in their home, which is where they are most likely to take the medicines. An advantage of household interviews, unlike interviews at drug outlets, is that a sample can be selected which is representative of the population in a certain area (by random sampling). How to conduct structured interviews In conducting the interviews the researcher uses a questionnaire as a tool. Developing a questionnaire is not an easy task. First the researcher has to clearly defi ne the objectives of the study, and the specifi c research questions. Only then can appropriate questions be formulated. The following points can serve as a guideline: • use the objectives of the study to compile a list of topics, and hypotheses • identify the variables to be measured, and the independent variables (such as socio-economic status, age, etc.) to which the fi ndings should be related. It is best to design the tables that are wanted as a study output, before designing the questionnaire • use semi-structured interviews or FGDs to learn about the way in which people talk about the topics in the local language. Use this understanding when preparing questions for the questionnaire • write the questionnaire in the local language, and translate it back to the original language to check that the content has not changed in the “translation” process • questionnaires should be short; omit any questions that are not needed to answer the study objectives • write guidelines for the interviewers, and pre-test the questionnaire in an area which is not where the actual research will be conducted but which has similar characteristics. In designing and pre-testing the questionnaires the interviewers should check for each question: 1. If it is understood. 2. If the question is neutral, i.e. it avoids leading the respondent to one of the possible answers. 3. That it does not contain implicit assumptions that are not valid, for example the question “which side-effects did you experience?” assumes that side-effects occur. 4. That it is needed; maybe there are other – easier and more reliable – ways to answer the research question. 5. That it elicits answers that are suffi ciently precise to meet the objectives of the research. For example, the question “which drugs did you take in the past months?” is not a useful question, because people simply cannot remember over 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES 35 such a long time span. The question “which drugs did you take yesterday, and the day before yesterday?” is much more reliable, as people are likely to remember what they did in the past two days quite accurately. This checklist can serve as a guideline to prevent the most obvious mistakes. If the researchers have limited research experience, it is best to consult a social scientist with experience in quantitative surveys when constructing a questionnaire. If the data are to be processed by computer, then data-processing personnel should be asked for advice on the best way to design the questionnaire and code the responses. The extent to which the responses can be coded depends on the questions. If so-called open questions are used, then the researchers have to code the responses after conducting the interviews. In the case of closed questions, containing a pre-defi ned list of possible answers, then each answer can be assigned a code on the interview form. This makes data processing easier. Finally, it is essential that the data forms are easy to use by the interviewers. Leave suffi cient space for the answers. In the small-scale surveys that are proposed in this guide, computer analysis is usually unnecessary. Because the questionnaires are short and the number of respondents are limited to around 100, the researcher can hand-tally the results. The statistics that are used are generally descriptive involving simple frequency tables and percentages. Strengths and weaknesses of structured interviews The strengths of structured interviews are: • useful for large-scale studies with many respondents who represent the population • they can be used to describe how often drug use practices occur • fi ndings can be compared with other studies and used to measure the impact of interventions • can test hypothesis using statistical tests. The weaknesses of structured interviews are: • respondents have little control over the interview • no data are obtained on aspects of the problem not included in questions • the validity of the responses may be low due to an “unnatural” atmosphere in the interview. One specifi c type of structured interview that has proved to be of great use in studying community medicines use is the weekly illness recall. 3.8 Weekly illness recalls Weekly illness recalls are a useful method for determining how people actually treat common health problems and how often certain drug use practices occur. Using this method, household members are interviewed about illnesses occurring recently (in the past few weeks) and related medicine use. This method can be used to collect information on: • illness-related medicine use • sources of medicines • sources of advice on medicines • spending on medicines. How to conduct weekly recalls Answers on medicine use are most reliable when they concern actual illness cases (as opposed to hypothetical ones) and cover a short period of time. If respondents HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 36 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES FAMILY HEALTH CALENDAR Children, list names August Father Mother Friday 1 Saturday 2 Sunday 3 Monday 4 Tuesday 5 Wednesday 6 Thursday 7 Friday 8 Saturday 9 Sunday 10 Monday 11 Tuesday 12 Wednesday 13 Thursday 14 Friday 15 Saturday 16 Sunday 17 Monday 18 Tuesday 19 Wednesday 20 Thursday 21 Friday 22 Saturday 23 Sunday 24 Monday 25 Tuesday 26 Wednesday 27 Thursday 28 Friday 29 Saturday 30 Sunday 31 Please fi ll in every day if a family member had, for example, cough, cold, diarrhoea, headache or anything else. Note: Researchers should adapt this list to local health problems before giving out the Family Calendar. 37 are asked to recall illness episodes, the best recall period is one week. In areas where respondents can read and write, a health calendar may be given to the households as a memory aid. The illnesses that occur during the study period can be noted on this calendar. During the fi rst visit to the households selected for the weekly illness recall, the researcher explains the aims of the research and asks the respondents if they want to participate in the study. The researcher can also explain to the respondent how to use a health calendar, if appropriate. The respondent should be told that the next visit will take place one week later, and that the illnesses occurring during that week should be recalled. It is important to stress that the research team will not provide medical aid. In past studies we have found that people tend to over-report illnesses if they expect that medicines will be given to them. A sample questionnaire designed for such a household interview and the form to record the data are given below. They are adapted from ones used for a comprehensive study on community drug use that aimed at: quantifying self-medication patterns; drug provision channels; the appropriate use of medicines; and most specifi cally, the appropriate treatment of diarrhoea and acute respiratory infection episodes. When conducting weekly illness recalls, you will need to decide how often the families should be visited. We suggest at least three times: once to explain the objectives of the study, and then twice more to interview them about illnesses occurring in the family and the treatments given. This means that the study will last at least three weeks. When visiting a family to recall illnesses the second time, you need to follow up on the illness cases recorded during the fi rst visit. You may need to add treatments to the cases recorded during the fi rst visit. During the last visit when you have established a certain level of rapport with the respondents, you can ask to see their medicine cabinets to fi nd out more about the medicines they use in self-care. You will also need to decide how many families you intend to interview and if you want to draw a representative population sample. Your sample size will be limited by budgetary constraints. To obtain a reasonable amount of information, we suggest that you interview at least 100 families. Often researchers focus on families with pre-school children as relatively they suffer a high burden of disease. This fact makes them an important target group for interventions. In the same way, you can purposely decide to sample households with elderly people, as this group consumes medicines regularly. If you do want to draw a representative sample for your study, make sure you consult a statistician (see Chapter 5 on sampling). When people are ill, they have several options: they may do nothing (no treatment), seek traditional therapy, seek treatment from a health care provider, or self-medicate with medicine. Weekly illness recalls such as the example given in the box above provide you with reliable data on people’s therapy choice. You can use the data on medicines used to describe: • sources of medicines: give a frequency distribution for specifi ed sources. You can also present these data in a diagram, as given in fi gure 3 in Chapter 2, “What Infl uences Medicines Use by Consumers” • most popular medicines in self-medication: list the 10 top names and give their generic contents and cost • most popular medicines used for specifi c health conditions: select a number of predominant health conditions (such as acute respiratory infections, diarrhoea and malaria), and list the top 10 medicines named. More information on processing and analysis of data collected in weekly illness recalls is given in Chapter 6. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 38 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES WEEKLY ILLNESS RECALL QUESTIONNAIRE Note for the interviewers: This questionnaire is to be used for the weekly visits to the respondent- families. During the fi rst visit explain that you are conducting this study to fi nd out more about the health problems in the community, and the way they are treated. Explain that you will be visiting them once a week for three weeks, and that they can use the health calendar to fi ll in any illnesses that occur during the week. Explain that their information will be treated anonymously, and that their privacy will be respected. After explaining this, ask if they have any questions, and then ask the respondents if they are willing to participate in the study. If yes, ask them to sign the informed consent form. You should fi ll in one illness form for each illness case identifi ed, see next page. 1. Has anyone in your family been ill during the past week? If yes continue below. 2. Who was ill? How old is (s)he? 3. What did (s)he suffer from? (Write down local terms used by respondent). 4. Did you give any treatment? Specify: none, or if treatment was given, the type of treatment, Specify the names of home or traditional remedies, as well as any Western medicines given. 5. What is the effect of the treatment? (Probe for all types of treatment given). For any pharmaceuticals given, ask: 6. Can I see the package of the medicine? Copy details of the medicine’s contents, if given on the package. 