1. 1 Learning about a Drug Use Problem

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

3. Learning about a Drug Use Problem3 Components of the Drug Use System

4. Learning about a Drug Use Problem4 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 in Outcomes (Quantitative & Qualitative Evaluation) improve intervention improvediagnosis

5. Learning about a Drug Use Problem5 Changing Drug Use Problems: 1. Examine Identify drug use issue of interestIdentify drug use issue of interest –Highest clinical risk? –Widely used or expensive drugs? –Easiest to correct? Collect data to describe practicesCollect data to describe practices –In all subgroups or interest –Most important prescribers? –High-risk patients?

6. Learning about a Drug Use Problem6 Describe problem in detailDescribe problem in detail –“Gold standard” to assess quality? –Specific problem behavior –Define important providers or patients Identify determinants of the problemIdentify determinants of the problem –Knowledge and beliefs –Cultural factors or peer practices –Patient demand and expectations Identify constraints to changeIdentify constraints to change –Economic constraints –Drug supply –Work environment Changing Drug Use Problems: 2. Diagnose

7. Learning about a Drug Use Problem7 Select target and design interventionSelect target and design intervention –Which behaviors can be changed? –Feasible interventions? –Cost-effectiveness? –Personnel required? Pilot testPilot test –Acceptability –Effectiveness Implement in stagesImplement in stages –Collect process and outcome data –Evaluate impacts Changing Drug Use Problems: 3. Treat

8. Learning about a Drug Use Problem8 Evaluate success in relation to intended outcomesEvaluate success in relation to intended outcomes –Was the intervention implemented as planned? –What changes occurred –Was the intervention cost-effective? Transferable? Consider unintended negative outcomesConsider unintended negative outcomes Feed back resultsFeed back results –To managers and policymakers –To staff –To providers and consumers Use results to plan future activitiesUse results to plan future activities Changing Drug Use Problems: 4. Follow Up

9. Learning about a Drug Use Problem9 Drug Use Encounter Definition: the interaction between a provider and a patient when decisions are made about which drugs to recommend or useDefinition: the interaction between a provider and a patient when decisions are made about which drugs to recommend or use Sites of drug use encountersSites of drug use encounters Where the pill meets the patient – hospital – private practice – pharmacy – home –health center –traditional healer –drug seller

10. Learning about a Drug Use Problem10 Who Is a Prescriber? Or Whose Behavior Do We Change? PhysiciansPhysicians ParamedicsParamedics PharmacistsPharmacists InjectionistsInjectionists PatientsPatients Clinical officersClinical officers Clinic attendantsClinic attendants DispensersDispensers Drug sellersDrug sellers Relatives/friendsRelatives/friends

11. Learning about a Drug Use Problem11 How to Collect Data Quantitative MethodsQuantitative Methods –what? or how much? –counts –rates –classifications Qualitative MethodsQualitative Methods –why? or how strong? –opinions –descriptions –observations

12. Learning about a Drug Use Problem12 Selecting Methods to Study Drug Use Depends on—Depends on— –Nature of the problem –Objectives of collecting data –Resource availability –Time available

13. Learning about a Drug Use Problem13 Quantitative Methods Routine DataRoutine Data –Drug supply or consumption data –Morbidity and mortality reports Record SystemsRecord Systems –Medical records –Pharmacy records Sample SurveysSample Surveys –Drug use encounters –Provider interviews –Patient & community interviews

14. Learning about a Drug Use Problem14 Types of Quantitative Data When collectedWhen collected –Retrospective –Prospective What levelWhat level –Aggregate –Patient-specific Diagnosis informationDiagnosis information –Known –Unknown Drug dataDrug data –Detailed (name, dose, amount, duration) –Uondetailed (name only, if injection, etc.)

15. Learning about a Drug Use Problem15 Where Can We Find Useful Quantitative Data? Administrative offices, medical storesAdministrative offices, medical stores Clinical treatment areas and medical record departmentsClinical treatment areas and medical record departments Health facility pharmaciesHealth facility pharmacies Private pharmacies and retail outletsPrivate pharmacies and retail outlets HouseholdsHouseholds

16. Learning about a Drug Use Problem16 Data Available at District Level District officeDistrict office –Data from routine health MIS –Morbidity and mortality reports –Previous drug use surveys –Drug supply orders District storesDistrict stores –Drug supply orders –Stock cards –Shipping and delivery receipts

17. Learning about a Drug Use Problem17 Data Available at Health Facilities RetrospectiveRetrospective –Patient registers –Treatment logs –Pharmacy receipts –Medical records ProspectiveProspective –Observation of clinical encounters –Patient exit surveys –Inpatient surveys

18. Learning about a Drug Use Problem18 Data from Drug Encounters FACILITYFACILITY PATIENTPATIENT PROVIDERPROVIDER INTERACTIONINTERACTION DRUGSDRUGS ID, characteristics, equipment, drugs availableID, characteristics, equipment, drugs available ID, date, age, gender, symptoms knowledge, beliefs, attitudesID, date, age, gender, symptoms knowledge, beliefs, attitudes qualification, training, access to information, knowledge, beliefs, attitudesqualification, training, access to information, knowledge, beliefs, attitudes exams, history, diagnosis, time spent, explanation about illness, explanation about drugsexams, history, diagnosis, time spent, explanation about illness, explanation about drugs brand, generic, strength, form, quantity, duration, if dispensed, how labeled, cost, patient chargebrand, generic, strength, form, quantity, duration, if dispensed, how labeled, cost, patient charge

19. Learning about a Drug Use Problem19 Activity 1 Strengths and Weaknesses of Different Data Sources

20. Learning about a Drug Use Problem20 Qualitative Methods These methods answer the question why. They provide insights into the reasons for behaviors.These methods answer the question why. They provide insights into the reasons for behaviors. Types of qualitative methodsTypes of qualitative methods –In-depth interviews –Focus group discussions –Structured observations –Structured questionnaires –Simulated purchase visits Qualitative methods require trained data collectors. Data analysis is more difficult, but the results can be very useful.Qualitative methods require trained data collectors. Data analysis is more difficult, but the results can be very useful.

