STRUCTURED QUESTIONNAIRES

This chapter focuses on structured questionnaires and how they can be used in drug use studies. It begins with a brief overview of the questionnaire method and indicates the types of study questions for which it is most suited. The greater part of the chapter is devoted to a discussion of the steps involved in using the method to study a particular drug use problem.

6.10:Overview

6.11:What is a Structured Questionnaire?

A questionnaire is a group or sequence of questions designed to elicit information from an informant or respondent when asked by an interviewer or completed unaided by the respondent. When an interviewer is involved, the questionnaire is sometimes referred to as an interview.

An unstructured questionnaire is an instrument or guide used by an interviewer who asks questions about a particular topic or issue. Although a question guide is provided for the interviewer to direct the interview, the specific questions and the sequence in which they are asked are not precisely determined in advance.

A structured questionnaire, on the other hand, is one in which the questions asked are precisely decided in advance. When used as an interviewing method, the questions are asked exactly as they are written, in the same sequence, using the same style, for all interviews. Nonetheless, the structured questionnaire can sometimes be left a bit open for the interviewer to amend to suit a specific context.

A semi-structured questionnaire is a mix of unstructured and structured questionnaires. Some of the questions and their sequence are determined in advance, while others evolve as the interview proceeds.

The focus of this chapter is on structured questionnaires.

CHAPTER SIX

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The list of questions that make up a structured questionnaire may be open ended or close ended, depending on how the questions are framed and asked An open - ended question is one in which possible responses are not supplied in advance. Each respondent=s statements should be recorded as fully as possible and in the respondent's own words. Open-ended questions are very useful for exploring sensitive issues and investigating topics concerning beliefs, attitudes, and practices.A close - ended question usually provides a set of responses or options from which a respondent indicates his/her choice. Where the study topic concerns factual issues, or is a familiar one with a limited range of responses, close-ended questions are particularly useful.

6.12:Use of Structured Questionnaire in Drug Use Studies

The structured questionnaire method can be used to study various aspects of drug use behavior involving providers and consumers. The method is appropriate to use where the study is aimed at:

! Estimating the prevalence of existing beliefs or attitudes as a means of confirming data obtained with either unstructured interview or other qualitative methods.

! Finding out more information to complement or follow up a previous exploratory study. The purpose of this may be to check the validity of previously collected data or observations to enrich the overall results of a study.

! Comparing responses in subgroups of a large population, such as knowledge about different drugs, the type of drugs used, how much they cost, and so on.

6.20:Steps for Using Structured Questionnaires

Drug use studies that employ the structured questionnaire method share some of the characteristics of other methods. Several steps are involved; these are outlined and described below.

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Table 6.1:Key Steps in Using a Structured Questionnaire in Drug Use Studies

Step 1: Plan how to carry out the study.

Step 2: Define and identify the target group for the study.

Step 3: Develop the questionnaire(s) and guides.

Step 4: Select interviewers and other field team personnel.

Step 5: Train field personnel and pilot test the questionnaire.

Step 6: Prepare and conduct the field work.

Step 7: Analyze and interpret the data.

6.21.STEP 1: Plan How to Carry out the Study

a. Why is Planning Necessary?

When planning a questionnaire study, you must first make a number of decisions regarding various aspects of the study and how it will proceed. These decisions will all have a major impact on the implementation and success of the study.

During the planning you must decide which target group will answer your questionnaire, how to select a sample, design the questionnaire, and select and train interviewers.

In addition, you need to plan study logistics and equipment. These include stationery, forms, transport and whether incentives will be offered to respondents. Field allowance for interviewers must also be decided at this stage. These issues are addressed in the rest of this chapter.

b. Is there the Need for a Resource Person?

Planning and implementing a questionnaire study is an interesting but

demanding task. Whether or not it is necessary to find a resource person to assist in planning and implementing the study will depend upon factors such as the scope of the study, available resources, and your own experience and confidence in applying the technique.

Of all the methods described in this manual, questionnaires are the most familiar to many health professionals, and the one technique with which many people have had experience. An investigator with some experience may be able to manage a small study by merely following the steps described here, since the skills required to design and implement a structured questionnaire are not as demanding as other methods. For a large study, you may consider the assistance of a social scientist who is experienced in questionnaire design and survey research.

