Extra Credit Journal 2

Methods Practice: Data Coding

For an extra credit methods practice I decided to apply some of the inquiry method techniques while working for a professor on campus. I have been doing research with this professor on genetic indicators of health conditions in adults. Most of what we have been doing this semester is coding data received from surveys that were collected last year. This is valuable experience for my field study since I will be coding data from surveys as well.

For this particular methods practice, I decided to not go so fast when coding the surveys so I could look for patterns in the data. I wrote down questions I had about the responses and patterns I saw in them. For example, I found that a lot of the responses on the questionnaire were in relation to medical conditions that I had never heard of. Taking the time to stop and look up each condition when I found it on a questionnaire was extremely helpful. I was able to see that some medical conditions reported on the surveys were actually in the same category as other health conditions (e.g. multiple medical conditions that all have to do with the cardiovascular system). Previous to this, I didn't know that these conditions were related, and with that knowledge, I am more able to analyze the data.

For my own project I plan to implement this slower coding technique every once in a while. It would be impractical to go this slow every time I coded a questionnaire in my research, but doing this periodically will give me insight into the data. I will be able to see patterns that I have not seen before.

Journal 30

Well, seeing as this is my last journal entry for this course, I think it's a good time to reflect on what I have learned. The most valuable lesson I learned from this class was the inquiry based learning method. I is so valuable when researching a topic. Taking information found from research and learning to see it from the perspective of 'but what about this?' is such a valuable tool. I found that it gave continuity to my research. Instead of finding information one day, then starting from scratch the next day finding new information in a different direction, you can begin each new day of research by reviewing the questions that you asked the previous day and keep going in the same direction. Asking questions, developing those questions into better questions, then answering the questions so you can move on to new questions is a great research method.

I also found that keeping a learning journal was very valuable for researching a topic. When I had to actually write down what I had been learning about in my research on this blog it made me continually process the information I was finding. Then when I wanted to use the information later, it was available for me to look back on in an organized way.

I don't mean to discount any of the field preparation I gained from this class because I learned a lot in that area as well. I just didn't come into the class expecting that I would learn these two lessons.

Journal 29

Answers to previous questions:
I took the past couple of days to work on my proposal so I didn't find the answers to the questions from last time. I really want to keep looking into the topic of clinical pharmacists though since that seems like a great solution to adverse drug effects from polypharmacy.

New Information:
I realized a couple of things while answering questions following my presentation on Friday. In my methods section I need to make it more clear what type of sample I will be taking. I am planning on doing a stratified sample from a number of cities in Utah County, but I didn't put that in my project proposal. For compensation I need to make sure I make it clear that I am going to use two dollar bills since I think that would be much more effective than two one dollar bills. In my data analysis section I need to include that my analysis will include linear regression analysis for the quantitative variables (like the relationship between age and number of medications) as well as bar chart analysis for qualitative variables (like the relationship between gender and polypharmacy status). I could also make it more clear what other hypothesis I might test once I have collected my data. I only have two written in my proposal for simplicity, but I could give specifics on the other hypothesis I might want to develop.


Keywords:
presentation, data analysis, compensation, stratified sample, hypothesis

Journal 28

Answers to Previous Questions:
I looked for other  health conditions that were indicators of polypharmacy. A major one that I found was depression. Patients taking antidepressants are much more likely to have polypharmacy. This leads to an interesting subject; how might the presence of an affective (psychological) disorder contribute to polypharmacy. There are a lot of different affective disorders and they probably shouldn't be categorized all as the same type of health condition, but there may be some common themes. This topic seems interesting, but is a bit of a tangent off of my main research topic so I'll hold off for now on investigating it more thoroughly.

New Information:
I found a new article that has an interesting solution to the problem of inappropriate prescribing as a result of polypharmacy. The researchers tested the effect of having a clinical pharmacist (someone with a pharmaceutical degree) involved in the prescribing process for older patients with polypharmacy. Primary care physicians often do not have time to review and adjust the drug regimens of older patients, thus inappropriate prescribing goes unaddressed. In this study, a clinical pharmacist reviewed the drug regimens of older patients with polypharmacy and made recommendations to the physician with changes to inappropriate prescriptions. After one year they found a 23% decrease in inappropriate prescriptions vs. a control group.

