Rapid Monitoring of Treatment Coverage The Supervisors Coverage

Rapid Monitoring of Treatment Coverage: The Supervisor's Coverage Tool Training material Dept. of Control of Neglected Tropical Diseases

Outline of Training Sessions I. III. IV. Background 9 Steps of the SCT Country Experiences Discussion of ‘best implementation practices’

Coverage Surveys Supervisor's Feedback from Program Managers: Coverage Tool (SCT) • Coverage Surveys are time consuming and Coverage Surveys expensive → can’t be done everywhere all the time • Coverage surveys are too late to improve current Coverage round. Coverage MDA Evaluations Monitoring • Teams found simplicity of LQAS appealing • Supervisors complained of having no tools for District-level, statistically rigorous, supervision Implemented periodically Simple, inexpensive, & rapid for routine use 3

Supervisor's Coverage Tool Quick, simple, inexpensive tool for monitoring and Objective supervising MDA; implemented by first-level supervisors Primary Uses • Classifying coverage as likely above/below the threshold • Supervising CDDs and sub-district planners/organizers • Detecting issues with compliance and the drug distribution • Identifying sub-districts in need of mop-up activities 4

Supervisor's Coverage Tool Who? Conducted by first-level or sub-district level supervisors When? < 2 weeks of the MDA round (to allow time for immediate action and mop-up if necessary) Where? How? Targeted supervision areas (sub-district or smaller) LQAS; interviewing 20 people selected randomly from within the Supervision Area 5

Supervisor's Coverage Tool (SCT) As a monitoring and supervisory tool the SCT can be used to ensure: – Villages/communities are not missed • And to conduct mop-up activities when necessary – Identify problems with the supply and drug distribution systems • And to strengthen these systems to improve performance of the next MDA round – Individual compliance is high • And where it isn’t, to identify and address reasons for the non-compliance – CDDs are accurately recording their work • And when they aren’t to identify and address the reasons for the discrepancy 6

SCT – Quick Overview Inadequate Borderline Good Action Plan

How is SCT unique from other monitoring tools? SCT Rapid Coverage Monitoring In-Process Monitoring Sampling Random Purposive Team Internal ? External

Supervisor's Coverage Tool (SCT) Overview: Step 1: Identify population to survey Step 2: Identify supervisory areas (SA) Step 3: Obtain a list of all households using a) registers or b) household enumeration Step 4: Randomly select 20 households Step 5: Selection of Individuals Step 6: Interview Individuals Step 7: Interpretation of Results Step 8: Develop an Action Plan Step 9: Implement the Action Plan 9

SCT: Planning Checklist: ü Questionnaire (at least 1 per SA per team) ü Random number table (ideally laminated) ü Coin (for random selection) ü Chalk ü Examples of the medication (and any additional visual aids – e. g. , dose pole) ü SCT Quick Guide ü Clipboard (1 per team) ü Household enumeration sheets ü Notebook for scrap paper ü Pencils ü Action Plan handout (at least 1 per SA) 10

SCT: Planning Team Composition • SCT is an internal monitoring tool • Designed for district and sub-district supervisor implementation • Team composition: SCT Implementer and >1 Enumerator 11

SCT: Planning Cost: $0 -$1, 000 per supervisory area* *depends on how well-integrated SCT is with the program’s existing supervisory activities and the cost of training Days: ½ - 1 day per SA 12

SCT: Planning Review reported coverage and identify low coverage or challenging areas from previous round to conduct SCT Pre-MDA Planning Implement SCT towards the end of, or immediately following, MDA Mop- Data aggregation up and reporting Conduct mop-up, if indicated by the SCT 13

STEP 1: IDENTIFY THE SURVEY POPULATION

Step 1: Identify the Survey Population = The population for which an estimate of preventive chemotherapy coverage is desired Disease Survey Population Lymphatic filariasis Everybody living in the survey area Onchocerciasis Everybody living in the survey area Schistosomiasis Soil-transmitted helminthiasis (STH) Trachoma May vary, based on national treatment priorities and could include: - School age children(5 -14 years) - High risk adults May vary, based on national treatment priorities and could include: - Preschool age children (1 -4 years) - School age children (5 -14 years) - Women of child-bearing age - Everybody living in the survey area at the time of MDA (for LF) Everybody living in the survey area 15