6.22.STEP 2: Identify the Target Group

One important decision is to identify the study population (the target groups of respondents who can best provide the information you need). The following steps provide a guide to the issue of sampling.

a. Determine Type of Sampling

Probability sampling methods are most commonly used in structured questionnaire studies. The purpose for using the questionnaire method usually involves confirming a hypothesis or generalizing the results of a study so relatively larger samples selected by probability methods are appropriate. The common probability sampling methods include:

! simple random sampling

! systematic sampling

! stratified sampling

! cluster sampling

! multi-stage sampling

These methods are described briefly in Annex A.

The basic principle underlying probability sampling is that the selection of any respondent or unit in the study population is based on a known (usually equal) probability. The most appropriate method for a particular study depends on the size of the target population, what lists of members are available, and whether the population is organized in natural clusters like

villages or health centers. [See also How to investigate drug use in health facilities: selected drug use indicators (WHO/DAP/93.1) for a more detailed discussion on sampling procedures.]

Sometimes, because of logistical constraints, the sample for studies of the knowledge, attitudes, or satisfaction of patients attending health facilities, or of patients with specific health problems, will not be selected randomly, but in the order in which they present for treatment (a convenience sample). In such samples, we must assume that patients in general, or patients with specific problems, present Arandomly@ from the underlying pool in the community, and that generalization to the larger underlying population is justified. Sometimes surveys will avoid sampling patients who attend early in the morning (more likely to be emergencies), or those who attend on market days (more likely to have no specific complaint) in order to avoid bias.

b. Who should be Selected?

The target population for a questionnaire survey will be chosen based on the drug use problem, the study objectives, and how the results are to be used. For example, you might be interested in inappropriate diarrhea treatment in the community. Previous research may have shown that most patients are treated without prescription in private pharmacies and drug retail outlets. A questionnaire survey of provider knowledge and beliefs may target all counter attendants in licensed pharmacies if that is an identifiable group for whom an intervention might be mounted. The most important principle is to ensure that all segments of the target population are well represented. Sometimes questionnaire surveys will include Aproxy@ cases; if so, criteria for who can be included must be clearly specified at the beginning. For example, in studying the use of antibiotics for treating ARI, an investigator is likely to talk to mothers with children who report with an episode of ARI. In cases where patients are accompanied by other relatives such as an aunt or neighbor, instead of the mother, the study should specify whether these persons can be interviewed or not.

c. Number to Interview

Sample size depends upon the aim of your study, and in particular how precise the sample estimates must be. Using the antibiotic example, if the purpose is simply to explore beliefs and attitudes about antibiotics in the treatment of cough in children, a small sample may be sufficient. However, if the purpose of a study is to estimate specific knowledge deficits in a population of paramedics in order to design a curriculum, a larger sample

might be necessary. Generally, if the goal of the study is to test a hypothesis or generalize the findings to a large population, then an adequate representative sample -- usually a large one -- must be taken to achieve a reliable result. d. Contacting Respondents

Respondents to a study may be contacted by mail, telephone, or personal contact; the latter is usually the most feasible in developing countries.

It is wise to contact the community or institution where the sample will be drawn in advance of the study. Depending on the focus of the study, contact people may include the chief or community head, health center officer-in-charge, or local government representative. Such influential people can later assist with field organization and logistics, and especially with providing an up-to-date list of the members of the target population (a sample frame).

During the initial contact, the aim of the study, when and for how long it will take place, and how it will benefit them should be explained to the agencies involved. Such information may encourage greater cooperation.

6.23. STEP 3: Develop the Questionnaire(s) and Guides

The design of a questionnaire and how questions are worded can greatly influence the reliability of the data collected. Developing a structured questionnaire is a relatively familiar activity, since questionnaires are so commonly used. Despite this, creating a good questionnaire is not a simple task, but one which requires careful testing and retesting. The suggested sequence of steps to assemble a questionnaire is:

1. Determine the contents of the questionnaire.

2. Formulate the questions.

3. Order the questions.

4. Arrange the questionnaire.

5. Translate the questionnaire (if necessary).

a. Determine the Contents of the Questionnaire

The first task is to determine which topics the questionnaire will cover and how it will be administered. The number of topics will depend on the objectives of the study, and on the

length of time it is reasonable to expect respondents to cooperate. Remember that the information collected should be relevant to the design of an intervention. The most frequent problem in questionnaire design is asking too many questions that are not directly useful or relevant. You can organize your work as follows:

! Outline the most important objectives of the study.