Questions from this Information:
How much is this implemented in different health care centers? The article had been cited by over 200 other sources so I assume it has been pretty widely implemented.
How many health care centers have clinical pharmacists available?

Keywords:
Clinical pharmacists, inappropriate prescriptions, affective disorders, indicators of polypharmacy

Journal 27

Answers to previous questions:
I looked through my proposal again and made some adjustments for the final draft. I also found that my references were lacking so I'll need to do some work on that aspect of the proposal before Monday.

New Information Found:
I found a new article that looked at the indicators of polypharmacy. This article was unique because it looked at indicators which lead to a patient who did not currently have polypharmacy developing polypharmacy by the end of the study. Among these indicators were a few health conditions that were positively associated with the development of polypharmacy:

coronary ischaemic diseases (lack of blood supply to the heart)
heart failure
hypertension (high blood pressure)
asthma
osteoarthritis
atrial fibrillation (heart condition)
dementia
esophagus and stomach diseases
depression

These types of findings are important because they give physicians the ability to focus polypharmacy prevention efforts on specific groups. This study was conducted in the Netherlands and their definition of polypharmacy included anyone taking two or more drugs, so it's different in those aspects.

Questions from this information:
Have these findings been replicated in the United States?
Are there more conditions that are indicators of the development of polypharmacy? It would be good to put together a list so I could test my data against it to see if the same condition are indicators of polypharmacy in my population.

Keywords:
indicators of polypharmacy, health conditions, Netherlands

Journal 26

Answers to previous questions:
I haven't been able to get in touch with a doctor since my last journal entry to ask about polypharmacy as an indicator of mortality. I will be contacting doctors soon since I need to shadow one before applying to medical school, so I will be able to ask about it then.

New information:
In class today we looked through our project proposals and did an activity to help us organize the sections/paragraphs more effectively. My background information is organized as follows:

Paragraph 1: Basic definition of polypharmacy and how it is defined by various researchers
Purpose: Tells reader what I am studying

Paragraph 2: Research has shown indicators of polypharmacy in patients
Purpose: Tells reader what research has been done already

Paragraph 3: Polypharmacy is a concern for older adults for a number of reasons.
Purpose: Tells reader why polypharmacy is worth researching, why it is a concern.

Paragraph 4: There are measures physicians can take to reduce polypharmacy among their elderly patients.
Purpose: Tells reader what solutions are possible to solve the problem.

Paragraph 5: Why my research is different than what has been done already and why it has value.
Purpose: Tells reader why my research is unique.

Paragraph 6: Outlines my methods for library research.
Purpose: Helps readers see that my library research methods are viable.

Questions and observations from this information:

How do I make this more of a persuasive essay?
Do I need to establish earlier in the essay that there is a knowledge gap in the research that I will fill by doing my project?
I seem to be missing a conclusion. My paragraph six seems to be a bad way to end this section if it is to be considered as a complete essay within my proposal. My paragraph five seems like a conclusion, but I can't just erase paragraph six since it is required in the proposal outline. Moving paragraph to any other place in the section would feel out of place.
I don't think I need to add any other paragraphs, but I do need to beef up the information in my paragraphs. This might lead to splitting some of them into separate paragraphs.

Keywords: project proposal

Learning Journal 25

In class on Wednesday we did an activity to help us learn skills in observing speech events. This journal entry shows the results of my observations.

1. Two people greeting each other
Two students, one man one woman, walk towards each other. Man hails woman with gesture made by right hand and verbal greeting "hey how's it going?" Location is library. They seem to be acquainted from a class since the subject matter of verbal communication is difficulty of particular assignment. They stand facing each other about two feet apart. It is 4:30 PM. Lots of influction in their voices, animated hand gestures.

2. Woman speaking with a man
Both people are sitting at a table facing the same direction, not each other. Woman speaks louder than the man, laughs often. Both are eating ice cream at a table in the Wilkinson center terrace. Woman looks at man more than the man looks at the woman. Subject of verbal communication is hobbies they like to do in the summertime. They seem to have romantic interest in each other (at least in my cultural reference frame) but are onlky acquaintences currently. They are sitting about one foot apart.