7. Ask about the dosage/duration: When did you start giving pharmaceutical medicine? How many days did you treat the problem? How many times per day did you give the medicine(s)? For all treatments ask: 8. Who advised you to take the treatment? 9. Where did you get the treatment? How much did it cost per capsule, tablet or per bottle? (Specify the number of mg active ingredient per capsule or tablet. If the drug is a syrup specify the number of mg/ml active ingredient and the total number of ml in the bottle). If you had an injection who gave it? 39 Name of patient: Illness suffered: Date: Interviewer: Community: Treatment: Age patient: (write down terms used by respondent) 1st treatment 2nd treatment 3rd treatment 4th treatment Name of treatment Effect of the treatment according to respondent For pharmaceuticals, give contents as written on package Dosage form (tablet, capsule, syrup, etc.) Duration of treatment in days, and number of doses/day (give start date in brackets) Who advised? Where obtained? Cost per unit, specify mg per tablet, ml per bottle Comments on appropriateness (to be made by pharmaceutical adviser to the study) ILLNESS FORM HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 40 Specifi c strengths and weaknesses of weekly illness recalls The main strengths of weekly illness recalls are: • data can easily be quantifi ed and compared with results of other studies (measuring the same variables, using similar questionnaires) • a lot of data can be collected in a short time • they provide information on actual illnesses, and actual treatment practices (as opposed to hypothetical ones). The main weaknesses of weekly illness recalls are: • the interviewer controls the discussion, and may infl uence the responses • no data on other aspects of the problem (not contained in a question) are collected • the reliability of responses may be low, because the interview is held in an “unnatural” manner • the information on illness-related medicine use is collected, not on the use of vitamins, tonics and other medicines to promote health • the information on less common health problems is lacking. The need for triangulation As mentioned in the introduction to this chapter, when conducting intervention- oriented studies, we intend to be effi cient, fl exible, participatory and interactive. The data are not collected for the sake of research, but as steps in a process towards the development and implementation of effective rational drug use interventions. We have seen that many different methods can be used. The selection of methods will depend on the research questions. Each method has strengths and weaknesses. To overcome these, it is best to combine methods. Observations, for example, can teach us what people do. Semi-structured interviews and FGDs teach us why people do what they do. The combination of various methods (usually three) to cross-check information is called ‘triangulation’. Table 2 overleaf gives an overview of the methods discussed above, by level of health care, including what the methods can be used for. Additional reading Abramson JH, Abramson ZH (1999). Survey methods in community medicine, 5th ed. Ed inburgh, Churchill Livingstone. de Zoysa J et al. (1988). Research steps in the development and evaluation of public health interventions. Bulletin of the World Health Organization, 76(2):127–133. Debus M (1986). Methodological review: a handbook for excellence in focus group re search. Wash- ington, DC, Academy for Educational Development, HEALTHCOM. (To re quest a free copy write to: BASICS, Information Center, l600 Wilson Blvd., Suite 300, Arlington, VA 22209, e-mail tperez@basics.org). Hudelson PM (1994). Qualitative research for health programmes. Geneva, World Health Organization. WHO/MNH/PSF/94.3.Rev.l. Ross-Degnan D et al. (1996). The impact of face-to-face educational outreach on di arrhoea treatment practices in pharmacies. Health Policy and Planning 11(3):308–318. Zimmerman M, Newton N, Frumin L, Wittett S (1996). Developing health and family plan ning print materials for low-literate audiences. Revised ed. Washington, PATH. WHO and HAI (2003) Medicine prices: a new approach to measurement. Geneva, World Health Organization and Health Action International. WHO/EDM/PAR/2003.2. 3. HOW TO STUDY MEDICINES USE IN COMMUNITIES 41 Table 2. Overview of quantitative and qualitative methods to collect information on drug use by consumers DATA SOURCE TYPE OF METHODS USEFUL TO COLLECT DATA ON: Households Weekly illness recalls • illness-related medicine use Homes • sources of treatments • sources of advice/information on medicines • perceived effects of medicines Semi-structured interviews • types of drug use practices • advantages and disadvantages of medicine sources • perceived drug use problems • why medicines are used irrationally Inventories of medicine cabinets • commonly used medicines • what medicines are used for • where medicines are obtained/who gave advice • experiences with medicines • costs of medicines Community Inventory of community drug • commonly sold medicines outlets • information provision on medicines • cost of medicines Focus group discussions • types of drug use practices • perceived effects of medicines • perceived drug use problems • division of drug consumption roles • perceived quality of care in health institutions • sources of medicines, and perceived advantages and disadvantages of each • source of information on medicines Health institution Review of patient records • quality of health worker prescribing by facility Structured observations • information provided to patients • quality of health worker prescribing Exit interviews • what people actually remember about prescriptions they received some time ago • the prescriptions they received Simulated client visits • types of medicines prescribed/sold • information given by the health worker/drug seller HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 42 4. PRIORITIZING AND ANALYSING COMMUNITY MEDICINES USE PROBLEMS 4 Prioritizing and analysing community medicines use problems 4.1 Introduction In order to select and develop interventions aimed at enhancing rational drug use by consumers, it is important that the problems identifi ed in step 1 are prioritized and choices made about which problems to address. The more focused rational medicines use interventions are, the more likely it is that consumers will understand them. In order to prioritize the problems, criteria need to be developed that are relevant to the operational setting in which the problem is to be addressed, and relevant to the people who are affected by the problem. This chapter fi rst discusses how you can prioritize drug use problems (step 2 in the development of effective consumer oriented rational drug use interventions), and then how through a participatory process, using research methods given in Chapter 3, you can analyse the problems and identify possible solutions (step 3). A process of prioritization can be carried out by policy-makers or health professionals but it can also be a participatory process in which various stakeholders are fully involved in identifying problems, setting and defi ning criteria and discussing how the priorities should be set. If stakeholders are involved there is likely to be more ownership of the problem and support for the result of the priority setting process. To identify problems, defi ne criteria and prioritize problems you could hold FGDs with people who are affected by the problem (stakeholders), such as: • men/women in the community • health workers in primary health care centres • provincial/district health policy-makers. It is best to hold separate discussions for each of these categories, as community members may not openly discuss their views with health policy-makers. But limit the number of participants. For our purpose it is important to choose key people who are knowledgeable, and whose views matter. In some cases, where community members are vocal and willing to express their views in ‘mixed’ groups, it may be possible to hold group discussions with people representing a variety of stakeholders. In such cases, good moderation is essential, to ensure that all parties speak up. 43 The group discussions can be used to achieve various objectives: Present the problems identifi ed. You can explain what essential drugs experts consider to be important public health problems. The various groups of stakeholders should be given the opportunity to comment on the list of problems identifi ed and to add to it. Develop criteria for priority-setting. You can ask the respondents to explain why each problem is important. Ask probing questions about why this is the case. In this way you can help to elicit criteria which determine why a problem is important. Set the priorities. This can be done in discussion and also with the use of tools such as rating, see below. 4.2 Prioritizing problems: the criteria (Step 2) Criteria which are commonly used to prioritize problems are: Scale of the problem One important question is how many people are affected by the drug misuse problem? Is misuse common or rare? Does it concern a common health problem, and therefore affect many people? Health risks The drug use problem can affect the health of individuals taking the medicines in various ways. You should consider the seriousness of the adverse effect of the medicines involved. For example, overuse of paracetamol can be described as a problem, but the adverse effects of this medicine (in normal dosages) are minimal. The health risks related to the way that the drug is administered should also be considered. For example, unhygienic injections can lead to abscesses and serious infections. Health consequences can be severe when life-threatening conditions, such as malaria with convulsions in small children, are treated incorrectly. Failure to provide the right treatment can lead to death. Palliative medicines can be relatively safe as medicine, but still have adverse health effects because they mask the severity of a disease. For example, the use of cough and cold remedies can mask the severity of a pneumonia episode. Drug use practices can have further negative health effects, because they contribute to microbial resistance. Inappropriate dosage of antibiotics leads to resistance, so the antibiotics become less effective when really needed. Costs The costs related to drug use problems should also be considered. Overuse of unnecessarily expensive medicines is a major problem that needs to be addressed. People may spend their scarce resources on non-essential vitamins and cough/cold remedies, leaving them with less to spend on food for their children. Poor people frequently borrow money to obtain medicines for sick family members. Problems related to inappropriate self-medication can lead to hospitalization, which is costly for them. Appropriateness of a community intervention to deal with the problem This criterion deals with the extent to which the people affected by the problem actually recognize it as serious, and whether a community intervention is an appropriate way to deal with it. For example, if the problem is related to health workers’ prescription practices, it does not make sense to prioritize it for community action. If the issue is very sensitive (such as use of medicines to induce abortions in a country where HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 44 abortion is illegal), the feasibility of starting a health communication campaign is questionable. 