Step 1: Identify the Survey Population Is it possible to use the SCT to monitor >1 drug package? YES, however this is only possible when the drug packages are being distributed at the same time through an integrated MDA. In such instances it will be necessary to clearly define the survey populations for each drug package. - e. g. , DEC and ALB - everybody PZQ - children 5 -14 years 16

Step 1: Identify the Survey Population Complete Exercise 1 (in the accompanying Participant’s Guide) 17

STEP 2: IDENTIFY THE SUPERVISION AREA(S)

Step 2: Identify Supervision Areas Supervision Area (SA) = corresponds to the smallest administrative or geographic unit for which a firstlevel supervisor is responsible. This typically the catchment area of someone who supervises the community drug distributors. 19

Step 2: Identify Supervision Areas District SA 6 SA 1 SA 9 SA 5 SA 2 SA 3 SA 4 SA 7 SA 11 SA 10 SA 8 20

Step 2: Identify Supervision Areas How to determine which SA(s) to pick for the Supervisor's Coverage Tool? 1. You suspect MDA coverage was poor 2. Recent migration or expansion make denominator estimates uncertain 3. You want to supervise the work of the drug distributors or their direct supervisors 4. Random selection

How to Use a Random Number Table For the SCT a random number table may be needed for the following Steps: Step 2. Identify the supervision area Step 4. Randomly select 20 households Step 5. Select one person to interview 22

How to Use a Random Number Table Instructions: 1. Make sure each item (e. g. , supervision area/household/segment) in your list is assigned a number. Determine how many digits are needed in your random number. The total number of digits will be equal to the maximum number items from which you are selecting. For example if the district has 127 supervision areas then the random number will need to have 3 digits (1 -2 -7). 2. Close your eyes and use a pointed object, such as a pen or pencil, to touch the random numbers in the table. Your starting point is the number closest to where you touched the random number table. 23

How to Use a Random Number Table Instructions Continued: 3. Read the number of the digits required from left to right, starting with the number that is closest to the tip of your pen. Numbers that are larger than the total number of items (e. g. , supervision areas/households/segments) will be discarded and the process should be repeated until you get a number that is less than or equal to the total number. 4. If, in selecting a random number from the table, the end of the row is reached before the desired number of digits is obtained, the selection of remaining digits should continue with the beginning of the next row. 24

How to Use A Random Number Table Example: Suppose there a total of 72 SAs listed in the district, therefore you need to pick a random number between 1 – 72. Because the total number has 2 digits (7 – 2) you will need to read 2 digits from the random number table. Close your eyes and touch the random number table with the tip of a pen and read the number that is closest. Suppose your pen lands on the number “ 8” and the next number to the right of it is “ 1”. This means your selected number is 81. Because the number 81 is > 72, you must continue reading the table to the right. The next number is 19. Since 19<72, this number is valid and means that the 19 th SA is selected. 25

How to Use A Random Number Table Complete Exercises 2 a & 2 b (in the accompanying Participant’s Guide) 26

STEP 3: OBTAIN A LIST OF ALL HOUSEHOLDS USING A) REGISTERS OR B) HOUSEHOLD ENUMERATION

Step 3: Obtain a list of all households using a) registers or b) household enumeration Keep in Mind: • Only 20 people selected per survey population per SA • Want everyone in the survey population to have a similar chance of being chosen Selection needs to be random

Step 3: Obtain a list of all households using a) registers or b) household enumeration Does an accurate SA register(s) exist?

Step 3: Obtain a list of all households using a) registers or b) household enumeration Does an accurate SA register(s) exist? How do I know if the register/census accurate? 1. Is the register routinely updated? 2. Are migrant or foreign-born populations that currently live in the village included in the register? 3. Does the register cover the entire SA? 4. Was register completed independently of a health campaign? If the answers to all of these questions are “Yes” then the register may be accurate

Step 3: Obtain a list of all households using a) registers or b) household enumeration Does an accurate SA register(s) exist? Should we use registers? Pros of using a register/census: § Can result in large time saving § Simple to select one HH Cons of using a register/census: § If register/census is inaccurate the survey results could be biased Ultimately, the decision to use an existing register/census is up to the supervisor conducting the SCT but should be consistent throughout the SA

Step 3: Obtain a list of all households using a) registers or b) household enumeration Does. No an accurate SA register(s) exist? Yes Scenario A) Registers 1. Obtain all registers in the SA 2. Assign a sequential number to each HH in the register