3. Man speaking with a man
Both are sitting at table facing the same direction, side by side. They make eye contact once per sentence, looking at the table the rest of the time. One man holds a baby and plays with the baby throughout the conversation. Both are older, maybe 70+ years old. Others are sitting at the table and the conversation switches to other periodically. Men seem to be related somehow. Men are dressed casually, polo shirts and khaki slacks. Location is the Wilkinson center terrace near the cougar eat. Time of day is 4:25 PM. Tone of voice is relaxed. Men are about two feet away from each other while talking.

How can I apply what I learned to my project?
The older population that I will be studying represents a different culture even though I live in the same location as them. I will probably not be doing observations like this or participant observations as a direct part of my research, but I will be using these skills to understand my population. When I encounter elderly people this summer I will apply these skills to gain insight into how my population communicates, what is important to them and how these things might influence my data. For example, understanding what is important to them could help me understand possible response biases for people being invited to participate in my research. This will help me with wording for my cover letter.

Keywords: participant observation, observing speech events, class activities

Journal 24

Answers to previous questions:
I looked into the list of potentially inappropriate prescriptions and didn't find anything about drug-to-drug interactions. The lists I found were just for drugs that have been found to have adverse effects in elderly patients in general. I need to keep looking for a list of potentially inappropriate prescription combinations for older adults specifically because of drug-to-drug interactions.

New Information:
I decided to pull back from researching the list of drug-to-drug combinations. Finding that list would be helpful, but I think it would be a time consuming tangent.
I found a new article that brought up some new points on the problems caused by polypharmacy in older patients. The background information contained in this article stated that polypharmacy in older adults reduces the quality of drug treatment. It was found that 50% of older patients that were prescribed more than five drugs were taking prescriptions that were unnecessary, ineffective, or therapeutic duplicates of other drugs they were already taking. Also, when patients experienced adverse reactions to drugs they were taking it was often interpreted as a new illness and more medications were prescribed to treat it. I don't think this can totally be blamed on physicians since incidence of polypharmacy is often an indicator of a patient requiring complex treatment combinations that would be difficult to balance.
The main finding of this article was that polypharmacy is an indicator of mortality in the patient within five years. Their definition of polypharmacy was different than many other studies that I have seen since they defined it as taking at least six drugs simultaneously. So with that definition of polypharmacy, yes, it is going to be an indicator for mortality within five years more than with a person taking two or three medications simultaneously. This finding has some interesting implications.

Questions from this information:
Do doctors need to be telling patients that polypharmacy (by their definition in the article) is an indicator of mortality in the next five years? If a person is very likely to die from a disease (for example) in the next five years their physician would tell them I think.
The information about loss in the quality of drug treatment was interesting. How could I find a doctors perspective on treating elderly patients with multiple conditions? Can I get a hold of a geriatric physician to interview? Who do I know that could help me with that?

Keywords: doctors telling patients polypharmacy is an indicator or conditions

Learning Journal 23

Answers to questions from previous journal entries:
I found it very difficult to find answers to the questions about time release medications. I might be looking for information in the wrong place.

New information found:
In a study that I found, a physician had looked at different factors that contribute to what he called adverse drug events. These are events that are harmful to a patient as a result of the medications they were taking. For example, falls, fractures, cognitive dysfunction, postural hypotension, electrolyte disorders and cardiac failure are events that could be caused by adverse drug effects. These events make up 23% of hospital visits in the elderly according to his sources. Also, he found that of all adverse drug effects in the elderly, 15-20% of them were due to drug-to-drug interactions.

The factors that increase the likelihood of adverse drug events are a higher number of drugs taken, older age, potentially inappropriate prescriptions, and others.

I started by looking into 'potentially inappropriate prescriptions' and it turns out that is an important key-phrase. When I began searching for articles using this phrase, I found a ton of information where I thought there was none. Apparently there are pretty widely accepted lists of potentially inappropriate prescriptions for adults age 65 and older.

New questions from this information:
How are the lists of potentially inappropriate prescriptions used?
Is it up to an individual physician to review it and make sure he is in compliance with it?
Are there policies being made to regulate prescribing drugs on the list? 