! List under each objective the types of information directly relevant and necessary in meeting these objectives.

! Rearrange and organize the lists into separate sub-themes or sections of the questionnaire.

! Decide how the questionnaire will be administered; i.e., whether it will be filled in by respondents themselves or by an interviewer (which is more common in developing countries).

b. Formulate the Questions

After identifying the sections of the questionnaire, you must formulate individual questions to gather the specific pieces of information needed.

Wording questions so that they are uniformly understood and tap into the desired category of response requires patience, practice, and, above all, pre-testing. Some general guidelines on good question formulation include:

1. Each question must be clear, simple, and specific

For example, a question such as "Where do you normally seek treatment when your child falls ill?" may be perceived differently by different respondents. AIllness@ can include many different types of health problems, and varying degrees of severity. AWhere@ can be interpreted as a physical location or a type of practitioner. ANormally@ is an imprecise word that means different things to different people. ASeek treatment@ may exclude self-medication in the minds of some respondents.

To overcome this problem, it is best to specify questions in clear, short and simple language. You may for instance break the question into pieces to assist respondents, for example, by asking specifically about ARI. Further limiting the duration to the last two weeks preceding the study or the last episode of illness will also enhance recall of respondent. You can further ask them to mention specifically the various actions they took since the illness was noticed. These may involve the following questions:

Has your child been ill with cough within the past two weeks?(If the answer is yes): Did you visit anyone for advice or treatment? Did you give the child any medicines?

(If the respondent indicates medicine(s) were given): Would you please list any medication(s) that the child has used since the illness started?

2. Each question must measure one thing at a time

Questions which measure two or more different things should be avoided. For example, the question "How do you and your staff normally treat children who present with cough?" should be divided into several questions to enable the respondent to give separate answers for different types of prescribers in the facility, since they may each have a preferred way of treating cough.

3. Questions should not be biased Leading questions can lead to biased responses. A leading question is one which suggests the expected answer. For example, the question: "When a child presents with ARI, do you prescribe an antibiotic?" is a leading one because it mentions antibiotic. An alternative would be to ask "What do you do when a child presents with ARI?"

Leading questions may also arise when presumptions are made about the respondents. For example, the question: "What additional fluids did you give your child when he was last ill with cough?" is biased because of the presumption that when the child has had an attack of cough, the respondent would give the child extra fluids.

A better set of questions might be: "Has your child had cough within the last two weeks?" (If yes): "Did you take any action?" (If yes): "What action did you take?"

4. Questions must be free from ambiguity

Words which are vaguely defined or have double meanings should be avoided. The question: "What kind of patient was he?" may lead to different types of responses such as `"poor" or "rich," "simple" or "complex," "cooperative" or "un-cooperative," and so on.

Also, "double barreled" questions, such as: "Do you think ampicillin and tetracycline are effective for treating cough?" are not good questions since a respondent could like one and not the other. In this case, a Yes or No response would not truly reflect the respondent's opinion. Divide such questions into two, each containing a single idea.

c. Sequence the Questions

After framing the questions, they must be organized in a sequence that is helpful for respondents. Following is a useful approach:

! Ensure a logical order of topics, and of questions within a topic. Ideas should flow smoothly from one question to another, moving from more general questions to more specific ones within each topic.

! Begin with relatively non-controversial and interesting questions, e.g., How many years have you worked at this health post?"

! Place sensitive questions concerning personal information such as age, education, occupation, and income at the end of the questionnaire since respondents may be unwilling to answer them if they are asked early, before a relationship of trust has been established.

! If the response to one question is likely to influence the response to another question, these questions should be separated.

! Any instructions for skipping one or more questions should be clearly indicated and, if possible, written in a different font or typeface.

d. Arrange the Questionnaire

Finalizing the draft questionnaire involves planning the layout to make it both "consumer" and "user" friendly. This involves the following:

! Provide necessary headings and spaces for labeling and identifying all questionnaires, ie., identifying information for respondent, date and place of interview, as well as name of interviewer.

! Provide necessary instructions at the start of each section of the questionnaire. Give guidance and reminders at relevant sections to the interviewers.

! Provide sufficient space between questions.

! Be consistent with codes or boxes for pre-categorized answers.