Step 3: Obtain a list of all households using a) registers

Step 3: Obtain a list of all households using a) registers 1. Upon arriving in an SA, request to see the village register/census 2. Check if each household in the register is assigned a sequential number 3. If households are not numbered, the SCT team should number each household in the register with pencil 4. If multiple registers are required to cover everyone in the SA, the households should be numbered sequentially across the registers, with no skipped numbers and no repeats

Step 3: Obtain a list of all households using a) registers HHs: #1 - #152 HHs HHs: #153 - #383 231 HHs: #384 - #471 88 HHs The SA has a total of 471 households 4. If multiple registers are required to cover everyone in the SA, the households should be numbered sequentially across the registers, with no skipped numbers and no repeats

Step 3: Obtain a list of all households using a) registers Complete Exercises 3 a (in the accompanying Participant’s Guide)

Step 3: Obtain a list of all households using a) registers or b) household enumeration Does. No an accurate SA register(s) exist? Yes Scenario A) Registers 1. Obtain all registers in the SA 2. Assign a number to each HH in the register No Scenario B) HH Enumeration Enumerate all households in the SA

Does an accurate supervisory area (SA) register(s) exist? 1. Is the register(s) routinely updated to include new households? 2. Does the register(s) cover the entire SA? 3. Are migrant or foreign-born populations that currently live in the village included in the register? 4. Was register completed independently of the MDA*? Yes, to all Scenario A) Registers 1. Obtain all registers in the SA 2. Assign a number to each HH in the register No, to one or more Scenario B) HH Enumeration Enumerate all households in the SA

Step 3: Obtain a list of all households using a) registers or b) household enumeration A Rapid Household Census Approach 1. Each member of the survey team should pair up with a local volunteer 2. Divide the village into sections so that each pair is assigned one section of the village 3. Assign each pair a letter code (e. g. “A”, “B”) 4. Each pair numbers ALL the households in their section using chalk to write the household code on each door (e. g. ‘A-1”, “A-2”, “A-3”, …”A 61”, ”A 62”) 5. After each team has numbered all houses in their section, the lists are combined to determine the TOTAL number of houses in the village. 39

Ro ad 3 Example SECTION 2 Road 1 market ⌂ School Ro a d 2 SECTION 1 SECTION 3 Road 4 School ⌂

Example Continued… Assign a code to each household in the segment and write this code on house with chalk (if acceptable): “Team code” + Number Example B -1 B-2 B-3 B-4. . . B 78

Example Continued… Combine each team’s list HH Code HH HH Picked? HH Code Picked? Count HH Code A-1 A-2 A-3 A-4 A-5 A-6 A-7 A-8 A-47 A-48 A-49 A-50 A-51 A-52 B-1 B-2 B-74 B-75 B-76 B-77 B-78 C-1 C-2 C-3 C-64 C-65 C-66 C-67 C-68 C-69 C-70 A-9 A-10 A-11 A-12 A-13 A-14 A-15 B-3 B-4 B-5 B-6 B-7 B-8 B-9 C-4 C-5 C-6 C-7 C-8 C-9 C-10 C-71 HH Code HH Picked? Count HH Picked Count ?

Example Continued… Fill in the cumulative household count HH Code HH Picked? Count HH Code HH HH Picked? HH Code Count HH Picked Count ? A-1 A-2 A-3 A-4 A-5 A-6 A-7 A-8 1 2 3 4 5 6 7 8 A-47 A-48 A-49 A-50 A-51 A-52 B-1 B-2 47 48 49 50 51 52 53 54 B-75 B-76 B-77 B-78 C-1 C-2 C-3 126 127 128 129 130 131 132 133 C-64 C-65 C-66 C-67 C-68 C-69 C-70 193 194 195 196 197 198 199 200 A-9 A-10 A-11 A-12 A-13 A-14 A-15 9 10 11 12 13 14 15 B-3 B-4 B-5 B-6 B-7 B-8 B-9 55 56 57 58 59 60 61 C-4 C-5 C-6 C-7 C-8 C-9 C-10 134 135 136 137 138 139 140 C-71 201

Household Enumeration Sheet

Step 3: Obtain a list of all households using a) registers or b) household enumeration Large Supervision Areas When the selected SA is large (e. g. , >5, 000 people) and there is no accurate village register(s), enumerating all households in the SA can become time-consuming and difficult. Instead the SCT implementer may choose to conduct the SCT in one or more subunits within the SA. But, as a result, the coverage classification resulting from the SCT will no longer be representative of the entire SA.

