A good analysis of the prioritized drug use problem, and participatory identification of possible solutions are essential requirements for a successful intervention. Specific objectives for this pre-intervention step are:
a. Describe the prioritized drug use problem in more detail, by finding 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 five 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 A review of literature, unpublished reports and secondary data.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 define 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 finding 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 define the core problem and develop your problem analysis diagram without consulting key informants and without organizing a workshop. You could even skip the fieldwork, 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 five proposed activities are discussed in detail below.
Review of literature, unpublished reports and secondary data
The first step to be taken is another review of documentation and literature. The first 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 identified? 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 find published reports. Getting hold of unpublished reports is usually more difficult. If you are able, it is often best to visit a few well-functioning documentation centres of health-related organizations and institutions. UNICEF national offices are often be a good source of information. Also, when conducting key informant interviews ask for any relevant reports or data.
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.
The questions on the check-list should help you find 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).
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 identified 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 influenced 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 define 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 identified 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 figure 5 as an example.
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 identified 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 financial 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 flexible 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.
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 influences 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 defined and analysed a core problem, and factors related to it. In the next activity you conduct field research to gather data that will help you to design an appropriate intervention.
Fieldwork on a core problem
It is unlikely that after activities 1-3 you will have sufficient information on your core problem to conduct an intervention. Using the problem analysis diagram as a point of departure you can define what questions need to be answered through fieldwork.
Formulating fieldwork questions
Formulating good fieldwork 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 help you to reformulate them so that they are sensitive to local realities and use appropriate language.
BOX 10. QUESTIONS ON THE INAPPROPRIATE USE OF ANTIBIOTICS IN CHILDHOOD ACUTE RESPIRATORY INFECTIONS
For the fieldwork on the inappropriate use of antibiotics, the following questions need to be answered:
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?
a. Why do people use antibiotics; what is their perceived efficacy?
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 specific 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?
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?
To analyse your core problem you will need to find 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 efficiency: do not collect more information than you need to develop a good intervention.
Selecting fieldwork 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 define relevant outcome measures on which you would need to collect baseline data.
Use a set of different methods to cross-check on findings 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 find 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 specific 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 efficient 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 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 efficiency: 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 specific set of methods.
In planning your fieldwork 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 fieldwork 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 find solutions and constraints to change.
Looking at reasons for the problems from the point of view of the “target” audience is essential to finding 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 defined 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.
Specific aims of this phase of step 3 (analysing problems and identifying solutions) are to:
a. Identify possible solutions to the drug use problem, specifically
- 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 difficult 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 sufficient resources it is good to do a series of focus group discussions. Feed back results of the fieldwork 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
Example of a research matrix
Questions and methods for fieldwork on the inappropriate use of antibiotics in childhood acute respiratory infections as for the workshop described above in activity 3: set clear objectives. Those key objectives are likely to be:
To what extent do people treat their children’s coughs and colds with antibiotics in self-care (without consulting a doctor)?
What other treatments are used (including non- drug therapies) and what are the attributes of these other treatments according to 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?
Weekly illness recalls among families with pre-school children on the occurrence of coughs and colds and the treatment of these disorders. Start with this method, as it provides information that can be used in the following sub-sets of methods.
Why do people use antibiotics: what is their perceived efficacy?
Are people aware of risks of antibiotics?
What are the attributes of these other treatments according to respondents as compared to antibiotics?
How many tablets/capsules over how many days do parents think are needed for specific cough/cold conditions?
FGDs with mothers of pre-school children, with a drug-sorting exercise (see the example of such an FGD in Chapter 3). For the drug-sorting exercise use actual packages of medicines which are reported in the weekly illness recalls.
Semi-structured interviews with a sub-sample of mothers who actually report a cough/cold case that is treated with an antibiotic.
What advice do health workers give on treatment of coughs and colds?
Review of medical records. 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 five days; with only slight fever, and no accompanying symptoms).
What kinds of antibiotics for the treatment of children’s coughs and colds are stocked in town pharmacies and community grocery shops?
What advice do sales persons give on the use of these antibiotics?
Do they advise on the need to use a full course?
Inventory of community stores and pharmacies on the kinds of antibiotics they sell for coughs and colds.
Simulated client method. Community members pose as the mother of a child who has cough/ cold (use the same hypothetical case as 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 specifically ask for one, referring to a brand which is often used (as reported in the weekly illness recalls).
a. Review the results of the fieldwork; present your findings 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 findings. Do they have anything to add?
b. Ask participants to:
- propose specific ways in which people could be convinced to use drugs more appropriately
- identify those health behaviours that are most amenable to change
- define who the target of an intervention should be
- identify appropriate communication channels to reach the identified 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. Define 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?
f. Discuss an action plan: Who can do what to help implement the solutions (short-term and long-term)?
BOX 11. KEY MESSAGES
In the workshop on the rapid appraisal of inappropriate use of antibiotics in childhood acute respiratory infections, participants defined 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 identified 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.
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 Medicine, 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 primary health care. Tokyo, United Nations University/Los Angeles, University of California.
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 Tropical Institute.
Vlassof C, Tanner M (1992). The relevance of rapid assessment to health research interventions. 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.