4.3 Rating the problems One way of prioritizing the problems is to rate them according to the criteria you have selected. You should examine each problem in the light of the criteria and you can award a mark or a rating (for instance on a scale of 1 to 5). If you do this for each of your problems you will come up with a number of points for each problem, which can enable you to make a quantitative comparison for priority-setting. The problem with the highest total rating should be the most important. You will need to consider whether all the criteria are of equal value. If, for example, you decide that one of your criteria – such as the appropriateness of a community intervention – is essential, you may focus your discussion on the problems that score high on that criterion, and then check which ones score high on other criteria as well. Rating1 is a useful way of shedding light on a diffi cult choice, but evaluating complex problems with a numerical value can produce questionable results. Rating should be seen as a tool to help you understand your choices and to provide you with a framework for discussing priorities. It should not be used to impose a choice according to a set of rules. The rating technique should be used to support informed discussion on prioritizing problems for action – not as a means to avoid diffi cult discussion. When you rate problems you will fi nd that it is not as easy as it seems. You may lack the necessary data to rate the problems; or problems may be so different that it is hard to prioritize them. Some problems are related. For example, misleading drug promotion on Viagra results in its overuse as an aphrodisiac. Below, we discuss an example to clarify how rating can be used to prioritize problems. 4. PRIORITIZING AND ANALYSING COMMUNITY MEDICINES USE PROBLEMS 1 Instead of rating you can also rank problems in terms of the criteria. For each criterion you rank the prob- lems, assigning 1 (most important) to 5 (least important) problem. The difference with rating is that you can only assign a rank once: so, as in a competition, only one problem gets the fi rst prize (rank 1); and only one problem ranks 2. This method leads to a lively discussion on which problem is most important, but can also be distorting, as some problems may score equally for one or more of the criteria. Figure 4. Rating matrix CRITERION Rate (1–5) problem 1 problem 2 problem 3 problem 4 problem 5 Scale of the problem Health risks Costs Appropriateness of an intervention TOTAL RATE 45 RATING TO HELP IN THE PROCESS OF PRIORITIZING: AN EXAMPLE Background Information In recent research three problems have emerged in a community: Problems • Over-use of cough mixtures • Over-use of analgesics • Misuse of antibiotics In analysing these problems three criteria have been identifi ed for priority-setting: Criteria • Scale of the problem • Health risks • Costs • Appropriateness of an intervention It has been agreed that one intervention will be developed to focus on one problem. A rating exercise is carried out with a group of stakeholders to select a priority. Rating the problems When you rate you look at one problem at a time and measure it against your criteria. Scale You can choose which scale to use – in this case a scale of 1–5 has been chosen. You need to make sure that everyone knows whether 1 is more serious or less serious. (In this case a high rating means more serious). Stakeholder meeting First cough mixtures are considered and discussed at some length by the stakeholder meeting. People regard the health risks as not very important. The economic waste is considered rather important. Resistance was not considered to be a major factor but it was not insignifi cant as a few of the combination cough mixtures contained antibiotics. After much discussion of the three problems the table is completed as follows: Rating Over-use of Over-use of Misuse of cough mixtures analgesics antibiotics Scale of the problem 3 3 5 Health risks 2 2 5 Costs 4 2 4 Appropriateness of an intervention 3 3 5 Total 12 10 19 The discussion and the rating exercise have helped the group to see that they regard the misuse of antibiotics as an urgent priority. You will need to consider whether all the criteria are of equal value. If, for example, you decide that one of your criteria e.g. the appropriateness of a community intervention – is essential, you may focus your discussion on the problems that score high on that criterion, and then check which ones score high on other criteria as well. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 46 4.4 Analysing problems and identifying possible solutions (Step 3) A good analysis of the prioritized drug use problem, and participatory identifi cation of possible solutions are essential requirements for a successful intervention. Specifi c objectives for this pre-intervention step are: a. Describe the prioritized drug use problem in more detail, by fi nding out about different sub-problems, which population groups are involved, and how different stakeholders see the problem. b. Analyse the core problem(s), by identifying what the different stakeholders see as the main causes of the core problem(s), including socio-cultural and health system factors which contribute to the problem(s). c. Collect additional information on these factors. d. Identify what different stakeholders see as possible solutions to the problem, including proposed messages, target audiences and communication channels for drug use interventions. e. Identify factors which can facilitate interventions aimed at improving drug use, as well as factors which are likely constraints to change. You can meet these objectives by conducting a participatory problem appraisal, including the following fi ve activities: 1. A review of literature, unpublished reports and secondary data. 2. Semi-structured interviews to further describe the problem and its related sub- problems, and to gain insight into the reasons for the present practices. 3. A multi-stakeholder workshop to focus on a core problem(s), further defi ne causes of the problem, and develop a problem analysis diagram. 4. Fieldwork on a core problem as a basis for community health education interventions. 5. A focus group discussion on fi nding solutions. This process may seem cumbersome and unnecessary. Interventions are often developed without such careful preparation. Indeed short cuts are possible. You could skip activities 2 and 3, and decide to defi ne the core problem and develop your problem analysis diagram without consulting key informants and without organizing a workshop. You could even skip the fi eldwork, assuming that you know enough about the problem. But be aware that if you skip these steps, your problem analysis is likely to be less comprehensive than if you had involved different stakeholders in its development. As a result your interventions may turn out to be inappropriate and ineffective. An investment in a well-designed rapid appraisal is worth it, if you have the resources. The fi ve proposed activities are discussed in detail below. ACTIVITY 1 Review of literature, unpublished reports and secondary data The fi rst step to be taken is another review of documentation and literature. The fi rst literature review is done in step one, when you describe and identify drug use problems. The difference is that this second review of literature is more focused. What do we know about the priority problem in the local settings? Have studies on the problem been done in other countries? What reasons for the problem were identifi ed? What sub-problems have been described? What population groups are affected? Have studies been done on community members’ perception of the problem in your country? What data are still lacking? In Chapter 3 we refer to several websites that help you to fi nd published reports. Getting hold of unpublished reports is usually more diffi cult. If you are able, it is often best to visit a few well-functioning documentation centres of health-related 4. PRIORITIZING AND ANALYSING COMMUNITY MEDICINES USE PROBLEMS 47 organizations and institutions. UNICEF national offi ces are often be a good source of information. Also, when conducting key informant interviews ask for any relevant reports or data. ACTIVITY 2 Describe the problem and its related sub-problems For this activity you need to decide who your informants on the priority drug use problem are. Informants are people who are confronted with the problem (for example, mothers, if the problem concerns the misuse of antibiotics for childhood respiratory infections), and other people who are knowledgeable about it. Try to limit the list of the people you will interview to around 15–20 who are likely to give you most information on the problem and have varied perspectives. Make sure that you interview different types of people: health workers and lay people; men and women; people from different socio-economic groups; and those of different ethnic backgrounds. BOX 8. SEMI-STRUCTURED INTERVIEWS ON THE INAPPROPRIATE USE OF ANTIBIOTICS Based on a descriptive drug use study, a country team selected the inappropriate use of antibiotics as a priority problem. This problem has been selected because it: • occurs on a wide scale • costs a lot, as antibiotics are expensive; non-essential use is a waste of scarce family resources • has severe health implications, not only for the individual who is not cured properly, but also for the population in general as it contributes to antibiotic resistance. Step 1 resulted in very little data on the drug use problem. The team was only able to obtain the sales statistics for 1998, which gave insight into the most commonly sold brands in the country. In Step 2 of the rapid appraisal the team conducts a series of key informant interviews using the following simple checklist: 1. What antibiotics are commonly used in the community? 2. What are they used for? 3. Why are they used for those conditions? 4. What are the problems related to the use of antibiotics for these conditions? The discussion during the round of key informant interviews on the use of antibiotics reveals that the problem is complex and can be divided into many different sub-problems: • People use antibiotics for many different types of health problems, including children’s coughs and colds, abdominal pain suffered by women, and men use them to prevent and treat STDs when visiting commercial sex workers. • In self-care people tend to use antibiotics for non-severe conditions that could be treated with home remedies or drugs which are less strong. People use antibiotics because they fear that the conditions will worsen and become life threatening. • Antibiotics are sold illegally by informal providers, who may or may not know how to use these drugs correctly. • Consumers have “learnt” which antibiotics to take for which conditions from observing prescriptions given for former illness episodes. • Economic reality leads patients to buy a few “magic capsules”, expecting instant cure from the powerful drugs. • Health workers over-prescribe antibiotics for self-limiting conditions, because they fear criticism by clients if they fail to treat the illness adequately. • Once prescribed, the problem is that people don’t comply with the advice to use a full course of antibiotics. They don’t see why they should continue to buy medicines when the condition has improved. • Neither health workers nor informal providers give people adequate advice on WHY they should take a full course of the medicines, and thus do not motivate consumers to take the (biomedically) correct action. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 48 4. PRIORITIZING AND ANALYSING COMMUNITY MEDICINES USE PROBLEMS The questions on the check-list should help you fi nd out not only WHAT people do, but also the REASONS WHY the problematic drug practices occur. Limit the questions. At this stage you are not yet trying to analyse the problem in-depth. Rather, you are trying to get a better picture of it. The round of key informant interviews will make clear that the priority drug use problem is in fact a set of related sub-problems, with a variety of causes. In the next step we propose that you organize a workshop to further analyse the problem, and select the core problem which will be the focus of your intervention. The round of key informant interviews should result in a list of sub-problems and factors associated with the problems (see box 8). ACTIVITY 3 Focus on a core problem(s) in a multi-stakeholder workshop This activity aims to prioritize the sub-problems and identify the core problem for intervention. The various interested parties interviewed in activity 2 are invited to a multi-stakeholder workshop to discuss and analyse the problem of antibiotic misuse. Limit the number of participants, and try to conduct the workshop in one day. The list of sub-problems and related factors identifi ed in activity 2 serves as input. Workshops are important in rapid appraisals as they are a means of bringing together the research team and representatives of various groups of stakeholders. Objectives must be clearly established at the outset. Ideally the workshop should be partly structured and partly informal, alternating plenary sessions with small sub-groups working on particular tasks. Note that the interviews, which were done prior to the workshop, allowed the various interested parties to give their views in individual interviews. The advantage is that they could speak relatively openly, without being intimidated or infl uenced by the views of others. This is a good basis for a consultation where representatives of the various parties now interact. You will need to defi ne clearly the workshop’s aims and the process you want to follow to achieve those aims. We suggest the following three objectives: 1. Review the list of problems identifi ed in the key information interviews and identify core problem(s). 2. Add further core problems that emerge. 3. Develop a problem analysis diagram. The rating exercise used to prioritize problems can be used here again to establish why people consider the sub-problems to be important and needing action. The stakeholders will need to identify a set of criteria for the scoring and rating exercise. Box 9 below gives an example of what the rating criteria and the outcome of such a process could be for the problem “inappropriate use of antibiotics”. Once the stakeholders have selected a core problem, they need to analyse its nature in more detail in the form of a problem analysis diagram. You should identify with them the factors that contribute to the core problem, and clarify the relationship between the problem and the contributing factors. To develop a problem analysis diagram, the core problem and contributing factors may be placed in boxes. The relationships between the factors can be indicated by one-way or two-way arrows. You can identify the core problem with a double line around it. See fi gure 5 as an example. 49 BOX 9. THE INAPPROPRIATE USE OF ANTIBIOTICS: SELECTING A CORE PROBLEM In the multi-stakeholder workshop on the inappropriate use of antibiotics, the following criteria are used to select a core problem: • magnitude of the problem • severity of the health consequences • vulnerability of the population affected • related costs • eagerness of the population to gain knowledge about the problem • relevance of a community intervention to address the problem. The core problem identifi ed in a matrix rating exercise is the inappropriate use of antibiotics in coughs and colds of pre-school children. It was selected as the core problem to be tackled because: • it affects children, who are a vulnerable group; mortality due to inappropriately treated pneumonia is high • children suffer a lot of coughs and colds, and antibiotics are often given: thus, this form of antibiotic abuse is frequent • sub-optimal dosages of antibiotics contribute to antibiotic resistance which affects the whole population • non-essential use of antibiotics in non-severe coughs/colds is a waste of scarce fi nancial resources • mothers are eager to gain more knowledge on how they can best treat their children’s health problems • clear guidelines on when antibiotics are needed exist in health programmes • a community health education intervention is an appropriate way of addressing the problem. Figure 5. Problem analysis diagram Example of a problem analysis diagram of the inappropriate use of antibiotics Note the fl exible nature of the proposed methodology for focusing and analysing the core problem. It involves learning-as-you-go, whereby newly generated information collected in key informant interviews serves as input into the workshop, where a core problem is selected. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 50 Brainstorming in small groups helps to identify various types of factors contributing to the problem. Consider also the factors discussed in the previous section: • what infl uences drug use by consumers? • are there factors at the community, health institution or national level which should be added to the problem analysis diagram? Diagrams are important tools in rapid appraisals because they present information in a readily understandable visual form. This usefulness is twofold. First the participatory act of constructing the diagram is an analytical procedure and second, the diagrams become a means of creating communication and discussion. We have now defi ned and analysed a core problem, and factors related to it. In the next activity you conduct fi eld research to gather data that will help you to design an appropriate intervention. ACTIVITY 4 Fieldwork on a core problem It is unlikely that after activities 1–3 you will have suffi cient information on your core problem to conduct an intervention. Using the problem analysis diagram as a point of departure you can defi ne what questions need to be answered through fi eldwork. Formulating fi eldwork questions Formulating good fi eldwork questions is essential to the success of the appraisal. The questions should be worked out together with people who will be responsible for the health interventions. This will increase the possibility of them being motivated to carry out the intervention (they will have ownership of the product/research), and it will add their practical experience to the perspective of the researcher(s). Ask stakeholders who participated in activities 1–3 to comment on the questions and 4. PRIORITIZING AND ANALYSING COMMUNITY MEDICINES USE PROBLEMS BOX 10. QUESTIONS ON THE INAPPROPRIATE USE OF ANTIBIOTICS IN CHILDHOOD ACUTE RESPIRATORY INFECTIONS For the fi eldwork on the inappropriate use of antibiotics, the following questions need to be answered: Treatment practice a. To what extent do people treat coughs and colds with antibiotics in self-care (without consulting a doctor)? b. What other treatments are used (including non-drug therapies)? c. What are the most commonly used antibiotics? Knowledge/attributes a. Why do people use antibiotics; what is their perceived effi cacy? b. What are the attributes of these other treatments, according to respondents, as compared to antibiotics? c. Are people aware of risks related to antibiotic use? d. How many tablets/capsules over how many days do parents think are needed for specifi c cough/cold conditions? Sources of antibiotics a. What kinds of antibiotics are stocked in town pharmacies and community grocery shops for the treatment of children’s coughs and colds? b. Where do people obtain the antibiotics? Advice/information a. Do sales people give advice on the need to use a full course of medicines? b. What advice do health workers give on antibiotics? c. What are sources of advice/information on the treatment of coughs and colds and on the use of antibiotics? 51 help you to reformulate them so that they are sensitive to local realities and use appropriate language. To analyse your core problem you will need to fi nd out: what people do, how often, which sub-groups in the population are most affected and why the practices occur. Do not forget to check if all the factors included in the diagram are covered in your list of research questions; and if not, why it is not necessary to include questions on them. Remember that one of the principles of rapid appraisal is effi ciency: do not collect more information than you need to develop a good intervention. Selecting fi eldwork methods A mix of methods is usually the most appropriate for answering your research questions (see also Chapter 3). You will need to use both quantitative and qualitative methods. This allows you to answer questions on how often practices occur, as well as on why they occur. Quantitative methods are especially important as they allow you to collect baseline data on the drug use problem, which can be used to evaluate the effect of the intervention. In the section on Monitoring and evaluation we discuss how you can defi ne relevant outcome measures on which you would need to collect baseline data. Use a set of different methods to cross-check on fi ndings and look at the problem from different “angles”. This is called triangulation, which we have seen is one of the principles for rapid appraisal. To decide on which methods to use you need to review your research questions – what do you want to know and how can you fi nd it out? The following quantitative and qualitative methods are often used to describe and analyse drug use problems. More details on how to use the methods can be found in Chapter 3. Weekly illness recalls: If your core problem concerns drug use in a specifi c illness condition, and if that illness condition is relatively common, you can use focused illness recalls which aim to collect data on people’s treatment practices. This involves interviewing a sample of the population on whether the illness has occurred in the past week, and if it has, conducting a very short interview on what was done and why. This is a very effi cient way of collecting accurate information on drug use practices. It is accurate because the data collected refer to actual illness cases, rather than hypothetical ones which are often used in surveys. Simulated patient/client methods: A research assistant, who has been prepared in advance to present a standardized complaint, visits health facilities, pharmacies and drug shops seeking treatment. The objective is to determine how a sample of providers react to the complaint, what treatments they recommend, and what information they