Keywords: potentially inappropriate prescriptions, drug prescribing policies

Extra Credit Learning Journal - Inquiry Conference

I attended the panel discussion following two presentations on Friday regarding the deaf community. The presenter that I heard, Charity, went to Ghana and studied education for the deaf. She learned that there is only one secondary school equipped to teach deaf students in the entire country. This makes secondary education for deaf students extremely limited. She also had insight into the social stigma regarding deaf children in Ghana. She made the comment that "they are treated like third class citizens in a third world country." There are also cultural explanations for why children are born such as the cursing of parents by a 'deaf god' to bear a deaf child. This type of cultural tradition many in the general population to view deaf children as 'pollutions.'

The part of the presentation that I found most applicable to my project came from the speaker before Charity whose name I don't remember. She will be attending law school in the coming year and has been involved in supporting public policy to help the deaf community. This made me think about my own project in that regard since solutions to many problems arising from polypharmacy will be found in policy changes. What type of legislation would it take to set up regulations for physicians prescribing multiple medications to the elderly? Have there been attempts in the past to set up certain regulations governing protocol for prescribing multiple medications to elderly patients? How do pharmaceutical companies view the issue of polypharmacy and are they willing to help set up regulations for physicians prescribing multiple drugs to elderly patients?

Keywords: inquiry conference

Learning Journal 22

Answers to questions from last entry:

I looked more into slow-release medications to see if there was a database with the effects of particular medications in the elderly. I didn't find anything and I guess that makes sense, that's why we go see a doctor, so they can tell us what effect certain medications will have in a patient. There's not a set way a medication will respond with every single person who takes it.

New information found:

I did find out a lot about slow-release medications though. Time release drugs have their active ingredient embedded in an insoluble matrix so that the molecules have to work their way through the matrix before released into the bloodstream. There is also a technology called microencapsulating which gives a more consistent release rate. These technologies only work for some types of medications however, ones where the pharmacological activity of the active ingredient is dependant upon blood levels. Also, if the active ingredient absorption involves an active transport protein mechanism then time release medications can be problematic.

I think this stuff is a whole different field that would take a ton of time and research to understand. I'm glad I found out that a basic concept though; that not all medications can be given in a time-release form with the current technology available. It seems like time-release medications are an effective way to increase patient compliance with prescription doses when the patient is elderly and is taking multiple medications.

Questions from this information:

What are the other methods to increase patient compliance that I can look into more?

Is there a big price difference with time-release medications?

When a time-release form of a medication is available do physicians know that prescribing it to an elderly person will make them more likely to comply with the prescription?

Keywords: patient compliance, time release medications

Learning Journal 21

Answer to questions from the last journal entry:
It turns out pharmacokinetics and pharmacodynamics are not the study of drug-to-drug interactions. After additional research I found that pharmacokinetics/dynamics is the study of the biological mechanisms of drugs.

New information found:
I found a study which showed that elderly patients are less likely to take the recommended doses of medications compared to other patients. This occurs for a number of reasons, but the reasons that are of interest to me are (1)too many prescriptions prescribed (2) poor synchronization of drugs (3)complexity of the medication schedule (4)not prescribing slow release drugs to limit the number of times per-day the patient must medicate (5)not paying attention to the size of capsules for prescribed drugs or utilizing syrups when possible.

Questions about this information:
Is there a database that has information on which drug combinations have adverse affects in elderly patients?
How many of the common drugs are available in a slow release form? This seems like it would be a good way to reduce the costs of medications for the elderly and increase the likelihood of patients actually taking their medications.

A possible survey question I could add might include:
Of all the medications that you take, how many do you follow the exact dosage recommended by your physician?

Notes to Maggie:
I realize that I haven't incorporated anything from the inquiry conference into my journal entry. At this point in my project I need to focus heavily on background research for my topic so I can complete section D in my IRB proposal by Friday. I'll make some connections between my project and what I learn from the conference in the extra-credit journal entry this week.
Also, Andrew wanted me to code my journal by keywords. Since this journal is viewed via web browser, the Ctr/F function allows me to search any text on the screen for certain words. When I want to search my journal by keyword I just enter Ctr/F and type in the keyword and that highlights the word throughout my whole journal. Is this sufficient for coding the journal?

Keywords: drug combinations, slow release drugs, patient compliance

Learning Journal 19

I have decided to shift the focus of my project. Since I am neither a psychologist nor a sociologist, I don't think I am very qualified to study social factors that contribute to high levels of stress in older adults. Instead, since I am a pre-medical student I will focus my research on polypharmacy (the use of multiple medications by a patient) in older adults.