Step 3: Obtain a list of all households using a) registers or b) household enumeration Complete Exercises 3 b (in the accompanying Participant’s Guide)

STEP 4: RANDOMLY SELECT 20 HOUSEHOLDS

Step 4: Randomly Select 20 Households • Pick 20 unique random numbers between: 1 – total #of households in the SA • The selected numbers correspond to the nth households in the register or on the cumulative list from the rapid enumeration Note: if the SA spans multiple villages it is necessary to enumerate all households in the entire SA first and then select the 20 random A brief pause to practice using a Random Number Table numbers once the total number of households is known 48

Step 4: Randomly Select 20 Households Once the 20 households have been selected, the team should have a local guide take them to each of the selected households. If there are multiple teams, the 20 households can be divided between the team members. A brief pause to practice using a Random Number Table 49

Example using rapid SA enumeration Randomly select the required # of households HH Code HH Picked? Count A-1 A-2 A-3 A-4 A-5 A-6 A-7 A-8 1 2 3 4 5 6 7 8 A-9 A-10 A-11 A-12 A-13 A-14 A-15 9 10 11 12 13 14 15 X HH Code HH HH Picked? HH Code Picked? Count A-47 A-48 A-49 A-50 A-51 A-52 B-1 B-2 47 48 49 50 51 52 53 54 B-75 B-76 B-77 B-78 C-1 C-2 C-3 126 127 128 129 130 131 132 133 B-4 B-5 B-6 B-7 B-8 B-9 55 56 57 58 59 60 61 C-4 C-5 C-6 C-7 C-8 C-9 C-10 134 135 136 137 138 139 140 X X X HH Code HH Picked Count ? C-63 C-64 C-65 C-66 C-67 C-68 C-69 C-70 193 194 195 196 197 198 199 200 C-71 201 X

Alternative approach to household enumeration: While the process of household enumeration and random selection described in Steps 3 and 4 is considered the best practice, in some settings this approach may not be programmatically feasible. In such settings, it is acceptable to use a modified ‘random walk’ approach, as was traditionally used by the Expanded Programme for Immunizations (EPI), to select the 20 random households for inclusion.

Alternative approach to household enumeration: Modified Random Walk 1. Find the center of town and spin a bottle 2. Walk in the direction that the bottle is pointing and count every house in your path to the edge of town 3. Pick a random number between 1 and the total number of households in step #2; this number will represent your starting house 4. Select one person randomly from this starting household to interview for the SCT 5. Proceed to the nearest neighbor household and select one person to interview for the SCT 6. Continue using this nearest neighbor approach until 20 people from 20 different household have been interviewed

Alternative approach to household enumeration: the modified random walk Complete Exercises 4 (in the accompanying Participant’s Guide)

STEP 5: SELECTION OF INDIVIDUALS

Step 5: Selection of Individuals Upon arrival at the selected household : i. ii. Introduce team and explain the purpose of visit List all the individuals living in the household who are part of the survey population (regardless of whether they are present at the time of the visit) iii. Randomly pick one of these individuals to interview by drawing slips of paper from a hat or using a random number table

Step 5: Selection of Individuals Survey Population M 33 yrs F 30 yrs F 16 yrs F 11 yrs M 8 yrs F 7 yrs Suppose your survey population is children 5 – 14 years old 1. F 11 yrs 2. M 8 yrs 3. F 7 yrs

Step 5: Selection of Individuals Integrated SCT 1. Go to the selected HH, list all members in survey population #1 (e. g. , all ages), and pick ONE person randomly to interview 2. Next list all people in survey population #2 (5 -14 yrs) and pick ONE to interview Survey Pop. #1(everyone ) A-3 1. 2. 3. 4. 5. 6. Martin – 65 Josefa – 64 Juana – 29 Maria-13 Louis-12 Abdel-8 Survey Pop. #2 (5 -14) 1. Maria-13 2. Louis-12 3. Abdel-8

Step 5: Selection of Individuals What if there is nobody in Survey Population (5 -14 years)? M 33 yrs F 30 yrs F 16 yrs Proceed to next house in the village/register until you find a household that has >1 child 5 -14 years