give. (These can also be used as qualitative tools). Review of medical records: Medical records can be reviewed to describe prescribing patterns of health workers in facilities. Structured observations: These can be used to describe client-provider interactions in health facilities, pharmacies and drug shops. (These can also be used as qualitative tools). Semi-structured interviews: These interviews can be used to gain more understanding of why the drug use problem occurs. Select respondents who can provide a lot of information on the problem, either because they are likely to have experience with it, or because they are involved in the problem in another way – as health care providers or dispensers of medicines. Focus group discussions: These can be used for the same purpose as the semi-structured interviews. Limit the number of FGDs, as they require a lot of time to prepare. We HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 52 4. PRIORITIZING AND ANALYSING COMMUNITY MEDICINES USE PROBLEMS suggest that you conduct focus groups only with the people affected directly by the medicines use problem. Others, such as health care providers and drug sellers, can be interviewed individually with a semi-structured list of questions (see above). Some problems may be too sensitive for FGDs, such as antibiotic use to prevent sexually transmitted diseases. In that case it is better to only do individual interviews. It is best to make a matrix in which you list all your research questions and the methods that you intend to use to answer them. Make sure that you use a set of methods, so that you can triangulate the results. Consider the principle of effi ciency: do not collect more information than you need to answer your research questions. The matrix (see page 54) gives an example of methods selected to answer the research questions related to inappropriate use of antibiotics in pre-school children’s coughs and colds. Four sub-sets of questions have been made that can each be answered using a specifi c set of methods. In planning your fi eldwork you need to take decisions on how many surveys, interviews and observations you want to do. Sampling strategies are different for the qualitative and quantitative methods (see Chapter 6). The result of the fi eldwork is a report on the core problem and factors contributing to it. This forms the basis for Activity 5 of this participatory problem appraisal that aims to fi nd solutions and constraints to change. ACTIVITY 5 Finding solutions Looking at reasons for the problems from the point of view of the “target” audience is essential to fi nding the right solutions to the problems. Possible solutions should be developed together with the target audiences. A common reason for health education projects to fail is the lack of attention to this point. Reasons for problems are commonly assigned by researchers and planners, based on the “objective” biomedical explanatory model. Solutions are prescribed based on this understanding. They are often defi ned as “lack of information”, with giving more knowledge as a standard solution. Very often, community members do not understand or identify with these reasons, and therefore the prescribed solutions are not experienced as relevant. The result is that they may not be implemented. Specifi c aims of this phase of step 3 (analysing problems and identifying solutions) are to: a. Identify possible solutions to the drug use problem, specifi cally — identify target audiences — identify possible communication channels in the community. What channels are currently used for communication on health matters? What channels are trusted? What types of events are likely to be understood? — formulate messages which encourage better use of drugs. b. Identify constraints to change. What factors will make it diffi cult for people to change their behaviour? c. Identify enabling factors. What could motivate people to change their behaviour? You can use different participatory appraisal techniques to identify possible solutions, constraints and enabling factors. If you have suffi cient resources it is good to do a series of focus group discussions. Feed back results of the fi eldwork to these groups, asking them to comment (this is also a way to validate results). Then ask them to give recommendations on how the problem can be addressed; what the messages and who the target audiences should be; what communication channel should be used. You can also organize a small-scale workshop again. Follow the same principles 53 Example of a research matrix Questions and methods for fi eldwork on the inappropriate use of antibiotics in childhood acute respiratory infections QUESTIONS SUGGESTED METHOD To what extent do people treat their children’s Weekly illness recalls among families with coughs and colds with antibiotics in self-care pre-school children on the occurrence of (without consulting a doctor)? coughs and colds and the treatment of these What other treatments are used (including non- disorders. Start with this method, as it drug therapies) and what are the attributes of provides information that can be used in the these other treatments according to following sub-sets of methods. respondents as compared to antibiotics? What dosages of antibiotics are used? Where do people obtain the antibiotics? What are sources of advice/information on the treatment of coughs and colds and on the use of antibiotics? Why do people use antibiotics: what is their FGDs with mothers of pre-school children, with perceived effi cacy? a drug-sorting exercise (see the example of Are people aware of risks of antibiotics? such an FGD in Chapter 3). For the drug- What are the attributes of these other sorting exercise use actual packages of treatments according to respondents as medicines which are reported in the weekly compared to antibiotics? illness recalls. How many tablets/capsules over how many days Semi-structured interviews with a sub-sample do parents think are needed for specifi c of mothers who actually report a cough/cold cough/cold conditions? case that is treated with an antibiotic. What advice do health workers give on Review of medical records. treatment of coughs and colds? Structured observations using a checklist to document what advice is given on various aspects of medicine use. Semi-structured interviews in which health workers are presented with hypothetical illness cases, i.e. a detailed case-description of a child with a non-severe episode of cough and cold (no longer than fi ve days; with only slight fever, and no accompanying symptoms). What kinds of antibiotics for the treatment of Inventory of community stores and children’s coughs and colds are stocked in pharmacies on the kinds of antibiotics they town pharmacies and community grocery sell for coughs and colds. shops? Simulated client method. Community members What advice do sales persons give on the use pose as the mother of a child who has cough/ of these antibiotics? cold (use the same hypothetical case as Do they advise on the need to use a full course? presented to the health workers above). The simulated clients ask for advice on therapy for their sick child. If they are not advised to take an antibiotic, they specifi cally ask for one, referring to a brand which is often used (as reported in the weekly illness recalls). HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 54 as for the workshop described above in activity 3: set clear objectives. Those key objectives are likely to be: a. Review the results of the fi eldwork; present your fi ndings on the size of the problem: who it affects most; why it occurs; where people obtain medicine and where they go for advice. Ask participants to comment on the fi ndings. Do they have anything to add? b. Ask participants to: — propose specifi c ways in which people could be convinced to use drugs more appropriately — identify those health behaviours that are most amenable to change — defi ne who the target of an intervention should be — identify appropriate communication channels to reach the identifi ed target audience — formulate key messages to be used to encourage more appropriate use of medicine. c. Ask what the implications are of implementing the solutions: What will/can happen if.? d. Defi ne enabling factors: What can be done to make the intervention work? How can people be convinced that the recommended behaviour is better? Who do people trust in health matters? Can these people be involved in the implementation of the intervention? e. Discuss constraints: Why would people not adopt the recommended behaviour? How can structural constraints (such as lack of drug supplies or distance to the health centre) be overcome to enable appropriate behaviour? 4. PRIORITIZING AND ANALYSING COMMUNITY MEDICINES USE PROBLEMS BOX 11. KEY MESSAGES In the workshop on the rapid appraisal of inappropriate use of antibiotics in childhood acute respiratory infections, participants defi ned as key messages for the intervention: 1. Seek advice from your health worker if your child breathes rapidly and is coughing. 2. Take a full course of antibiotics, when antibiotics are prescribed. When asked why people would not follow such advice, participants at the workshop identifi ed the following constraints: — The clinic is far away, and not open at convenient times. — The transport to the clinic is expensive/not easily available. — The health worker treats the clients very roughly, and always blames the mother for not coming sooner. — There are no drugs in the clinic, the drugs have to be bought at the local community pharmacy. — The health worker does not explain why it is necessary to take a full course of antibiotics, she just tells people to do it. — A full course of antibiotics is very expensive. — Parents see that children get well after a few days on the medicine, and do not want to waste scarce resources without good reason. When asked what could convince people to adopt the recommended behaviour, participants pointed out that there may be people in the community who use antibiotics in a correct way, and have had very good results from this (i.e. healthy children). These individuals would be very useful positive motivators to help implement the solutions. There are also trained and/or motivated informal drug sellers in the community who should get further training in assessing when children should be referred to a clinic, and also to follow up on them buying and taking a full course of the drugs when they return. Informal providers are an important source of information on medicines in the community. Training programmes for health workers exist. However, they focus on technical aspects of drug prescribing. The addition of a module on face to face education on rational use to health workers’ training would encourage them to be better educators on appropriate drug use. 55 f. Discuss an action plan: Who can do what to help implement the solutions (short- term and long-term)? The outcome of the participatory appraisal can guide you in the selection of interventions, the messages to include, the target audiences that you intend to reach, and the communication channels you intend to use. The involvement of stakeholders in the formulation of possible solutions to the drug use problem is also likely to enhance their participation in the implementation of an intervention. Additional reading and cited references Cornwall A, Jewkes R (1995). What is participatory research? Social Science and Med icine, 4(12):1667–1676. Curtis V et al. (1997). Dirt and diarrhoea: formative research for the design of hygiene promotion programmes. Health Policy and Planning 12(2):122–131. Oyoo AO et al. (1991). Rapid feedback from household surveys in PHC planning: an ex ample from Kenya. Health Policy and Planning 6(4):380–383. Scrimshaw SCM, Hurtado E (1987). Rapid assessment procedures for nutrition and pri mary health care. Tokyo, United Nations University/Los Angeles, University of Cal ifornia. Varkevisser CM, Alihonou E, Inoussa S (1993). Rapid appraisal of health and nutrition in a PHC project in Pahou, Benin. Methods and results. Cotonou, CREDESA/Amsterdam, Royal Trop ical Institute. Vlassof C, Tanner M (1992). The relevance of rapid assessment to health research in ter - ven tions. Health Policy and Planning, 7(1):1–9. Video “Who holds the stick” has been produced by World Wildlife Fund and the Institute of Development Studies. For copies contact: WWF International, Avenue du Mont-Blanc, Gland, CH-1196, Switzerland. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 56 5. SAMPLING 5 Sampling 5.1 Introduction Sampling involves the selection of a number of study units from a defi ned study population. When drawing a sample, a researcher first needs to decide which population (s)he intends to study. This depends on the research objectives and questions. Sampling strategies need to be defi ned as you can rarely cover every person in the selected population. In qualitative studies they aim to identify information-rich cases or informants. Information-rich cases are those from which one can learn a great deal about issues of central importance to the purpose of the research, so the term purposeful sampling is used when such people are selected. For example, when understanding is needed of how infertile women cope, in-depth interviews should be conducted with women who experience infertility. Probability sampling typically depends on large samples selected randomly. A truly random and statistically representative sample allows for generalization from the sample to the larger population. The purpose of such sampling methods is not to gain in-depth understanding of an issue, but to be able to generalize fi ndings. Such sampling can be stratifi ed to ensure that all groups of interest are included. 5.2 Selection of study sites and study units Before selecting health facilities, drug outlets, households or individuals, a researcher needs to identify relevant study sites or in other words, the population from which a sample is to be drawn. The selection of study sites depends both on the objectives of the study and on pragmatic factors (such as the distance to be travelled, the willingness of key individuals to be involved in future rational drug use interventions, and contacts which can facilitate entry into the community). The research objectives provide the researcher with criteria to select study sites. For example, a study on treatment practices in childhood malaria is best done in communities with a high incidence of malaria. The next step is to consider the heterogeneity of the potential study population – i.e. households with children who live in malaria-endemic areas. If economic status or educational level are important factors, the researcher may want to select communities with different socio-economic profi les. 57 In the preparatory phase of a study, researchers should identify various research sites, taking into consideration the research objectives. During on-site visits, they should discuss the study’s objectives and plans for future research with health programme managers, community leaders and representatives of other relevant institutions. Final selection of study sites is based not only on the research site characteristics, but also on the willingness of health workers and community leaders to participate in and facilitate the study, and conduct the research. When the research sites have been selected, the researchers need to decide on the sampling method to be used to select the study units: health facilities, drug outlets, individuals and/or households in the community. The most commonly used qualitative and quantitative sampling methods are discussed below. 5.3 Purposeful sampling for qualitative studies There are several strategies for purposeful sampling of information-rich cases. The methods most commonly used in qualitative studies are given here, including the purpose for which the method is especially useful and its disadvantages. Convenience sampling Convenience sampling is a method in which, for convenience sake, the study units that happen to be available at the time of data collection are selected in the sample. Many health facility or drug-outlet-based studies use convenience samples. If you wanted to study information provision on medicines in pharmacies, you could observe all client-drug-seller interactions during one particular day. This is more convenient than taking a random sample of people in the village and it gives a useful fi rst impression. A drawback of convenience sampling is that the sample may be quite biased. Some people may be overselected, others underselected or missed altogether. In this example, the interactions observed may be biased because the pharmacist does not work on the day observed. You also miss the clients who obtain their medicines from other sources. Informal drug outlets in communities are often as important as pharmacies as sources of medicines. It is necessary to study interactions at those outlets as well, to get a good impression of the provision of information on drugs. Maximum variation sampling This sampling method aims to select study units which represent a wide range of variation in dimensions of interest. For example, the researcher may be interested in the reasons that people do not comply with antibiotic prescriptions, and assume that gender and socio-economic status are important background variables. The researcher is afraid to miss men, who are often not at home when researchers visit to conduct semi-structured interviews. Therefore, the researchers decide to conduct interviews during the day and in the evenings, and to ensure that at least 15 men and women are included in the sample. Maximum variation can also be used as a strategy to select communities in which to do research. In the example, this would imply that the researcher selects one relatively rich and one poor community. Maximum variation sampling is also often used when deciding on which groups to involve in focus group discussions. Remember, the informants participating in each FGD should be relatively homogenous as far as key background variables for the study are concerned. Snowball sampling Snowball sampling is perhaps the most common sampling method used in qualitative studies. The researcher starts by identifying some (at least two) individuals who are relevant to the study, for example, women with pre-school children in a study on HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 58 home-treatments in malaria, and then asking them to locate other useful informants, i.e. other mothers of pre-school children. The advantage of this method is that one informant refers the researcher to another, so that the researcher has a good introduction for the next interview. A disadvantage is that the variation in the sample may be limited because it consists of informants who belong to the networks of the index cases. This is why it is important to have at least two different additional entrances in the community. Sampling contrasting cases Comparative studies sampling will involve two or more population groups with distinct characteristics. This sampling method is useful in comparative studies that aim to explain problems by establishing which factors are associated with them or cause them. For example, in a study aimed at understanding why mothers do not use oral rehydration therapy (ORT) to prevent childhood death in diarrhoea cases, both women who use ORT and those who do not can be sampled and compared. Contrast sampling can also be used in selecting research sites. For example, when evaluating a health programme, a research site can be selected where (according to statistical information) the programme has been successful (for example, in promoting ORT) and where this is not the case. Comparison can help in analysing which factors contribute to success and which factors constrain programme success. Contrast sampling can also be used to select participants for focus group discussions. Within each group the informants should be relatively homogenous in terms of the important dimensions of the study; but for the different groups you select contrasting cases (for example, men and women; younger and older; users and non users). Qualitative sampling respondents for semi-structured interviews and FGDs The qualitative methods presented in Chapter 3 for investigation on drug use include semi-structured interviews and FGDs. How can we sample respondents for these methods? Sampling for semi-structured interviews First you need to defi ne whom you want to interview. If you are aiming to get an overview of drug use problems, it is best to select a wide range of individuals. If you are analysing a specifi c drug use problem, you concentrate on people who have direct experience with the drug use practice that is problematic, and people who are knowledgeable about it. Snowball sampling is the most common sampling method used in selecting respondents for semi-structured interviews. You can also decide to conduct contrast sampling. You can get an idea about which groups to select by reviewing your problem analysis diagram. Which socio-cultural factors seem to be related to the problem? Can we test these assumptions by comparing ideas and practices in different groups? It is also useful to contrast groups that use drugs appropriately with those who do not. Information on whether or not drugs are used appropriately can be obtained from the focused illness recalls. By conducting semi- structured interviews with both groups and comparing fi ndings you can get an idea of the reasons for appropriate and inappropriate practices. Sampling for focus group discussions The main decision you need to take when planning focus group discussions is what focus you intend to have, and how many FGDs you intend to hold. FGDs are often used to contrast views of different ‘focused’ groups: for example, adolescents versus adults; or men versus women. Decide which population sub-groups need to be interviewed. Limit the scope of the study to those sub-groups which have direct 5. SAMPLING 59 experience with the problem. Usually local leaders are asked to select respondents for the focus groups. Aim for around 6–8 participants per group; and conduct at least two FGDs per population group involved. So, for example, two with men and two with women, or two with adults and two with adolescents. If the conclusions of the two groups are not in agreement you may need to hold a third FGD to further investigate the issues. 