I have read some literature on this subject that has given me background information on the issue of polypharmacy. As adults age, they are likely to have a combination of chronic medical conditions that require medication (i.e. a patient is diagnosed with diabetes, osteoporosis and hypertension). While these medications are warranted for the treatment of particular conditions, there are often considerations that must be taken into account due to the combination of multiple medications. Some of these considerations are pill burden (the high cost of multiple medications), drug-to-drug interactions (pharmacokinetics, pharmacodynamics) within the patient, and lack of coordination between multiple health-care providers (i.e. a patient visits multiple specialists, each prescribing medications).

How can there can be a lack of coordination between health care providers who see the same patient? Doesn't a person had a medical record that can be viewed by any physician?

How much do we know about drug-to-drug interactions (pharmacokinetics, pharmacodynamics) for specific medication combinations?

I read that the odds of being prescribed inappropriate medications increased by 22% for each additional medication prescribed. That seems very high to me. Why does this occur?

Keywords: polypharmacy, pharmacokinetics, pharmacodynamics

Learning Journal 20

I decided not to go to Ghana since I got engaged and decided to be married June 18th. Obviously this will have major implications for my project. I will not be going to Wiamoase for a field study so my project will completely change.

My first step is to develop a new research question and begin the 25 question exercise again:

Research question - What social factors contribute to high levels of anxiety in adults age fifty and older in Utah County?

25 questions beginning -

1. How large of a population sample do I need to eliminate population bias from my study?
2.Will a sample from Utah County give me useful data by itself or will I need a comparison group?
3. What is the best way to target adults age fifty and older while making the sample as random as possible?
4. What are some lurking variables that could potentially affect the study results? How do I include as many of these as possible so I am aware of all factors?
5. What type of response bias will be introduced if my sample is taken from this population? If the subjects know that I am a BYU student will that affect their willingness to participate and will that create a noticeable response bias in my data?
6. How can I evaluate stress levels of subjects while minimizing the risk of causing emotional stress from recalling stressful experiences?
7. This is a potentially vulnerable population (the elderly). What can I do to minimize other risks to my population?
8. Since anxiety is an affective disorder would subjects that have been diagnosed with anxiety be another vulnerable population?
9. What are indicators of anxiety for my population?
10. Are there common medications for anxiety that I should include in the survey as indicators on anxiety?

Keywords: Utah county, older adults, anxiety, 25 questions

Journal Entry 18

I've been reading the article from the malERA on vector control. The three main challenges facing effective control of anopheles vectors are (1)the preservation and improvement of existing insecticide based interventions (2)the development of interventions targeting species not currently affected by insecticides (3)the development of novel approaches that reduce the high vectorial capacities of sub-Saharan Africa. The questions this article led me to were these:

1. How can insecticides be used to target reproductive habitat for mosquitoes?
2. What ecological factors effect whether an area is more likely to have high vector populations?
3. Would it have a negative impact on Ghanaian ecology if mosquitoes were eliminated? How much would that cost?

I can see that there is not a ton of continuity in my learning journal entries. Each one seems to be separate from the others and I often don't address the questions that I asked in the previous entry. I think the reason for this is that my research is still quite broad. I find new material addressing questions that I had never thought of before quite frequently. And I find that the questions I ask are not always pertinent or easily answered so spending my research time answering these could take a significant amount of time and not be very helpful. I think at this point I am still doing a lot of exploratory research and want the information I find to dictate my research path rather than my questions.

Keywords: insecticides, malaria eradication research agenda, ecology

Learning Journal 17

I stumbled on a great resource online recently. It's a set of articles called the Malaria Eradication Research Agenda (malERA). These articles were written by the malERA Consultative Groups, each focusing on a particular aspect of the malaria eradication campaign (e.g. vector control, drugs, vaccines, diagnoses). This also led me to a very valuable resource called the WHO's malaria elimination field manual. This manual contains information on the feasibility of malaria eradication, tools for specific elimination programs, monitoring evaluation of progress, prevention of the re-establishment of malaria, etc. These two resources contain a ton of information that I am eager to implement into my project. I have only read a couple of pages of each and they have led me to some questions:

1. Why did the Global Malaria Eradication Project in the 1950's and 1960's fail to produce results in sub-Saharan Africa?