If the selected individual is not present… Will they return later the same day? Yes No Can they be reached locally or via cell phone? Return later in the day to interview the person No Yes Interview the person locally or via cell phone Yes Allow the HH member to provide a proxy response Can someone else in the HH respond on their behalf? No Advance to the next numbered HH as replacement

Step 5: Selection of Individuals HH Code HH Picked? Count A-1 A-2 A-3 A-4 A-5 A-6 A-7 A-8 1 2 3 4 5 6 7 8 A-9 A-10 A-11 A-12 A-13 A-14 A-15 9 10 11 12 13 14 15 X HH Code HH HH Picked? HH Code Picked? Count A-47 A-48 A-49 A-50 A-51 A-52 B-1 B-2 47 48 49 50 51 52 53 54 B-75 B-76 B-77 B-78 C-1 C-2 C-3 126 127 128 129 130 131 132 133 B-4 B-5 B-6 B-7 B-8 B-9 55 56 57 58 59 60 61 C-4 C-5 C-6 C-7 C-8 C-9 C-10 134 135 136 137 138 139 140 X x X X HH Code C-63 C-64 C-65 C-66 C-67 C-68 C-69 C-70 C 71 HH Picked Count ? 193 194 195 196 197 198 199 200 201 X

Step 5: Selection of Individuals Complete Exercises 4 & 5 (in the accompanying Participant’s Guide)

STEP 6: INTERVIEW THE SELECTED INDIVIDUALS

Step 6: Interview Individual • Use the data collection form to interview the selected individual(s) to determine whether or not they were offered and if so, swallowed the drug(s) • It is important to bring samples of the drug(s) to show the interviewee and help aid with recall

Step 6: Interview Individual Complete Exercise 6 (in the accompanying Participant’s Guide)

Step 7: INTERPRET THE RESULTS

Step 7: Interpretation of Results Survey populations for which coverage thresholds are set Coverage thresholds specified by WHO The numbers in the columns correspond to the number of people (out of the 20 interviewed) answering “yes” to the coverage question SCT Decision Rule Table Disease Survey Population Threshold for coverage Decision Rules: Based on the number covered out of 20 people sampled Good Coverage* Cannot Conclude Coverage was Good Inadequate Coverage* Lymphatic Filariasis Everybody 65% >=16 11 -15 <=10 Onchocerciasis Everybody 65% >=16 11 -15 <=10 STH / Schistosomiasis SAC (5 -14 yrs) 75% >=18 13 -17 <=12 Trachoma Everybody 80% >=19 14 -18 <=13 *Based on alpha = 0. 1 67

Coverage Conclusion: Interpretation: Suggested Next Steps: Good Inadequate (> the threshold) Cannot conclude coverage was good (< the threshold) It is very likely that the true coverage in the SA is at or above the target threshold. Not enough information to conclude with statistical confidence if coverage was above or below threshold. It is very likely that the true coverage in the SA is below the target threshold. • Try to understand reasons why coverage may have been poor by looking at the “no” responses from the SCT. • Investigate why coverage may have been poor by looking at the “no” responses from the SCT (e. g. , was it insufficient supply? poor compliance? drug distributor performance? insufficient social mobilization? ). • Does the reported coverage show that coverage is above the target threshold? If so, it is important to identify reasons for the discrepancy; consider conducting a data quality selfassessment. • Investigate why coverage may have been poor by looking at the “no” responses from the SCT (e. g. , was it insufficient supply? poor compliance? drug distributor performance? insufficient social mobilization? ). • Is a mop-up campaign needed? • Do these results agree with the reported coverage (e. g. , is the reported coverage also above threshold)? If not, try to identify reasons for the discrepancy. • Share these positive findings with those involved in the MDA. • If persons were identified who should have swallowed the drugs but did not, review the reasons why and take whatever steps are indicated to raise coverage even higher than it already is.