! Provide enough space for writing down answers to open-ended questions.

e. Translate the Questionnaire (if necessary)

Most interviews involving patients in developing countries are conducted in local languages. To ensure consistency in the use of words and meanings, questionnaires must be thoroughly translated before the field work begins.

One effective way of checking the accuracy of translations is to have a different translator do a back translation into the original language in which the questionnaire was written. The two versions can then be compared to iron out any differences. Table 6.2. is an example of a questionnaire.

Table 6.2.: Example of A Structured Questionnaire

DRUG USE STUDIES IN ACUTE RESPIRATORY INFECTION (ARI)

Client Intercept Questionnaire

Name of District.......................................................................... Date of Interview..............................................

Name of Town............................................................................. Name of Interviewer.........................................

Name of Facility..........................................................................

Name of Patient...........................................................................

DIAGNOSIS1. Can you tell me in your own words what the problem is with your child?

2. Why did you choose to come to this facility today for treatment?

3. Have you ever been to this facility before?

Yes________

No________

4. Did you try any other kind of treatment before you came here?

Yes________

No________

If yes: What kind of treatment was that?

DRUG USE5. Could you please show me the drugs you were given here today? Examine drugs

to be able to later fill in the questions on drug labeling on the dispensing form.

Did anyone here tell you how to use these drugs?

Yes________

No________

If yes: Who was it that explained this to you?

Did you understand what they explained to you?

Yes________

No________

b. The drugs you were given? Yes No

3. Can you explain why you were not satisfied, or in what ways might you have been more satisfied?

4. If your child's cough does not improve after taking these drugs, what do you plan to do?

d) Socio-Demographic characteristics8. Sex of Respondent Male Female

9. Highest level of education a. Primary d. Other Tertiaryb. Secondary e. Other(Specialties)c. University f. No formal education

Table 6.2. (Continued)6. Could you please explain the use of each drug to me? Hold each drug in turn for the

adult to see.Drug Described Use

a.

b.

c.

d.

e.

SATISFACTION WITH CARE7. Are you satisfied with the treatment obtained? Yes________ No________

The way the child was examined? Yes________ No________

The drugs you were given? Yes________ No________

8. If you could change one thing about the care here to make it better, what would that be?

9. If your child=s cough does not improve after taking these drugs, what do you plan to do?

SOCIO-DEMOGRAPHIC CHARACTERISTICS

10. Sex of Respondent Male_______ Female________

11. Highest level of education (Check one):

Primary ______________________ Other Tertiary ____________________

Secondary ______________________ Other (Specialties)____________________

University ______________________ No formal education __________________

6.24. STEP 4: Select Field Personnel

The calibre of field personnel who administer the questionnaire have a great influence on the quality of data. In structured questionnaire interviews, the field team personnel usually include interviewers and supervisors.

a. Selecting Interviewers The interviewer is the one who "sells" the aims, objectives, and intended use of the information to the respondents. The following are qualities to consider when recruiting interviewers.

1. Educational qualifications

Administering a structured questionnaire does not necessarily require high qualifications. Usually people with high school or second cycle education who can read and write well would be appropriate. In fact, using personnel with high qualifications may even prove risky since such people have a greater tendency to get bored with repetitive work.

2. Personal qualities

The following are useful personal qualities in an interviewer:

! ability to develop rapport with people;

! ability to speak all languages, if multiple languages are being

used;

! fluency in local language where this is essential;

! ability to work alone and under difficult conditions;

! honest and with a strong motivation to work;

! previous experience in conducting interviews;

! good communication skills.

Someone who is shy, aggressive, or has an unpleasant appearance is not likely to be a good interviewer

b. Selecting Supervisors

A supervisor is responsible for seeing that the field work is done properly. In addition to the personal qualities listed under Interviewer (above), the role of the supervisor demands the following additional qualities:

! ability to work with an motivate people;

! highly motivated and intelligent;

! considerable field experience is most preferable;

In general the duties of a supervisor include:

! consulting relevant authorities when a team enters a community or an institution for the necessary permission;

! checking the progress of the interviewers in the field;

! acting as point of contact between interviewers in the field;

! maintaining schedules and coordinating work in the field;

! solving any problems or difficulties that need to be resolved in the field;

! reviewing and editing completed interview schedules on a daily basis to avoid or minimize any problems during the analysis;

! re-interviewing small samples of respondents on important

aspects of the interview to provide some measure of quality control in the data obtained.

