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FIELDWORK

trainer’s notes (for Use with Manual)

PURPOSE AND CONTENT

This session includes a half day preparatory session and a full day actual fieldwork and presentation of results. It aims to give participants experience in developing tools for research on drug use problems and in conducting qualitative research. The results of the fieldwork are not analysed fully, but used to re-focus the problem analysis diagram which was designed in the RAP session and to reflect on the strengths and weaknesses of the various tools used. The Session Notes give some general background on how to conduct the study, and four group activities.

In each country where the course is held the host institution should review the session and adapt to local conditions. The host institution should:

  • Select drug use problems as focus for the fieldwork.
  • Prepare background information on the problems, to be used in Activity 1 of the session onConducting a Rapid Appraisal to Analyse Problems and Identify Possible Solutions.
  • Review and change the appraisal matrices in Activity 1 of the fieldwork session.
  • Review Activities 2 and 3 and adapt the tools in Annex 2.

The matrices and tools developed by the host institution and course facilitators enable the participants to prepare for the fieldwork in only half a day. The participants are encouraged to add tools, and to revise the ones prepared for them. In this way they get hands on experience in developing them.

OBJECTIVES

At the end of the session participants will:

  1. Be able to define the research methods needed to analyse drug use problem.
  2. Be able to develop research tools.
  3. Have experience with key methods to study drug use practices and ideas, e.g. semi-structured interviews, drug inventories in pharmacies and community drug stores, and simulated client visits.
  4. Have gained insight into the strengths and weaknesses of the various methods; and how a combination of methods can be used to triangulate the results.
  5. Have an understanding of how qualitative research can be used to re-focus and refine a problem analysis diagram as a basis for appropriate interventions.

1

FieldworkTrainers Notes

PREPARATION

Participants and the trainer should:

  1. Read the Session Notes.
  1. Review the tools prepared for the field work by the host institution, see Annex 2.
  2. Review Chapter 3 of the Manual “How to investigate the use of medicines by consumers” onInvestigating Drug Use Patterns and Identifying Problems; it contains methods that can be used for the rapid appraisal.

This session requires a lot of preparation by the host institution in consultation with the trainer. They should ensure that the following is done:

  • Identify respondents in communities and in health institutions for the semi-structured interviews and identify pharmacies for the simulated client visits, as specified in Activity 3. Other logistics such as transport (preferably mini-buses), lunch for the participants and – to be agreed upon by host organisation – incentives for the people to be interviewed, also have to be arranged.
  • Divide the group of participants into four sub-groups:

a)community group working with ARV users

b)health institution group working with health workers

  • Assign tables to each group and make sure the groups have enough local language participants to translate during the interviews. Consider if it is appropriate for women/men to interview certain groups.
  • Each sub-group should have at least one, preferably two translators: minimum of four and maximum of eight. The more translators the smaller the groups which conduct the interviews, the more ‘respondent friendly’ the interviews can be. Too many interviewers can be rather daunting. Usually university students are asked to participate as translators. The translators should be present for Activities 2 and 3.
  • Each sub-group should receive the appraisal matrix and tools on diskette and they should have access to a computer to be able to revise them.
  • A photocopying service should be available during the preparatory afternoon for groups to multiply the number of forms they need.
  • Each sub-group also needs a flipchart and overheads for their presentation, in Activity 4.
  • Efficient transport is needed to and from the communities. The aim is to practise tools, so it is best if the communities are not far. Have each sub-group use their own taxi/bus, so that they are flexible in going back to the training centre when the fieldwork is done.
  • Each group should carry their own lunch to facilitate maximum use of time. This should be organised with the hotel.

organisation of the session AND KEY POINTS

The session includes four activities for group work, with a very limited amount of plenary inputs by the trainer at the beginning of the afternoon in which the fieldwork is planned, and a plenary feedback from the four sub-groups in the evening of the fieldwork done.

Structure and timing of the session

Afternoon fieldwork preparation session
  • Objectives and purpose - 5 minutes
  • Overview of the four group activities in this session - 5 minutes
  • Participatory lecture on how to conduct semi-structured interviews and simulated client visits - 20 minutes
  • Activity 1: initial review of the appraisal matrix and adaption of tools - 60 minutes
  • Tea break - 15 minutes.
  • Activity 2: pretesting the tools and preparing a plan for fieldwork - 90 minutes.

Fieldwork day (exact timing depends on distance to community/appointments made with respondents):

  • Sub-groups conduct field work - 6 hours
  • Sub-groups conduct Activity 4 - 3 hours
  • Evening: presentation of results and plenary discussion on weaknesses and strengths of methods used.

