1 Session 8. Understanding the Problems Associated with Medicine Use— Qualitative Methods Drug and Therapeutics Committee

Objectives  Identify four methods used to investigate reasons underlying medicine use and prescribing behavior  Understand the use of qualitative methods to identify why documented medicine use problems occur  Design a simple qualitative instrument to investigate medicine use

Outline  Introduction  Applying qualitative methods to medicine use studies  Qualitative methods  Focus group discussions  In-depth interviews  Structured observations  Structured questionnaires  Activities  Summary

Introduction (1)  Quantitative study methods identify presence of medicine use problems  Indicator studies  Aggregate data: DDD, ABC, VEN  Record review and DUE  What else is needed to plan an intervention?  Need to know why the problem exists, that is, qualitative methods

Introduction (2)  Four qualitative study methods  Focus group discussions  In-depth interviews  Structured observations  Questionnaires

Applying Qualitative Methods (1)  Complement results of a quantitative study  Explore a topic about which little is known  Provide background data before developing training materials for a planned educational intervention and for developing managerial and regulatory interventions

Applying Qualitative Methods (2) Example of using qualitative methods  Prescribing by brand name was very popular at the district hospital. Despite numerous interventions including face-to-face discussions, in-service education, policy and procedures changes, physicians continued to prescribe by brand name.  Using qualitative methods, investigators discovered that physicians were receiving educational “benefits” from pharmaceutical companies in exchange for theicorrected once the reasons for the medicine use behavior became known.

Some Factors Influencing Medicine Use MEDICINE USE Cultural Beliefs Knowledge Deficits Unbiased Information Relation With Peers Authority & Supervision Influence of Industry Workload & Staffing Infra- structure Acquired Habits Patient Demand Interpersonal Workplace Workgroup Personal Informational

Focus Group Discussions (1)  A short discussion (1–2 hours) led by a moderator in which a small groups of respondents (6–10) talk in depth about topics of interest  A trained moderator leads the discussion and encourages participants to reveal underlying opinions, attitudes, and reasons for the problem being studied  The discussion is recorded and analyzed to identify key themes and issues

Focus Group Discussions (2)  6–10 participants who share similar characteristics (e.g., age, gender, type of work)  Locale convenient to participants and one in which they will feel comfortable  Number of focus groups discussions should be sufficient to gain the views of all the various target groups involved in the medicine use problem  Moderator and recorder must be skilled and trained

Focus Group Discussions (3)  Advantages  Relatively cheap and easy to organize  Identifies a range of beliefs and ideas  Disadvantages  Group may not represent the larger population  Success depends on the skill of the moderator

In-depth Interview (1)  An extended discussion between a respondent and an trained interviewer (who is knowledgeable about the topic) based on a brief interview guide that usually covers 10–20 topics  The interview is flexible and often unstructured  The questions are open ended to encourage the interviewee to talk at length on the topic of interest  5–10 interviews with each important subgroup, often opinion leaders and key informants

In-depth Interview (2)  Advantages  Can develop trust between interviewer and interviewee  Possible to probe deeper and therefore gain unexpected insights or new ideas  Can reveal unsought, but significant, data  Disadvantages  Generates lots of data and analysis may be difficult and time consuming  Interviewees may give answers they think the interviewer wants to hear

Structured Observation (1)  Systematic observations by trained observers of a series of encounters between health providers and patients  Observers record in structured manner behaviors and impressions they witness during the encounters or they record a score for each observed interaction  Data may be recorded as coded indicators and scales or lists of behaviors and events, and then frequency of behaviors may be calculated

Structured Observation (2)  To prepare for the study, the observer should provide a nonthreatening explanation and spend time “blending in”  At least 30 encounters should be observed to calculate the frequency of behaviors  At least 10 sites should be visited to observe behavior

Structured Observation (3)  Advantages  Best way to study the complex provider-patient interactions, including patient demand and quality of communication  Can learn about provider behavior in natural setting  Data on actual—rather than reported—behavior collected  Disadvantages  Observed providers may modify their behavior because of observer’s presence  Requires skilled, patient observers  Inappropriate for infrequent behaviors

Structured Questionnaire (1)  A fixed set of questions asked to a large sample of respondents selected according to strict rules to represent a larger population  The questions have a fixed set of responses or options to collect the desired information in a standard way from all respondents  The questionnaire may be administered by an interviewer or filled out alone by the respondent

Structured Questionnaire (2)  At least 50–75 respondents from each target group  Respondents chosen randomly  Training and supervision of interviewers required  Questions asked in a standardized way; no leading questions

Structured Questionnaire (3)  Advantages  Best for measuring strength and frequency of attitudes, beliefs, knowledge, and population characteristics  Can generalize to a wider population  Disadvantages  Does not uncover the unexpected  Sensitive to the way questions are phrased leading to possible bias; respondents may answer even when they have no true opinion  Large surveys are expensive

Activity 1  What qualitative methods can be used to investigate the reasons underlying a particular behavior?  What questions should be asked in—  An in-depth interview with a prescriber?  A questionnaire with an exiting patient?  What activities should be observed during the—  Consultation  Dispensing process  Group work followed by plenary discussion

Activity 2  Antibiotic consumption in your hospital is high and often unnecessary, according to a recent prescription audit  Each group will develop one qualitative instrument to investigate the reasons underlying antibiotic overuse  In-depth interview with prescribers  Structured interviews with exiting patients  Structured observation of the consultation  Each group to role-play based on the instrument  During each role-play, everyone to note the following:  Was the instrument clear?  Did the instrument detect an underlying motive?

Summary  Before an intervention can be designed to correct poor practice or irrational use of medicines, need to know why that behavior is occurring  Qualitative methods should be used to investigate the behavior from different perspectives and with regard to different actors (e.g., patients, staff)  Triangulation of results using different methods should be done to identify the major reasons underlying a particular behavior