2. The WHO has summits and conferences where they develop proposals for malaria eradication strategies. How does Ghana implement these strategies.

I think the answers to these questions are in the resources I found, it will just take me a while to get through it all.

Keywords: malaria eradication research agenda, WHO's malaria elimination field manual

Learning Journal 16

I think volunteering at the clinic will be a valuable resource throughout my project. When I come to new developments in my research findings I can discuss them with staff at the clinic and get their perspective on an ongoing basis. I think they will give me valuable insight on the local implementation of treatments that will be useful throughout. My facilitator also mentioned a contact that students have interviewed in the past named Dr. Agyei in Agona. In my proposal I planned on interviewing him somewhere in the middle of my field study, but I think it would be valuable to interview him as I am developing my questionnaire. He will also have valuable insights on the current research agenda for the area. If I interview him early enough in the project I can incorporate things that I learn from him before I got going too far in one direction. I'm not sure how I will contact him. Maybe some of the employees at the clinic will be able to help me get his contact information.

I am realizing that it will be important when I get there to get in contact with as many locals doing research on malaria as possible so my research can be in line with what is already being done. I have already established that the clinic will be a good resource, but I haven't looked into many other possibilities. Who might I contact to learn more about that?

Keywords: volunteering at the clinic, community contacts

Journal Entry 15

Putting together my first draft of my project proposal made me aware of a couple things I had not thought about. First of all, what is it that I want to learn from volunteering and interviewing at the health clinic? Do I want to spend a lot of time learning about their treatment methods? Will I be able to interview patients who are diagnosed with malaria or will I be able to interview staff and health care providers only? How much time each day do I want to spend volunteering at the clinic? Will I only want to volunteer there at the beginning of my study then towards the end spend all of my time interviewing participants in the community? I get the feeling that some of these questions I will only be able to answer when I see the situation first hand, but it's good to think about considerations like this because it leads to other considerations that can be addressed beforehand.

Keywords: project proposal, volunteering at the clinic

Journal Entry 14

In the preparation course we are learning about entering a community right now. I will be entering a community where BYU field studies have been before so at least some of the local population will know who we are. I am realizing that I have no idea how to go about seeking a volunteer position at the clinic. Will the doctor we live with just give us an opportunity to volunteer there or will we need to seek out an administrator? Who is the gatekeeper for that type of position? It seems like in order to conduct my actual research I will not need approval from anyone. I intend to recruit participants by going door-to-door and requesting participation from people. Are there certain approvals I need in order to do that? I think I will just talk with my host family and some informants at the clinic about my proposed method of recruitment and see if they think it will work.

Keywords: entering a community, gatekeeper, recruitment methods

Project Proposal Draft 1

Follow this link to view my project proposal in a Google document

Journal Entry 13

How possible would it be to do a survey of as many citizens in Wiamoase and the surrounding areas? I would first need to develop a hypothesis to test. Some ideas I have had so far are:

• Lower income households are more likely to have an infant die from malaria
• As distance from a health-care center increases, the likelihood of an infant dying from malaria increases
• Education level of a parent/caretaker correlates to the likelihood of an infant dying from malaria
• As the number of children in a household increases, the likelihood of an infant dying from malaria increases
• Households that use an insecticide treated bednet are less likely to have an infant die due to malaria

A lot of these hypothesis have probably been tested so I will need to investigate these thoroughly so I am not doing research that has already been done. I would need to develop a set of questions that I could ask when I go to interview households. I could include a number of questions that would allow me to test multiple hypothesis (for example I can ask questions about household income and number of children in the household in the same interview). I have quite a few questions about doing this type of research though:

1. How will I define terms such as household income when I am developing interview questions? I know assessing wealth is much different in Ghana than it is here.
2. How willing will participants be to answer questions like 'what is your education level' and 'what is your income'? How can I ask these questions without prying and offending?
3. If an infant dies from malaria, but was never diagnosed how can I determine that the death of the infant can be attributed to malaria? Can I ask specific questions about the symptoms of the illness that took the child's life and determine if it was most likely malaria?
4. Would it be better to ask the questions in a highly-structured interview setting or should I develop a questionnaire to take around with me that participants can fill out. Can most people in Wiamoase and the outlying areas read well enough to fill out a questionnaire? Would I be able to find a place to print out questionnaires when I am in Wiamoase?