You may decide to select your personnel through interview, or written test (for language competency). It is advisable to make the selection provisional, subject to good performance during training and field testing.

6.25.STEP 5: Train Field Personnel and Pilot-test Questionnaire

The purpose of training is to impart the needed skills to the field team before they embark upon the field work. The training curriculum must cover both the technical aspects of questionnaire surveys, as well as practical training in how to implement them effectively.

a. Technical Background on Structured Questionnaires

Provide interviewers with adequate background knowledge on structured questionnaires and the survey process. This theoretical aspect of the training must include the following:

! an overview of structured questionnaires;

! how questionnaires will be used in this drug use study;

! the role of field personnel, including interviewers and supervisors;

! how to sample and locate respondents in the field;

! how to gain rapport with respondents and conduct a successful interview;

! how to record, process, or edit data in the field;

! how the data will be analyzed.

b. Relevant Background Knowledge about the Study

Inform the team about the problem, purpose and objectives of the study so that they can understand it in context. Provide information about the study community and target population.

Discuss the possible problems that could be encountered with respondents on the field. Explain any anticipated sensitivities on the part of community leaders, facility administrators, or respondents. This is especially important if it is possible that the questionnaire is seen as evaluating or judging knowledge or performance. c. Instructions for Recording Responses

Much of a structured questionnaire is completed by an interviewer marking or circling the appropriate response. In order to avoid inconcsistency, it should be made clear exactly how the interviewer is to complete each item. For multiple response lists, indicate whether the interviewer is to read the list to respondents, and also whether multiple responses are possible. If the interviewer makes a mistake filling in a question, explain how the mistake is to be corrected ( e.g., by blocking out, erasing, circling with an X, etc.).

Each respondent has to answer open-ended questions in his or her own way.

The interviewer therefore needs to be cautious in recording open-ended responses. Such responses should be written in full. However sometimes this is impractical, and interviewers must learn to extract the key information. The respondent can be asked politely to repeat a response if it is not well understood.Interviewers must not spend a lot of time writing since this can interrupt the flow of the session. Abbreviations are very useful, but interviewers should avoid those that are difficult to read later. Introducing a common set of abbreviations for vocabulary that will be frequently used is very helpful.

d. Role Play Sessions

The practical sessions of training consist of two parts. First are the role plays in which interviewers and other field staff practice among themselves in artificially created situations. Interviews should play the part of both interviewers and respondents.

The trainer and other experienced interviewers can observe and comment on the performance of interviewers in order to improve both the interviewers' style and the questionnaire.

e. Pilot Tests

As with all applied qualitative methods, it is important to pilot test the questionnaire and the field procedures. This involves trying out the prepared questionnaire in a group and an environment similar to that expected in the actual study situation. It affords interviewers the opportunity to practice all the activities that they are expected to carry out in the field. Functionally, pilot tests serve to:

! assist interviewers in becoming familiar with the questionnaire;

! help improve and sharpen interviewing skills;

! afford a means of checking, revising, and finalizing the questionnaire by improving the clarity and order of questions and removing ambiguous and unnecessary questions;

! enable the investigator to learn about possible problems that lie ahead, thereby providing an opportunity to make changes in the study organization before embarking on the field work.

6.26.STEP 6: Prepare for the Field Work

Once the training and pilot testing and over, you are almost ready to move into the field. Preliminary preparations do, however, need to be made to ensure that the field work proceeds successfully.

a. Review and Revise the Questionnaire

After the pilot test, review and revise the questionnaire and the guidelines for the actual field work. This review should take into account all issues related to the successful administration of the questionnaire. These will include the following:

! interviewer's approach to respondents;

! target response rates;

! what to do about partial or irrelevant responses;

! mistakes in following instructions on the questionnaires;

! time required for completing the interview.

Before printing the final questionnaire, have it thoroughly proof read to correct any hidden mistakes.

b. Prepare a Work Plan

As part of your preparation for the field work, you need a work plan and a time-table of how you will proceed with the field interviews. Particularly if the study is a large one with several interviewers and other staff, your work schedule will involve:

! composition of various teams of interviewers and supervisors;

! assignment of teams to specific locations or delineated areas;

! transportation and accommodation arrangements;

! schedule of work.

c. Plan for Supporting Materials

Before you finally move into the field, ensure that instruments and other interviewing materials and logistics for the field work are ready. Your checklist should include:

! introductory letters;

! sufficient questionnaires for the interviews;

! waterproof folders for the questionnaires in case of rain (if needed);

! instruction list for interviewers and supervisors;

! pens/pencils and note books for interviewers and supervisors;

! bags for carrying interviews and materials.