5.4 Probability sampling methods for quantitative studies In quantitative studies we aim to measure variables and generalize fi ndings obtained from a representative sample from the total population. In such studies, we will be confronted with the following questions: • which group of people (study population) do we want to draw a sample from? • how many people do we need in our sample? • how will these people be selected? Is there an administrative list of the (sampling frame) units of the population involved? The study population has to be clearly defi ned, for example, according to age, sex and residence. Apart from people, a study population may consist of villages, institutions, records, etc. Each study population consists of study units. The way one defi nes the study population and the study unit depends on the problem to be investigated. If researchers want to draw conclusions that are valid for the whole study population, they should take care to draw a sample in such a way that it is representative of that population. A representative sample is one that has all the important characteristics of the population from which it is drawn. If it is intended to interview 100 mothers to obtain a complete picture of drug use practices in District X these mothers would need to be selected from a representative sample of villages. It would be unwise to select them from only one or two villages, as this might give a distorted or biased picture. It would also be unwise to interview only mothers who attend the under-fi ves clinic, as those who do not attend this clinic may wean their children differently. An important issue infl uencing the choice of the most appropriate sampling method is whether a sampling frame is available, that is, a listing of all the units that compose the study population. If a sampling frame does exist or can be compiled, probability sampling methods can be used. With these methods, each study unit has an equal or at least a known probability of being selected in the sample. Five probability sampling methods are discussed below: — Simple random sampling — Systematic sampling — Stratifi ed sampling — Cluster sampling — Multi-stage sampling. Simple random sampling This is the simplest form of probability sampling. To select a simple random sample you need to: • make a numbered list of all the units in the population from which you want to draw a sample or use an already existing one (sampling frame) • decide on the size of the sample (this will be discussed in section 5.6) • select the required number of sampling units, using a ‘lottery’ method or a table of random numbers. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 60 Simple random sampling can be used for the weekly illness recall method and when selecting facilities for simulated client visits (see Chapter 3). Systematic sampling In systematic sampling, individuals or households are chosen at regular intervals from the sampling frame. For this method we randomly select a number to tell us where to start selecting individuals from the list. For example, a systematic sample is to be selected from 1,200 students at a school. The sample size selected is 100. The sampling fraction is 1200/100. The sampling interval is therefore 12. The number of the fi rst student to be included in the sample is chosen randomly, for example, by blindly picking one out of 12 pieces of paper, numbered 1 to 12. If number 6 is picked, then every twelfth student will be included in the sample, starting with student number 6, until 100 students are selected. The numbers selected would be 6, 18, 30, 42, etc. Systematic sampling is usually less time-consuming and easier to perform than simple random sampling. However, there is a risk of bias, as the sampling interval may coincide with a systematic variation in the sampling frame. For instance, if we want to select a random sample of days on which to count clinic attendance, systematic sampling with a sampling interval of 7 days would be inappropriate, as all study days would fall on the same day of the week, which might, for example, be a market day. Stratifi ed sampling The simple random sampling method described above does not ensure that the proportion of some individuals with certain characteristics will be included. If it is important that the sample includes representative groups of study units with specifi c characteristics (for example, residents from urban and rural areas, or different age groups), then the sampling frame must be divided into groups, or strata, according to these characteristics. Random or systematic samples of a predetermined size will then have to be obtained from each group (stratum). This is called stratifi ed sampling. Stratifi ed sampling is only possible when we know what proportion of the study population belongs to each group we are interested in. An advantage of stratifi ed sampling is that it is possible to take a relatively large sample from a small group in the study population. This makes it possible to get a sample that is big enough to enable researchers to draw valid conclusions about a relatively small group without having to collect an unnecessarily large (and hence expensive) sample of the other, larger groups. However, in doing so, unequal sampling fractions are used and it is important to correct for this when generalizing our fi ndings to the whole study population. A survey is conducted on self-medication practices in a district comprising 20,000 households, of which 20% are urban and 80% rural. It is suspected that in urban areas self-medication is less common due to the vicinity of health centres. A decision is made to include 100 urban households (out of 4,000, which gives a 1 in 40 sample) and 200 rural households (out of 16,000, which gives a 1 in 80 sample). This allows for a good comparison between urban and rural self-medication practices. Because we know the sampling fraction for both strata, the rates for self-medication for all the district households can be calculated. Cluster sampling It may be diffi cult or impossible to take a simple random sample of the units of the study population, either because a complete sampling frame does not exist or because of other logistical diffi culties (e.g., visiting people scattered over a large area may be too time-consuming). However, when a list of groupings of study units is available (for example, villages or schools) or can be easily compiled, a number of these groupings 5. SAMPLING 61 can be randomly selected. The selection of groups of study units (clusters) instead of the selection of study units individually is called cluster sampling. Clusters are often geographic units (for example, districts, villages) or organizational units (e.g., clinics, training groups). In a study of the knowledge, attitudes and practices related to family planning in a region’s rural communities, a list is made of all the villages. Using this list, a random sample of villages is chosen and a defi ned number of adults in the selected villages are interviewed. Multi-stage sampling A multi-stage sampling procedure is carried out in phases and usually involves more than one sampling method. In very large and diverse populations sampling may be done in two or more stages. This is often the case in community-based studies, in which the people to be interviewed are from different villages, and the villages have to be chosen from different areas. In a study of a district’s treatment of acute respiratory infections, 150 households are to be visited for interviews with family members, as well as for observations on medicines kept in the homes. The district is composed of six wards and each ward has between six and nine villages. The following four-stage sampling procedure could be performed: 1. Select three wards out of the six by simple random sampling. 2. For each ward, select fi ve villages by simple random sampling (15 villages in total). 3. For each village select 10 households. Because simply choosing households in the centre of the village would produce a biased sample, the following systematic sampling procedure is proposed: — go to the centre of the village — choose a direction in a random way: spin a bottle on the ground and choose the direction the bottleneck indicates — walk in the chosen direction and select every third or every fi fth household (depending on the size of the village) until you have the 10 you need. If you reach the boundary of the village and you still do not have 10 households, return to the centre of the village, walk in the opposite direction and continue to select your sample in the same way until you have 10. If there is nobody in a chosen household, take the next nearest one. Decide beforehand who to interview (for example, the head of the household, if present, or the oldest adult who lives there and who is available). Strengths and weaknesses of cluster and multi-stage sampling The strengths of cluster and multi-stage sampling are that: • a sampling frame of individual units is not required for the whole population. Initially a sampling frame of clusters is suffi cient. Only within the clusters that are fi nally selected do we need to list and sample the individual units • the sample is easier to select than a simple random sample of similar size because the individual units in the sample are physically together in groups, instead of scattered all over the study population. The weakness of cluster and multi-stage sampling is that: • compared to simple random sampling, there is a larger probability that the fi nal sample will not be representative of the total study population. The likelihood of the sample not being representative depends mainly on the number of clusters selected in the fi rst stage. The larger the number of clusters, the greater the likelihood that the sample will be representative. If you use cluster-sampling, you should increase your sample size by about 50%. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 62 5.5 Bias in sampling Bias in sampling is a systematic error in sampling procedures that leads to a distortion in the results of the study. Bias can also be introduced as a consequence of improper sampling procedures that result in the sample not being representative of the study population. For example, a study to determine the drug information needs of a rural population and plan a community drug use intervention failed to give a picture of the health needs of the total population because a nomadic tribe, which accounted for one-third of the total population, was left out of the study. There are several possible sources of bias in sampling. The best known source of bias is non-response. In a survey trying to establish how men treat sexually transmitted infections (STIs), it was found that many men refused to answer certain questions, such as whether they had attended an STI clinic in the past month. It is possible that these men feared the consequences of disclosing such sensitive information to an outsider. The researchers may therefore not get a realistic picture of the treatment of STI in the community. Non-response is encountered mainly in studies where people are being interviewed or asked to fi ll in a questionnaire. They may refuse to be interviewed or forget to fi ll in the questionnaire. The problem lies in the fact that non-respondents in a sample may exhibit characteristics that differ systematically from the characteristics of respondents. There are several ways to deal with this problem and reduce the possibility of bias: • data-collection tools (including written introductions for the interviewers to use with potential respondents) have to be pretested. If necessary, adjustments should be made to ensure better cooperation. • if non-response is due to absence of the subjects, follow-up of non-respondents may be considered. • if non-response is due to refusal to cooperate, a few extra questions to non- respondents may be considered to discover to what extent they differ from respondents. • another strategy is to include additional people in the sample, so that non- respondents who were absent during data collection can be replaced. However, this can only be justifi ed if their absence was very unlikely to be related to the topic being studied. The bigger the non-response rate, the greater the need to take remedial action. It is important in any study to mention the non-response rate and to discuss honestly whether and how it might have infl uenced the results. Other sources of bias in sampling may be less obvious, but are at least as serious: • Studying volunteers only. This produces selectivity (or bias) in assigning subjects to various groups. The fact that volunteers are motivated to participate in the study may mean that they are also different from the study population in the factors being studied. It is better to avoid using non-random procedures that introduce the element of choice. • Sampling of registered patients only. Patients reporting to a clinic are likely to differ systematically from people using self-medication. • Seasonal bias. It may be that the problem under study exhibits different characteristics in different seasons of the year. For this reason, data on the prevalence and distribution of malnutrition in a community, for example, should be collected during all seasons rather than just at one time. When investigating health services’ performance, to give another example, one has to take into account that towards the end of the fi nancial year shortages may occur in certain budget items which may affect the quality of services delivered. • Tarmac bias. Study areas are often selected because they are easily accessible. However, these areas are likely to be systematically different from more inaccessible areas. 5. SAMPLING 63 If the recommendations from a study will be implemented in the entire study population, you should aim to draw a sample from this population in a representative way. If part way through the research new evidence suggests that the sample was not representative, this should be mentioned in any publication concerning the study, and care must be taken not to draw conclusions or make recommendations that are not justifi ed. 5.6 Sample size We now have to determine our sample size. It is a widespread belief among researchers that the bigger the sample, the better the study becomes. This is not necessarily true. In general it is much better to increase the accuracy of data collection (for example, by improving the training of interviewers or by better pretesting of the data-collection tools) than to increase the sample size after a certain point. In qualitative studies the aim is not to be representative of the population. The validity, meaningfulness and insights generated from such studies have more to do with the information richness of the cases selected, and the analytical qualities of the researcher than with the sample size. There are no rules for sample size in qualitative research. It depends on what one wants to know, the purpose of the study and practical factors. Often qualitative researchers refer to the redundancy criterion: that is when no new information is forthcoming from new sampled units, stop collecting data. One can also use pragmatic criteria in defi ning sample size, considering the amount of time it costs to do and transcribe the interviews and the number of sub-groups from which one will select respondents. A qualitative study with 40 informants is a relatively large study. Generally qualitative comparative studies have at least 10 informants per group. In quantitative studies, as a general rule we can say that the desirable sample size is determined by the expected variation in the data: the more varied the data are, the larger the sample size we will need to attain the same level of accuracy. You need to consult a statistician, who can usually make precise calculations to determine the desirable sample size. Examples of such calculations follow below. For descriptive studies, we cannot say more than that the sample size needs to be large enough to refl ect important variations in the population, but small enough to allow for intensive study methods. You should aim for at least 30 people in each group of interest. The EPI-Info 6.04 software includes an easy to use sample-size calculator. In a study on reasons for non-use of oral rehydration therapy, you may decide to interview two categories of informants (non-users and users), and start with 20 to 30 interviews per category. This number could be increased if the data obtained for each category do not indicate a certain trend or if results are confl icting. The eventual sample size is usually a compromise between what is desirable and what is feasible. A quantitative study should aim to quantify well-defi ned variables, for example, the proportion of under-fi ve-year-olds treated with oral rehydration therapy. Sample size calculations are based on estimates of what these proportions are likely to be (informed guess or results of previous surveys). These estimates are made before selecting a sample. For a simple random sample the table can be used to determine the required sample size. Example: The aim of the survey is to measure the proportion of people going to the village shop. Although there is no clear information on this, it is assumed that 40% of the people would go to a village shop. This is taken as the preliminary estimate, i.e. a population of 0.4 goes to the village shop. From table 3, it is seen that the desirable sample size for a proportion of 0.4 is 145. Sampling size calculations for multi-stage sampling are more complicated. It is best to consult a statistician. Statistical advice is also needed to defi ne sample sizes HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 64 for comparative studies (such as those done in evaluation studies when experimental groups are compared with control groups), where one wants to test differences between two groups. The desirable sample size can usually be calculated, with some assistance, if the researcher is able to make a rough estimate of the outcome of the study, and is clear about its main objectives and variables. The feasible sample size is determined by the availability of resources: — time — human resources — transport — money. Remember that if people are to be interviewed in their homes, it is often more time- consuming to go and trace the people than to actually do the interview. In addition, remember that resources are not only needed to collect the information, but also to analyse it! If many variables are included in the study (which is usually the case in an exploratory type of study) the sample size should be relatively small to avoid problems during analysis. If one has few variables, one can afford to have a larger sample. The following general rules may help to determine the desirable sample size of any given study: • the desired sample size depends on the rates one expects for key variables. • the desirable sample size also depends on the expected variation in the data (of the most important variables): the more varied the data, the larger the sample size one would need to attain the same level of accuracy. For descriptive studies it is important that the sample size is large enough to refl ect important variations in the population, but small enough to allow for intensive study methods. • the desirable sample size also depends on the number of cells one will have in the cross-tabulations required to analyse the results. A rough guideline is to have at least 20 to 30 study units per cell. 5. SAMPLING Table 3. Sample size for a simple random sample1 ESTIMATED DESIRABLE ESTIMATED PROPORTION SAMPLE SIZE* PROPORTION 0.05 420 0.95 0.10 325 0.90 0.15 290 0.85 0.20 255 0.80 0.25 225 0.75 0.30 195 0.70 0.35 170 0.65 0.40 145 0.60 0.45 120 0.55 0.50 100 0.50 The desirable sample size is given in the middle (second) column. The table is entered using either the left (fi rst) column or the right (third) column depending on whether the estimated proportion is less than or greater than 0.5 * For the information of survey specialists: In this table the estimated S.E./p gradually increases from 0.10 for p = 0.5 to 0.21 for p = 0.05 1 Source: Lutz. W. 1982, ibid. 65 References Hardon A et al (2001). Analysis of qualitative data. In: Applied health research manual: Anthropology of health care. Amsterdam, Het Spinhuis. Hudelson PM (1994). Qualitative research for health programmes. Geneva, World Health Or gan i- zation. WHO/MNH/PSF/94.3.Rev.l. Lutz W (1982). Sampling: how to select people, households, places to study community health, 3rd ed. International Epidemiological Association. Edinburgh. Varkevisser CM, Pathmanathan I, Brownlee A. (1992). Designing and implementing health systems research projects. Volume 2: Geneva, Health Sciences Division of the In ternational Development Research Centre and World Health Organization. HOW TO INVESTIGATE THE USE OF MEDICINES BY CONSUMERS 66 6 6. DATA ANALYSIS Data analysis 6.1 Introduction Before conducting a study, a plan for data processing and analysis should be prepared. Such a plan helps the researcher ensure that at the end of the study: • all the necessary information has been collected • unnecessary data that will never be analysed are not collected. This means that the plan for data processing and analysis must be closely linked to the study objectives and research questions, as well as a list of relevant variables. The procedures for analysis of data collected through qualitative and quantitative techniques are quite different. For qualitative data, it is a matter of expanding notes from interviews and/or transcribing tapes, and then ordering, describing, summarizing, and interpreting data obtained for each study unit or for each group of study units. Here the researcher starts analysing while collecting the data, so that questions that remain unanswered (or new questions that come up) can be addressed before data collection is over. For quantitative data, the variables have been defi ned prior to the study. Variables are characteristics of persons, objects or phenomena that can take on different values. The values of variables can be expressed as numbers (for example age, expressed in years); such variables are called numerical variables. Or, they can be expressed in categories (for example, ‘source of advice’; the categories for this variable are: no advice; family; health worker; pharmacist; and others). Such variables are ‘categorical variables’. If you develop a problem analysis diagram in preparation for a fi eld study, you identify factors that infl uence the core problem, see table 4. Note that in the table, waiting time is easy to operationalize as a numerical variable. It can be measured in minutes. The other variables can be made operational as categorical variables. Operationalizing variable

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