Keywords: survey, hypothesis, objectively define variables

Learning Journal

Learning Journal 3

The three other students going to Ghana and I are enrolled in a Twi language course. This class will be useful obviously to help us communicate when we get to Wiamoase, but there is another benefit inherit in the class. Since half of the class is Ghanaian the other field study students and I are already getting a small glimpse into the culture we will be attempting to assimilate into. I have made a few observations so far:

•  Understanding and relating to the humor of the people seems like it will have to be learned rather than intuitive.
• We will need to be the ones taking initiative to cross the culture barrier, we cannot expect those in our area to do so in our behalf.
• It seems like social norms such as the teacher-student relationship are different and we will need to adapt to those norms.

Keywords: social norms, Twi language, adapting

Learning Journal 4

I found an article called Malaria-related beliefs and behaviour in southern Ghana: implications for treatment, prevention and control. Researchers from Noguchi Memorial Institute for Medical Research studied the variables of malaria transmission in two locations in southern Ghana. They found that ecological factors play a major role in the occurrence or malaria transmission. For example, interference with the local ecology by building dams, mining areas and clearing rain forests for farming may create breeding sites for mosquitoes.

Also, I learned that Ronald Ross was the scientist who discovered Anopheles mosquitoes to be responsible for spreading the malaria parasite. This won him the Nobel Prize in Physiology or Medicine in 1902. The discovery of how malaria is transmitted laid the groundwork for developing strategies to combat the parasite.

Keywords: malaria related beliefs, ecological factors

Learning Journal 5

I studied another article from the Tropical Medicine and International Health publication entitle "How local community knowledge about malaria affects insecticide-treated net use in northern Ghana." In this study the researchers observed that health care educators and local citizens often had no real agreement on the definition of malaria. Locals would often not correlate the biomedical term malaria with what they perceived as a separate illness (which was actually malaria). They did not understand the use of bednets to control exposure to vector mosquitoes during nighttime. In general, health care educators/providers and locals disagree on the mode of malaria transmission. There were many implications from this article to suggest that the largest problem facing health educators in Ghana is a lack of common understanding between them and locals when it comes to the definition of malaria.

Keywords: community knowledge about malaria

Learning Journal 6

I studied an article entitled "Intermittent Screening and Treatment versus Intermittent Preventive Treatment of Malaria in Pregnancy: A Randomised controlled Non-Inferiority Trial." There are two methods for preventing malaria in pregnant women that were studied in this experiment. The first is called Intermittent Preventive Treatment with sulphadoxine-pyrimethamine and insecticide treated bednets. The second is Intermittent Screening Tests with a rapid diagnostic test and treatment of infected patients with amodiaquine+artesunate. In the first method all pregnant women are given preventive treatments whether or not they are infected. As a result, many women who would not have been infected with malaria are treated. The alternative method screens pregnant women in antenatal visits to the clinic and if their rapid diagnostic test shows they are infected with malaria they will be given an antimalarial drug. This article made me wonder how accessible these teatment methods are in the clinic in Wiamoase. Do women consistently attend their antenatal clinic visits enough for this to be effective? Can women buy the insecticide treated nets from the medical clinic?

Keywords: screening, treatment, amodiaquine, artesunate, sulphadoxine-pyrimethamine

Learning Journal 7

I studied an article entitled "Effectiveness of combined intermittent preventive treatment for children and timely home treatment for malaria control" and learned some interesting facts. IPT for children is more effective if distributed in homes, but the concern is that opening up that method of treatment could lead to the abuse of sulphadoxine/pyramethamine and the subsequent resistance of Plasmodium falciparum to it. Thus, treatment is limited to health care centers where the distribution is more controlled. What treatment method is currently used in Wiamoase? What is the possibility of implementing a new, more effective treatment method in the community?

Keywords: treatment for children, intermittent preventive treatment, timely home treatment

Learning Journal 8

I need to correct a statement made in the last journal entry. I thought the article stated that it was impossible to implement an IPTC program for home-based treatment of children because of the concern that the AS+AQ drug would be over-distributed and the P. falciparum parasite would develop a resistance to it. In the results of the study it was shown that implementation of a home treatment program was possible with local assistants trained to give the home-based IPTC and timely home treatments. The research authors had to go to the community twice a year to collect IPTC forms and at the beginning of each round of treatment for a few days to supervise the local research assistants. Other than these visits, the home-based treatment program was self-sustained within the community. The results of this research showed that this treatment method was successful with a decrease in febrile malaria incidents in children dropping by 88% over a period of one year. Is it feasible to implement this program in other communities? What is the total cost of this type of treatment compared what is currently done in Wiamoase? If IPTC is so effective why do people not just go to the clinic three times a year to get treated? Or do they in some locations? How do I find out the situation in Wiamoase?