6.27.STEP 7: Administer the Questionnaire

a. The Interview Process

Interviews are best conducted with respondents alone in a place that offers reasonable comfort and privacy. Providers and patients/clients may be interviewed in a health facility or drug retail outlet. Community members can also be interviewed in their homes which is where they are most likely to stock and take their medicines.

The interview session can be divided in three stages: introduction and rapport building; interviewing; and closing the interview.

1. Introduction and Rapport Building

The opening part of the interview is aimed at introducing the respondent to the topic and making him/her relaxed for the interview. The interviewer seeks to do the following:

! greet the respondent, keeping with local custom;

! introduce himself/herself;

! briefly explain the purpose of the interview;

! assure respondent that responses will be anonymous and confidential;

! politely ask respondent to introduce himself/herself;

! seek respondent's consent to start interview.2. Interviewing

After establishing rapport, the most important aspect of the interview is asking questions in a standardized way. Following are interviewing techniques to guide the interviewer:

! Questions should be asked without changing the wording, order, or emphasis. Rationale: All respondents should be given the same information and asked the same questions, under similar conditions.

! Instructions which introduce sections of the questionnaire must be read out clearly and distinctly. Rationale: These instructions help respondents think about and prepare their answers.

! Interviewers must read out questions at a reasonable pace. Rationale: If the interview is rushed, respondents may give answers that tend to come to mind first instead of thinking about questions; if the pace is too slow, the interview can drag along and tire respondents.

! If a question is not understood, the interviewer must repeat the question in the same words, with the same emphasis and the same instructions. Rationale: Putting questions in different words can easily change the meaning and emphasis.

! Interviewers must avoid returning to questions which could previously not be answered. Rationale: Repeating questions this way can expose the intent and influence the responses.

! The interviewer must show neutrality as much as possible.Rationale: Certain reactions by an interviewer can change the attitude of a respondent. Examples are: frowning or irritated voice, smiling or laughing suspiciously,winking an eye, or raising eyebrows.

3. Closing the Interview

Before the interview is brought to an end, the interviewer must politely thank the respondent, explain that the interview is now completed, and ask if the respondent has any comments or questions. It is a good idea to ask respondents if they felt that the interview captured all of their opinions about the subject matter. Often respondents will offer useful opinions that may not have been covered in any of the questions.

In the final wrap-up, the interviewer must remember to:

! repeat the value placed on the respondent=s opinions and their likely benefits;

! reassure the respondent of confidentiality;

! express goodwill or polite farewell.

b. Anticipating and Managing Possible Problems

There are some problems that are commonly encountered during interview surveys. Sometimes these can be anticipated and prevented. Common problems and suggested ways to deal with them include:

! A respondent refuses an interview altogether: The best way to guard against refusals is by polite introduction, explaining the intended benefits of the study, and assuring the potential respondent that the interview will be brief. When refusals occur, note any reasons for the refusal and leave the respondent.

! A respondent abandons the interview halfway:Keeping interviews on track and moving along at a good pace

will decrease abandoned interviews. Well-designed questionnaires also help by maintaining the respondent=s interest. When interviews are abandoned, record any comments as to why this occurred.

! Respondent gives careless answers:Well-trained interviewers are always alert for respondents who do not seem to be responding seriously or thoughtfully. Sometimes the respondent is temporarily distracted or hurried, and the interview can be re-scheduled for completion at another time. In any case, record any doubts and suspicions, and indicate obviously suspicious answers.

Remember: the interview does not end until the interviewer has said Athank you@ to the respondent.

! Noisy environment:Queues of patients, curious onlookers, and young children can all distract respondents. Finding a more private place for the interview is the best solution. If this is impossible, carry on as best as you can; find out from the respondent whether something can be done about the problem.

! Others present try to intrude in respondent's answers:Any unusual activity in a health facility or home tends to attract interest. Onlookers can bias responses not only by directly answering questions, but also because respondents may not be able to give honest answers in their presence. Politely ask helpful onlookers to stop; at the extreme, suspend and re-schedule the interview with the consent of the respondent.