This number is compared with the decision rule table Note that the target thresholds are based on the % who swallowed MDA; this is the number that should correspond with the reported coverage 69

Step 7: Interpretation of Results Exercise 8 Discuss the following scenarios as a group. Determine the appropriate interpretation, according to the decision rule table, and follow-up recommended Scenario 1: You are using the SCT to classify coverage for lymphatic filariasis, interpret the following results: Number who were offered the drug: 17 Number who swallowed the drug: 17 Reported coverage for the implementation unit: 88% 70

Step 7: Interpretation of Results Scenario 2: You are using the SCT to classify coverage for soiltransmitted helminthiases. Interpret the following results: Number who were offered the drug: 19 Number who swallowed the drug: 16 Reported coverage for the implementation unit: 70% 71

Step 7: Interpretation of Results Scenario 3: You are using the SCT to classify coverage for schistosomiasis. Interpret the following results: Number who were offered the drug: 11 Number who swallowed the drug: 11 Reported coverage for the implementation unit: 90% 72

Step 7: Interpretation of Results Scenario 4: You are using the SCT to classify coverage for trachoma. Interpret the following results: Number who were offered the drug: 16 Number who swallowed the drug: 16 Reported coverage for the implementation unit: 98% 73

Step 8: DEVELOP AN ACTION PLAN

Step 8: Develop an Action Plan • Helps the district and provincial-level supervisors come up with an actionable plan to improve MDA performance. • Action Plan must be developed immediately following the SCT to allow time for mop-up activities if necessary. • Treatment mop-up is indicated in any SA classified as having ‘inadequate’ coverage • District supervisor may choose to limit the mop-up to only those SA(s) where coverage was classified as ‘inadequate’ or he/she may choose to extend the mop-up activities to other parts of the district.

Step 8: Develop an Action Plan Once the survey results are tallied it is important to complete the SCT Action Plan document to help interpret the results and identify the next steps that need to be taken to improve the program. 76

Step 8: Develop an Action Plan Potential Actions ü Conduct treatment mop-up ü Provide refresher trainings to drug distributors and/or first-level supervisors ü Improve community registers ü Increase social mobilization efforts or try new strategy ü Adapt information/education materials before next round to target common reasons for non-compliance ü Congratulate and/or publicly acknowledge drug distributors and first-level supervisors doing well

Step 8: Develop an Action Plan Complete Exercise 7 (in the accompanying Participant’s Guide)

Step 9: IMPLEMENT THE ACTION PLAN

Step 9: Implement the Action Plan • Some actions, like treatment mop-up, will require immediate mobilization to implement Improved coverage effective MDA • Other actions may take place during period between MDA rounds or immediately proceeding next MDA • Up to national program how completed Action Plans are shared

COUNTRY EXPERIENCES

REVIEW

Summary of SCT Steps Step 1: Identify population to survey Step 2: Identify supervisory areas (SA) Step 3: Obtain a list of all households using a) registers or b) household enumeration Step 4: Randomly select 20 households Step 5: Selection of Individuals Step 6: Interview Individuals Step 7: Interpretation of Results Step 8: Develop an Action Plan Step 9: Implement the Action Plan 83

Limitations of the SCT • The SCT cannot be used to generate an estimate of coverage, but rather can only be used to classify coverage as likely good/poor • The SCT is not an equal probability sample • The SCT has poor power, meaning it will often classify SAs with coverage that is truly above or below the threshold as being “consistent with the threshold. ” 84

Benefits of the SCT • Inexpensive and can be easily implemented by sub-district supervisors • Can be adapted for any of the PC NTDs, including integrated • Internal self-assessment, not external audit • Timing of tool provides opportunity for mop-up • Can identify gaps in social mobilization or drug distribution 85

THANK YOU

Review Quiz • What is the name of the tool we have discussed today? • How soon after MDA should you implement the tool? • What is a supervision area and how do you choose one? • How many people are sampled per survey population in one supervision area? • How do you determine if it is appropriate to use village registers to select the households? • If an accurate register exists, how do we determine the maximum range for our random number? 87

Review Quiz • If there are 377 households in the register how many digits should our random number have? • Should we include people who are ineligible for MDA in an LF SCT? • What happens if the selected household is empty? • What if the person selected is not present? • What is meant by “target threshold”? • What do you do after you have collected data on all 20 individuals? 88

Review Quiz • Why do we ask if the drug was offered and if it was swallowed as separate questions? • If 16 people swallowed the drugs for LF how should we classify coverage? • What should you do if the reported coverage is 95% but using the SCT you find only 13 people who report having swallowed the drug? • What actions might you take if the number of people who swallowed the drug is classified as “inadequate”? • What is the last step of the SCT? 89