Visual aids

  1. Title slide
  2. Fieldwork objectives
  3. Group activities
  4. How to conduct semi-structured interviews
  5. How to conduct semi-structured interviews 2
  6. How to conduct semi-structured interviews 3
  7. How to conduct simulated client visits
  8. Strengths of semi-structured interviews
  9. Weaknesses of semi-structured interviews
  10. Strengths of simulated client visits
  11. Weaknesses of simulated client visits

Objectives and purpose (5 minutes)

Show OH 2 and stress that the aim of the fieldwork is to gain experience in using qualitative methods. Explain that there is limited time for the exercise, and that is why the host institution has done preparatory work, developed tools. But that these tools need to be revised and that new tools can be added. The day will be mainly group work. Trainers can be asked for help.

Overview of group activities (5 minutes)

Use OH 3 and briefly describe what the groups will be doing in the afternoon and tomorrow during the fieldwork. Point out on which page they can find the appraisal matrix for Activity 1, and where they can find the tools. Make sure that they all understand that the tools have been adapted based on the appraisal matrix prepared by the groups. Stress also that the tools are not complete.

Explain that each group will receive the prepared tools on diskette. They are responsible for revising the tools and printing/photocopying them during the afternoon session.

Make sure everyone knows in which group they are working. And explain that they will work in two sub-groups: the community sub-group and health institution sub-group. Clarify that these groups have different tasks in the preparatory afternoon and tomorrow.

Participatory lecture on how to conduct semi-structured interviews and simulated client visits

(20 minutes)

Ask if anyone in the group has experience in using these methods. Ask them to give guidelines on how to conduct the methods. Start with semi-structured interviews. Write the suggestions on a flip chart. Continue with simulated client visits. Use OH 4-7 to sum up.

It might be good to give some tips on observation skills which can be used (regardless of research methodolgy).

Activity 1: making an appraisal matrix and preparing tools (60 minutes)

Explain that the matrix provided is the basis for developing tools. Also explain that to adapt the matrix they should consider the objective of the appraisal which was formulated in Activity 1 of the session on Conducting a rapid appraisal to analyse problems and identify possible solutions, and the factors in the problem analysis diagram. Participants have to check if all factors are translated into research questions. And they can delete the research questions that are not relevant for their objective. Clarify that research questions are not yet interview questions. It also allows you to seek triangulation – using different methods to answer the questions. Briefly summarize the exercise and urge participants to ask help if they have difficulty doing the tasks.

The tasks given in the Session Notes are:

  • To decide on which methods to use you need to review the research questions which you formulated in Activity 1 of the session onConducting a rapid appraisal to analyse problems and identify possible solutions: what do you want to know and how can you find it out?
  • Below you find an appraisal matrix for each of the drug use problems. It shows which research questions will be answered using which methods. Adapt this matrix so it includes the questions you consider important.
  • Discuss the advantages and disadvantages of using the proposed methods.
  • Review the research tools prepared by the host organisation. Using the matrix, check if the tools include all relevant questions. Amend the tools, and add ones which are not included in the pack.

Appraisal matrix on non-adherence to HAART

Formulating good research questions as well as selecting appropriate study methods are essential to the success of the appraisal. The matrix below provides an example of questions and methods that you can choose and adapt.

Research Questions / Suggested Methods

Health facility assessment

On access to ARVs:
  1. Which ARVs are in stock in the health facility? Did any stock-out of ARVs occur in the past 3 months?
  2. Which combinations of ARVs are prescribed to patients as first-line therapies?
  3. How are decisions concerning the switching of treatments taken?
  4. Which selection criteria / conditions are used to select ARV users? Do these criteria / conditions include the consideration of factors which are likely to determine adherence (such as disclosure of HIV status, partner notification, bringing a buddy, and/or adherence to prophylactic treatment to prevent opportunistic infections)
  5. What is the cost of the first line treatment to users, (including transport and related costs for diagnostics etc)? Are the costs a barrier to consumers?
  6. Are there any other barriers to use of ARVs?
/ Interview with health staff involved in ARV prescribing and counseling
Exit Interview
Observations of stock of ARVs
Review of records