! Aggressive and other unacceptable behavior change in respondents:Sometimes a particular question or simply an overly lengthy interview can trigger hostility in a respondent. In these situations, end the interview with a polite excuse; record the actual details of the closure on the questionnaire.

6.28.STEP 8: Analyze and Interpret the Data

After the field work, data from the questionnaires must be processed, analyzed, and presented in the form of a report. The process involves the following activities:

a. Processing Questionnaire Data

1. Check and Edit Questionnaires

For purposes of easy identification, all questionnaires must be numbered separately after they have been completed. Field supervisors should maintain a log of the number of completed questionnaires received from interviewers each day. This helps to prevent lost questionnaires, and also can be used to check interviewer productivity.

Interviewers should routinely edit questionnaires under the supervision of the field supervisor to correct errors, omissions, or logical inconsistencies in filling them. The process is particularly useful at the early stages of data collection, as it allows errors to be fed back to the interviewers in order to avoid further mistakes.

Before the data process begins, a complete re-check and editing is necessary to clean the data.

2. Categorize Responses

The first stage of data processing involves categorizing the responses. This is the process of listing all responses to a question under clearly defined options. In structured questionnaire, categorization is necessary for open-ended questions. For example, an answer to the question: "Why did you choose to come here today for treatment?", could contain possible categories such as "accessibility", "faith in treatment", "treatment is scientific", and "referred".

The process begins by first examining the raw data to draw up a list of clearly defined responses for each question. Each category should be precisely described in a few words. Again, the list of categories for each question should not be too long as this can make the analysis difficult. For each question, place similar responses under one category. The process takes the analysis a step on to coding.

3. Code Data

Coding involves assigning symbols to categories. Commonly, numbers are used. Coding makes data processing easier, particularly where the analysis involves the use of a computer. Codes are written on each questionnaire next to the responses. It is ideal to maintain consistency in coding by writing the codes on one side, i.e., either left or right margin of the questionnaire, since this facilitates speed and helps minimize errors in data entry.

For each question, if the number of categories does not exceed 9, which may be the case in most situations, assign A1" to the first category, A2" to the second category, and so on. If the number of categories exceeds 9, assign "01" to the first group, "02" to the second group, "03" to the third group, and so on.

When developing a coding list, it is advisable to give the same code to common responses, irrespective of the question, to minimize mistakes by coders.

Example: No = ШYes = 1

There are no common types of missing values that must be assigned codes. Sometimes a response is missing because the respondent did not know the answer; this is sometimes assigned the code A8" or A88" in numerically coded questions or ADK@ in categorical systems. A response can also be missing if the respondent refuses to answer, the interview was not finished, the item was skipped, or for other reasons; these missing values are after assigned A9" or A99" codes in numeric systems, or ANA@ if categories are used. When you have finished developing your codes, compile them into a code book and ensure that there are enough copies for all coders. During coding a supervisor must periodically review a sample of each coder's work to ensure that coding is being done correctly.

4. Analyzing Data

After coding, the stages of analysis will vary depending upon whether it is manual or involves a computer. If the analysis is manual, the use of dummy tables or a master sheet is very helpful.

1. Using data master sheets

When data are to be analyzed manually, you will need tools for organizing the coded data from the questionnaires and aggregating them into

summary tables. The data master sheet is one tool for organizing data. This technique is particularly helpful for small samples. Basically, it is a sheet containing the various coded responses on the questionnaire that makes it easier to tally the individual responses by hand.

The advantage of using a master sheet is that direct counts can be done easily for coded responses, e.g., for socio-economic and other background characteristics. It may not be feasible to use master sheets if the questionnaire involves many open-ended responses. In such cases, hand compilation may be more useful in order to capture the whole range of responses. Table 6.3. is an example of part of a master sheet.

Table 6.3. Example of a Data Master Sheet

Respon-dent ID

Sex Age

Diag-nosis

Pres-criber

Drugs Satisfaction Knowledge

No. Pre-scribed

Anti-biotic?

Inject-ion?

With drugs

Withcare

About diagnosis

Aboutdrugs

1

2

3

Etc.

TOTAL

2. Using Tally Sheets

After data have been organized on master sheets, it is easier to compute totals for individual variables. However, the other advantage is that more complex data presentations can be developed easily from the master sheets, such as two-way and three-way tables.