Keywords: home based treatment

Learning Journal 9

I had an interview with my facilitator who had visited Ghana in 2008 to ask some questions about how my preparatory research so far applied to Wiamoase. This proved to be very useful since a lot of the treatment methods I have been researching are not applied in that community. The main thing I learned is that in Wiamoase there is no IPT or home based treatment of any kind. From what he said, I concluded that as long as the situation hasn't changed since 2008, any treatment of malaria in Wiamoase is done in the clinic. The reason for this was that there were not enough personnel to have home visits for administering AS+AQ or SP, and also that their method of treatment was essentially 100% effective. It seems that if a person displays severe symptoms of malaria (fever, aches, etc.) they will visit the medical clinic and receive treatment which always works. This led me to a lot of new questions: Why is the mortality rate for malaria in Ghana so high if even in rural areas there seems to be adequate treatment. Why are there so many studies being done for IPT if that isn't cost effective or practical? Is Wiamoase very much different from the other locations where these studies were conducted?

Keywords: wiamoase treatment, intermittent preventive treatment, home based treatment

Learning Journal 10

So I really need to revamp my project question. I think I can learn about all of the different treatment methods before I even get to the field. It sounds like it's pretty common knowledge that ITN's work really well for vector control, AS+AQ and SP are 100% effective (that is, until Plasmodium falciparum develops a resistance to it, but that research needs to be done in a lab). From what I have learned about Wiamoase, they are content with these treatment methods. But I feel like I really need to get specifics about the location. Is there a way for me to get some kind of contact in the community before I go? If I could have an informant that I could get information from as I prepare I think it would really help me make my preparation meaningful. Or maybe I need to spend more of my preparation time learning research methods and techniques so that even if I am not an expert on the topic I am researching I could at least have more adequate skills to conduct the research when I'm there. Right now I feel limited by the fact the the location I am going to is fixed and that I don't know how to get information on the specific location aside from asking my facilitator, but that's not necessarily what he is supposed to do. What I need to do is find out how to get information on Wiamoase and what there is to study in that location. That's where I'll focus my research for the next while.

Keywords: insecticide treated nets, project question

Learning Journal 11

So, new development. I am learning that a lot of the problem isn't that the treatment the clinic offers isn't adequate, but that a lot of people do not have access to the clinic. I didn't even consider that infants die from malaria because they cannot get treatment, I was assuming that everyone could get help if they really needed it. This is a whole different issue than what I was thinking. That explains why there are so many studies done of in-home prophylaxis treatment, not everyone can get to a health care center. If one of the Millenium Development Goals is to decrease the infant mortality rate for infants due to malaria what action is being taken near Wiamoase to achieve that goal? Are there groups that are working on distributing bednets or intermittent preventive treatment near Wiamoase?

Going this direction with my project question would mean I would be spending a lot of time away from the clinic I think. Is there anything even being done for preventive treatment near Wiamoase? Can I go online and find organizations that are working on distributing bednets and/or treatmentm for infants in rural areas?

Keywords: non-governmental organizations, millenium development goals

Journal 12

I searched on the internet for any NGO's near Kumasi that are working on getting bednets distributed. All I could find were ways to donate money to the organizations. I think looking for NGO's isn't the best way to go about finding what is being done to make bednets or prophylaxis more accessible. What is the government doing to work on this? I'm guessing the Ghana Health Ministry will have a program running to address distribution in rural areas. Is there a nationwide program that should be implemented in Wiamoase as well?

The problems I foresee facing the distribution of bednets and prophylaxis treatment are (1) funding and  (2) personnel. What other problems face this project? Are bednets subsidized enough to make them affordable to the people that need them most?

Is this the direction I really want to be going with my project? This is turning out to be more of a public health type issue than I realized.

Keywords: non-governmental organizations, bednets, prophylaxis