1. Learning About a Drug Use Problem

2. Learning About a Drug Use Problem: Objectives
Describe model for developing interventions
Identify and evaluate sources of quantitative data
Understand the importance of studying provider and patient motivations
Introduce qualitative research methods
Develop instruments for field visit
Learning About Drug Use

3. Components of the Drug Use System
Drug Imports
Local
Manufacture
Hospital or
Health Center
Private Physician or
Other Practitioner
Pharmacist or
Drug Trader
The Drug Supply
Process
Provider and
Consumer Behavior
Illness Patterns +
Public
Emphasize that many types of data about drug use can be collected at any of the points in the drug use system
Learning About Drug Use

4. An Overview of the Process of Changing Drug Use
1. EXAMINE
Measure Existing
Practices
(Descriptive
Quantitative Studies)
2. DIAGNOSE
Identify Specific
Problems & Causes
(In-depth Quantitative
& Qualitative Studies)
3. TREAT
Design & Implement
Interventions
(Collect Data to
Measure Outcomes)
4. FOLLOW UP
Measure Changes
in Outcomes
(Quantitative & Qualitative
Evaluation)
improve
intervention
diagnosis
Move quickly around the cycle, and expand on details in the slides that follow. Make the analogy to the process of clinical care. Key points of interest:
Intervention orientation
Interdisciplinary approach
Evidence-based recommendation
Learning About Drug Use

5. Changing Drug Use Problems: 1. Examine
Identify drug use issue of interest
highest clinical risk?
widely used or expensive drugs?
easiest to correct?
Collect data to describe practices
in all subgroups or interest
most important prescribers?
high risk patients?
Key point: focus attention on a small number of issues, and use quantitative methods to examine patterns of drug use.
Learning About Drug Use

6. Changing Drug Use Problems: 2. Diagnose
Describe problem in detail
"gold standard" to assess quality?
specific problem behavior
define important providers or patients
Identify determinants of the problem
knowledge and beliefs
cultural factors or peer practices
patient demand and expectations
Identify constraints to change
economic constraints
drug supply
work environment
Key points:
What are major causes of problems?
What are key barriers to change?
Learning About Drug Use

7. Changing Drug Use Problems: 3. Treat
Select target and design intervention
which behaviors can be changed?
feasible interventions?
cost-effectiveness?
personnel required?
Pilot test
acceptability
effectiveness
Implement in stages
collect process and outcome data
evaluate impacts
Key Points:
Interventions depend on the causes refined during the diagnosis phase
Learning About Drug Use

8. Changing Drug Use Problems: 4. Follow-up
Evaluate success in relation to intended outcomes
Was the intervention implemented as planned?
What changes occurred
Was the intervention cost effective? transferable?
Consider unintended negative outcomes
Feedback results
To managers and policymakers
To staff
To providers and consumers
Use results to plan future activities
Key Points:
Follow-up completes the quality improvement cycle.
Learning About Drug Use

9. Where the pill meets the patient
Drug Use Encounter
Definition: the interaction between a provider and a patient when decisions are made about which drugs to recommend or use
Sites of drug use encounters
Where the pill meets the patient
Key Points:
Drug use encounters are the main focus of attention for learning about therapeutic decisions made by a variety of health providers.
hospital
private practice
pharmacy
at home
health center
traditional healer
drug seller
Learning About Drug Use

10. Who is a Prescriber? Or Whose Behavior Do We Change?
physicians
paramedics
pharmacists
injectionists
patients
clinical officers
clinic attendants
dispensers
drug sellers
relatives/friends
Key Points:
Interventions can target many different decision makers
Learning About Drug Use

11. How to Collect Data Quantitative Methods counts rates classifications
What? or How Much?
Qualitative Methods
opinions
descriptions
observations
Why? or How Strong?
Key Points:
Primary objective of quantitative method
Primary objective of qualitative method
Learning About Drug Use

12. Selecting Methods to Study Drug Use
Depends on:
nature of the problem
objectives of collecting data
resource availability
time available
Key Points:
Availability of different methods for studying drug use depending on the situation.
Learning About Drug Use

13. Quantitative Methods Routine Data Record Systems Sample Surveys
drug supply or consumption data
morbidity and mortality reports
Record Systems
medical records
pharmacy records
Sample Surveys
drug use encounters
provider interviews
patient & community interviews
Key Points:
Many sources for quantitative data
Learning About Drug Use

14. Types of Quantitative Data
When collected
retrospective
prospective
What level
aggregate
patient-specific
Diagnosis information
known
unknown
Drug data
detailed (name, dose, amount, duration)
non-detailed (name only, if injection, etc.)
Learning About Drug Use

15. Where Can We Find Useful Quantitative Data?
Administrative Offices, Medical Stores
Clinical Treatment Areas & Medical Record Departments
Health Facility Pharmacies
Private Pharmacies and Retail Outlets
Households
Learning About Drug Use

16. Data Available at District Level
District Office
data from routine health MIS
morbidity and mortality reports
previous drug use surveys
drug supply orders
District Stores
stock cards
shipping and delivery receipts
Key Points:
The importance of district level as sources of data on public sector drug use.
Learning About Drug Use

17. Data Available at Health Facilities
Retrospective
patient registers
treatment logs
pharmacy receipts
medical records
Prospective
observation of clinical encounters
patient exit surveys
inpatient surveys
Key Point:
Different workers in health facilities are aware of different sources of data.
Learning About Drug Use

18. Data From Drug Encounters
FACILITY
PATIENT
PROVIDER
INTERACTION
DRUGS
ID, characteristics, equipment, drugs available
ID, date, age, gender, symptoms knowledge, beliefs, attitudes
qualification, training, access to information, knowledge, beliefs, attitudes
exams, history, diagnosis, time spent, explanation about illness, explanation about drugs
brand, generic, strength, form, quantity, duration, if dispensed, how labeled, cost, patient charge
Key Points:
level of detail will depend on where and how data are collected
Learning About Drug Use