To develop a complex data presentation, it is first necessary to lay out a dummy table that will contrast totals within categories. An example of a dummy table contrasting level of satisfaction for patients who received or did not receive an injection by diagnosis is shown in Table 6.4.

Table 6.4. Example of a Dummy Table

Received Injection No Injection

Satisfied Not satisfied Satisfied Not Satisfied

ARI

Diarrhea

Malaria

Other

Diagnoses

Once a dummy table has been laid down, each respondent=s data from the master sheet can be recorded as a tick mark in the appropriate cell of the table. After all respondents= data are entered, tallying the tick marks gives the totals for the sample as a whole.

3. Using a microcomputer for analysis

If a study involves a large volume of data, it is generally easier if a computer is used for the analysis. This will, however, also depend upon the resources available. The following steps provide guidance on how computerized analysis would be conducted.

4. Choose appropriate software

Various computer software programs are available for use in processing data. For most drug use studies some of the common ones include the following:

! Epi Info version 5 or 6.

! spreadsheet LOTUS 123 program

! dBase or other database management program

! Statistical Package for Social Sciences (SPSS) or other statistical package

Before you decide on what program to use, however, it is advisable to consult an expert in the area. In fact such a person ought to be consulted at the planning stage of writing the questionnaire in order to pre-plan how questions should be framed, and what kind of analysis could be done. This has the advantage of preventing or minimizing difficulties in analysis.

5. Enter data

For the data to be entered into a computer, a data entry format must first be developed. This is a screen containing the questions in the questionnaire with a space provided for entering appropriate responses. Epi Info 6 is especially well-suited for developing data entry routines directly from the wordprocessing files used to print the questionnaire. When this has been done, the data are then entered into the computer in their coded form. It is fastest to have specially trained data entry clerks do the data entry.

6. Edit data

After all data have been entered into the computer, a verification must be done to correct errors and omissions made in the process. Examples of such obvious mistakes may involve wrong codes such as entering 6 as code for sex when the allowable codes for sex in most cases are 0 or 1, and so on. To avoid or minimize such mistakes, it is sometimes possible to build checks into the program to detect and refuse such data entry mistakes. Another option is to enter data twice and have the computer check the equivalence of both entries.

7. Carry Out Analyses

The great advantage of using a computer lies in its ability to do several kinds of analysis in a relatively short time. After the data have been cleaned, you can run the analysis to obtain the needed output. Results can be produced in the form of graphs, tables, charts, and a range of statistical tests. You need to decide the most appropriate and useful but also interesting way of making this presentation.

c. Presenting and Interpreting Data

Two basic approaches are involved in the presentation and interpretation of data from structured questionnaires. The approach is determined by the nature of the questions asked; ie., whether they are close-ended or open-ended.

The analysis of close-ended questions, which are more or less quantitative, involves:

! First summarizing the information in a tabular or statistical form, and then

! Describing in words or text the information presented.

The presentation can be descriptive or analytical depending upon the purpose of the study and the intended use of the results. Simple statistical procedures that are used in most studies include calculating averages, percentages, proportions and ratios. As already mentioned, presentations can be in the form of tables, graphs, pie charts and several others as best as the investigator can manage.

Open-ended questions may also be reported as percentages if categorized and coded, but the content of each response or categories of any particular question may also be analyzed in more depth. As much as possible, responses that ask for knowledge, attitudes, and practices should be described as well as quantified.

The last stage of the data presentation is interpretation. It involves explaining the underlying reasons for the findings, and drawing implications from them. The discussion can highlight the significance of the main findings by contrasting them with other studies on the subject.

Based on the findings and discussion, recommendations for further action can be made. This may involve the introduction of interventions such as health education, targeted at the community people, or policy changes to streamline the managerial capacity of the institution(s) involved.

d. Writing the Report

Findings from a questionnaire study are presented in the form of a report. An outline of the final report should ideally be developed at the initial stage of the study and reviewed after the pilot test. The components of the final report should consist of the following:

Introduction: Statement of problem, research objectives, rationale, scope, operational definition, outline of the chapter.

Methodology: Research approach and method, instruments, study setting, sampling, personnel, field work organization and supervision, mode of data analysis.

Findings: This embodies tabulating and describing the study results.

Discussion: Underlying reasons and explanations of the main findings.

Conclusion and Recommendations: Inferences, suggestions, and likely follow-up

interventions.