On Information and communication

7. Do new & switching ARV-users receive information on:
  • How ARVs work
  • How to use them
  • The need to continue treatment
  • What to do if a pill is forgotten
  • Possible interactions with other drugs
  • Which side effects can occur & what to do if they occur
  • (Breast) feeding requirements
  • When and where to get re-supply
    Do clients receive written information about these points?
  1. Are health workers:
  • treating ARV users with respect, and in privacy?
  • listening to ARV users and let them ask questions about the treatments and the effects on their bodies and their lives?
  • ask the ARV users about their experiences with ARVs in their everyday life when they come for follow-up visits, and to take problems with the drugs serious?
  1. Do health workers fear acquiring AIDS?
    Specifically, do they think they can get AIDS:
  • by shaking hands with an AIDS patient
  • by using the same toilet
  • if an AIDS patient coughs in their vicinity.
  1. Do health workers liase with family and community members to enhance adherence to ARVs? In what ways do they do so? How effective are these adherence support measures in their view? How could they be improved?
  2. Does the health facility have a system to follow-up ARV users?
  3. What are the levels of non-adherence to ARV regimes according to the health workers? What are the reasons for non-adherence according to them? Who adheres best and worst? What are main factors?
/ Interview with health staff involved in ARV prescribing and counseling
Exit Interview with ARV users
Structured observations
On technical competence, human resource issues and available facilities:
  1. Are health workers working in the ARV treatment programs trained in comprehensive AIDS Care, including both technical and psycho-social skills?
  2. Are guidelines on care for PLWA available?
  3. Is prescription in accordance with the guidelines? Specifically which CD4 count cut-off points are used for treatment initiation?
  4. For new users, is the history of ARVs used previously checked?
  5. Are diagnostic facilities (CD4 counts, viral loads) available? Which? Are they used appropriately? IF not, are clinical markers used to initiate and monitor treatment outcomes?
  6. In what way does the ARV treatment program affect the workload and job-satisfaction of health workers?
  7. What do health workers consider as major problems regarding treatment of and care for ARV users?

PLWA using ARVs

  1. What is the view of PLWA on the quality of ARV care in the different health facilities offering care? What is considered good and what is considered problematic in the care provided by the different facilities available to them?
  2. Do ARV users feel listened to and treated with respect at the health facilities, specifically do they get a chance to ask questions about the treatments and the effects on their bodies and their lives?
  3. Do ARV users trust the health workers?
  4. Do they feel dependent on the health workers, and do they fear this dependence on them as source of life-prolonging treatment?
  5. What are the views of ARV users on efficacy and safety of the ARVs that they are taking?
  6. What are their experiences with the drugs. What is it like to take drugs? How do they fit in everyday life routines, like going to town, working, going to school?
  7. How should the drugs be used according to them? Are they aware of the correct treatment schedule? Do they know why they need to adhere to the schedule?
  8. Have there been times when they could not take medicines according to the prescription? If so, why not? What were the consequences of missing a dose? Was it perceived to be a problem? If yes, what is done to avoid missing a dose? Specifically in the past week, were doses missed? When and why?
  9. What is the cost of the treatment to the users, including transportation, food, diagnostic tests and other related costs.
  10. Are appointments with the ART facility kept? If not, why not? (delay, waiting time, waiting space)
  11. Do the users experience side-effects? Which? What have they done to diminish these side-effects? Did they or do they want to switch drugs?
  12. Do family friends and members know that ARVs are taken by the user? If yes, do they support the ARV users in his/her treatment? How? If not, why has the user not disclosed their HIV status and/or use of medicines? Do they have a designated buddy system?
  13. What do they perceive as most problematic regarding adherence to ARV treatment? What could be done to improve this?
/ In-depth interview at a location of choice with PLWA using ARVs for more than one month
Focus group discussion with men and women ARV users

Community

  1. What local terms are used to refer to HIV/AIDS?
  2. Is HIV/AIDS a stigmatizing condition? Are PLWA subject to discrimination at health facilities, work, school or in the community. What types of stigmatization occur. Has the availability of ARVs in the health facilities diminished stigma? If not, why not?
  3. Do people generally disclose their HIV status? Do they disclose that they are taking medicines? If not, why not?
  4. Do people know how HIV is transmitted? And how it is not transmitted?
  5. Are people aware of voluntary testing and counseling facilities? To what extent do they use them? If not, why not?
  6. Are people aware of the availability of AIDS medicines in health facilities? What is their view of the quality of care of the different facilities providing ARVs? What are the advantages and disadvantages of the different facilities providing ARV care in the area?
  7. Have community organizations, church organizations, and/or organizations of people living with HIV and AIDS living in the community been involved in preparing for the introduction of ARVs in the facilites? Are these organizations involved in treatment literacy and adherence support programs?
  8. What are the costs and benefits of taking ARVs according to PLWA, and their family members and relatives?
  9. Do community members want an AIDS treatment facility to be established in their community? If yes, what would the community be willing to contribute?
/ Semi-structured interviews with community leaders (teachers, community health workers, community support groups. Organizations of PLWA, church groups, social workers etc)
Focus group discussion with adult married men and women, and young men and women.
Focus groups with men and women living with HIV/AIDS

TEABREAK (15 minutes)