19. Strengths and Weaknesses of Different Data Sources
Activity One
Strengths and Weaknesses of Different Data Sources
Learning About Drug Use

20. Qualitative Methods
These methods answer the question why. They provide insights into the reasons for behaviors.
Types of Qualitative Methods
In-depth interviews
Focus Group Discussions
Structured Observations
Structured Questionnaires
Simulated Purchase Visits
Qualitative methods require skilled trained data collectors. Data analysis is more difficult than for quantitative data. But the results can be very useful.
Key Point:
Different participants may be aware of or have experience in the use of qualitative methods.
Learning About Drug Use

21. In-Depth Interviews Definition:
an extended discussion between a respondent and an interviewer based on a brief interview guide that usually covers topics
Learning About Drug Use

22. In-Depth Interview: Key Points
open-ended topics explored in depth rather than fixed questions
can target key informants, opinion leaders, or others in special position
5-10 interviews may be enough to get a feel for important issues
if target group is diverse, generally 5-10 interviews are held with each important subgroup
Learning About Drug Use

23. In-Depth Interview: Strengths and Weaknesses
unexpected insights or new ideas
helps create trust between interviewer and respondent
less intrusive than questionnaire
useful with illiterate respondents
Weaknesses
time-consuming compared to structured questionnaire
data analysis can be difficult
bias toward socially acceptable or expected responses
requires well-trained interviewers
Learning About Drug Use

24. Focus Group Discussions
Definition:
a short (1 1/2 - 2 hour) discussion led by a moderator in which a small group of respondents (6-10) talk in depth about a defined list of topics of interest
Learning About Drug Use

25. Focus Groups: Key Points
Small
5-11 people, promotes equal participation
Homogeneous
common characteristics shared viewpoint
Guided
led by moderator, topics kept in focus
Informal
free interaction, open sharing of ideas
Recorded
analysis at later time, notes kept by assistant
Learning About Drug Use

26. Focus Groups: Strengths and Weaknesses
good at eliciting the beliefs and opinions of a group
provides richness and depth
easy and inexpensive to organize
Weaknesses
need for skilled moderator
do beliefs and opinions represent true feelings?
potential bias in analysis
Learning About Drug Use

27. Structured Observations
Definition:
systematic observations by trained observers of a series of encounters between health providers and patients .
Learning About Drug Use

28. Observations: Key Points
to prepare for study, observer should:
introduce non-threatening explanation
spend enough time to "blend in"
data can be recorded as:
coded indicators and scales
list of behaviors and events
diary of observer's impressions
observation studies vary in scope:
to count frequency of behaviors, at least 30 cases in each category
to understand typical features, a few cases in 5-6 settings may be enough
Key Points:
Observations can introduce bias in the behaviors of the persons observed, and efforts must be made to desensitize the process before beginning to record data
Learning About Drug Use

29. Observations: Strengths and Weaknesses
best way to study the complex provider-patient interactions
can learn about provider behavior in its natural setting
best way to learn about patient demand, quality of communication
Weaknesses
behavior may not be natural because of observer's presence
requires skilled, patient observers
not useful for infrequent behaviors
Learning About Drug Use

30. Structured Questionnaires
Definition:
a fixed set of items asked to a large sample of respondents selected according to strict rules to represent a larger population ? ? ? ? ? ? ?
Learning About Drug Use

31. Questionnaires: Key Points
Nature of questions
useful for attitudes, opinions, and beliefs as well as facts
questions always asked in a standardized way
can have fixed or open-ended responses
Sample size
depends on target population, type of sampling, desired accuracy, and available resources
usually at least respondents from each important subgroup
Key Points:
Questionnaires are useful for many purposes. Here we emphasize using them to measure attitudes, opinions, and beliefs, especially with rating scales and open-ended questions
Learning About Drug Use

32. Questionnaires: Strengths and Weaknesses
best to study frequency of knowledge, attitudes, population characteristics
familiar to managers and respondents
required skills often locally available
Weaknesses
attitudes often difficult to quantify
respondents often answer a direct question even if they have no true opinion
results sensitive to which questions are asked and wording
large surveys can be expensive
Learning About Drug Use

33. Simulated Purchase Visits
Definition:
a research assistant, prepared in advance to present a standard complaint, visit providers seeking treatment in order to determine their practices
Simulated purchases are a form of structured observations
Learning About Drug Use

34. Simulated Visits: Key Points
usually sample 30+ providers
collect data on many aspects of practice
history-taking
examination
treatment
advice
frequently used to examine practices in private pharmacies
scenario can be varied (e.g. watery vs. bloody diarrhea)
Key Points:
Because the scenario is standardized, the method only measures a limited range of behavior. Varying the scenario systematically can illustrate behavior in responses to a range of likely situations.
Learning About Drug Use

35. Simulated Visits: Strengths and Weaknesses
can compare knowledge & reported practice with actual practice
relatively quick & easy to conduct
data are simple to analyze
Weaknesses
response may be specific to the scenario presented
research assistants can vary widely in reliability
ethical problem?
Learning About Drug Use

36. Conclusion: Which Method to Use?
Best method depends on:
nature of the problem
objectives of collecting data
available resources and time
local capacity and experience
Use multiple methods
quantitative + qualitative
"triangulate" findings
each method can look at different aspects of a problem
Learning About Drug Use

37. Designing Qualitative Instruments
Activity 2
Designing Qualitative Instruments
Learning About Drug Use

38. Preparing for a Field Visit
Activity 3
Preparing for a Field Visit
Learning About Drug Use