21. Learning about a Drug Use Problem21 In-Depth Interviews Definition:Definition: An extended discussion between a respondent and an interviewer based on a brief interview guide that usually covers 10-30 topics

22. Learning about a Drug Use Problem22 In-Depth Interview: Key Points Open-ended topics explored in depth rather than fixed questionsOpen-ended topics explored in depth rather than fixed questions Can target key informants, opinion leaders, or others in special positionCan target key informants, opinion leaders, or others in special position 5-10 interviews may be enough to get a feel for important issues5-10 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 subgroupIf target group is diverse, generally 5-10 interviews are held with each important subgroup

23. Learning about a Drug Use Problem23 In-Depth Interview: Strengths and Weaknesses StrengthsStrengths –Unexpected insights or new ideas –Helps create trust between interviewer and respondent –Less intrusive than questionnaire –Useful with illiterate respondents WeaknessesWeaknesses –Time-consuming compared with structured questionnaire –Data analysis can be difficult –Bias toward socially acceptable or expected responses –Requires well-trained interviewers

24. Learning about a Drug Use Problem24 Focus Group Discussions Definition: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

25. Learning about a Drug Use Problem25 SmallSmall –5-11 people, promotes equal participation HomogeneousHomogeneous –Common characteristics, shared viewpoint GuidedGuided –Led by moderator, topics kept in focus InformalInformal – Free interaction, open sharing of ideas RecordedRecorded –Analysis at later time, notes kept by assistant Focus Groups: Key Points

26. Learning about a Drug Use Problem26 Focus Groups: Strengths and Weaknesses StrengthsStrengths –Elicits the beliefs and opinions of a group –Provides richness and depth –Easy and inexpensive to organize WeaknessesWeaknesses –Need for skilled moderator –Do beliefs and opinions represent true feelings? –Potential bias in analysis

27. Learning about a Drug Use Problem27 Structured Observations Definition:Definition: Systematic observations by trained observers of a series of encounters between health providers and patients.

28. Learning about a Drug Use Problem28 Observations: Key Points To prepare for study, observer should—To prepare for study, observer should— –Introduce nonthreatening explanation –Spend enough time to "blend in" Data can be recorded as—Data can be recorded as— –Coded indicators and scales –List of behaviors and events –Diary of observer's impressions Observation studies vary in scope—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

29. Learning about a Drug Use Problem29 Observations: Strengths and Weaknesses StrengthsStrengths –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 WeaknessesWeaknesses –Behavior may not be natural because of observer's presence –Requires skilled, patient observers –Not useful for infrequent behaviors

30. Learning about a Drug Use Problem30 Structured Questionnaires DefinitionDefinition A fixed set of items asked to a large sample of respondents selected according to strict rules to represent a larger population ? ? ? ? ?? ?

31. Learning about a Drug Use Problem31 Questionnaires: Key Points Nature of questionsNature 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 sizeSample size –Depends on target population, type of sampling, desired accuracy, and available resources –Usually at least 50–75 respondents from each important subgroup

32. Learning about a Drug Use Problem32 StrengthsStrengths –Best to study frequency of knowledge, attitudes, population characteristics –Familiar to managers and respondents –Required skills often locally available WeaknessesWeaknesses –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 Questionnaires: Strengths and Weaknesses

33. Learning about a Drug Use Problem33 Simulated Purchase Visits Definition:Definition: A research assistant, prepared in advance to present a standard complaint, visits providers seeking treatment in order to determine their practices

34. Learning about a Drug Use Problem34 Simulated Visits: Key Points Usually sample 30+ providersUsually sample 30+ providers Collect data on many aspects of practiceCollect data on many aspects of practice –History-taking –Examination –Treatment –Advice Frequently used to examine practices in private pharmaciesFrequently used to examine practices in private pharmacies Scenario can be varied (e.g., watery vs. bloody diarrhea)Scenario can be varied (e.g., watery vs. bloody diarrhea)

35. Learning about a Drug Use Problem35 StrengthsStrengths –Can compare knowledge & reported practice with actual practice –Relatively quick & easy to conduct –Data are simple to analyze WeaknessesWeaknesses –Response may be specific to the scenario presented –Research assistants can vary widely in reliability –Ethical problem? Simulated Visits: Strengths and Weaknesses

36. Learning about a Drug Use Problem36 Conclusion: Which Method to Use? Best method depends on—Best method depends on— –Nature of the problem –Objectives of collecting data –Available resources and time –Local capacity and experience Use multiple methodsUse multiple methods –Quantitative qualitative –“Triangulate” findings –Each method can look at different aspects of a problem

37. Learning about a Drug Use Problem37 Activity 2 Designing Qualitative Instruments

38. Learning about a Drug Use Problem38 Activity 3 Preparing for a Field Visit