1. Promoting rational drug use in the community Investigating drug use patterns and identifying problems

2. WHO 2 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Objectives  Help you understand when research is needed in the development of interventions  Define what questions you need to ask  Identify key quantitative and qualitative methods  Reflect on limitations of available sources of data on drug use problems

3. WHO 3 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Why study drug use  People often use medicines without health worker advice  People have their own experiences with medicines which shape their drug use practices  People obtain medicines from informal community sources

4. WHO 4 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Extent to which health worker advice is sought  Thailand: 7% of 1755 episodes (rural)  Philippines: 8% of 1411 episodes (urban), 20% of 422 episodes (rural infants)  Pakistan: 56% in NGO-PHC area, 48% in controls (rural)  Ghana: 42% in urban, 43% in rural Sources: Le Grand A, Sringernyuang L (1989); Hardon A (1991); Hardon AP (1987); Rasmussen ZA et al (1996); Wondergem PW, Senah KA, Glover EK (1989)

5. WHO 5 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Trends in medicine use  Overall, modern medicines used in around 50% of illness episodes treated in self-care  When health workers advise, nearly always medicines are prescribed  Around 50-60 percent of patients do not comply with prescribed regime

6. WHO 6 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Town Clinics (2%) Hospital (1%) Doctors (7%) Drugstores (35%) Household stocks and free-clinics (8%) Neighbourhood stores (40%) Neighbours and relatives (5%) Neighbourhood MEDICINES (n=1324) Community drug distribution Source: Hardon A (1991). Confronting ill health: medicines, self-care and the poor in Manila

7. WHO 7 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Framework for developing interventions: When is research needed?

8. WHO 8 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Steps in an effective communication intervention

9. WHO 9 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Step 1: describe  Aim to identify wide range of possible drug use problems  Describe what people DO with drugs –By reviewing a wide-range of existing secondary data-sources, and –Collecting new data with key qualitative and quantitative methods

10. WHO 10 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Step 2: prioritise  Develop criteria for prioritisation  Rate/rank problems using criteria  Select priority problem(s) based on rating/ranking exercise

11. WHO 11 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Step 3: analyse and focus  Identify sub-problems  Select and analyse core-problems  Explore possible solutions

12. WHO 12 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Research also needed for  Pre-testing (Step 5)  Evaluation and monitoring (Step 7)

13. WHO 13 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Activity 1: Inventory of drug use problems  Appoint a facilitator and rapporteur  The facilitator asks participants to share the drug use problems they identified prior to course  The rapporteur tries to group them in a logical way  The facilitator asks group members to discuss which problems are most important. Select five!  The group discusses a brief description of the 5 problems

14. WHO 14 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Questions: individual/community level  What are common health problems? How treated? Appropriate?  What medicines are commonly used? What for? Appropriate?  What are perceived drug use problems?  What are important sources of drugs?  What are perceived advantages and disadvantages of each source?

15. WHO 15 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Questions: continued individual/community  What are important sources of advice on treatment of common illnesses?  Where do people get information on medicines?  Is the information adequate in their view?  Would they value access to more information on drugs?

16. WHO 16 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Questions: Health institution level  How appropriate are prescribing practices? What are the main problems?  To what extent do health workers and pharmacy staff provide adequate drug information?  What other health IEC activities take place? Do they contain messages on RDU? Which?  What do health workers and pharmacy staff consider to be problems in drug use by consumers?

17. WHO 17 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Questions: National level  What are key messages in drug advertisements directed towards consumers?  What medicines are sold most in the country. For what? Appropriate?  Does the government have a NDP? Is it implemented? What is done to promote RDU? To regulate drug promotion?

18. WHO 18 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Activity 1, Step 2 Review of existing data sources  The trainer gives each group a matrix on which the four selected problems can be written.  For each problem, review what sources of data on the problem exist.  What are limitations of these sources  What additional research is needed?

19. WHO 19 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Matrix for review of existing data sources

20. WHO 20 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Limitations of existing data sources  Limited data on drug use by consumers -- more known about drug prescribing and supply  Surveys are common sources of data But: often focus on specific health problems --> difficult to generalise  Data often limited geographically

21. WHO 21 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Limitations of existing data sources continued  Few attempts to ask consumers what their problems are?  Few studies assess existing drug information channels and messages  Few analyse problems: why do they occur?

22. WHO 22 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Additional quantitative research needed  To describe variety of drug use practices and how often they occur.  To quantify where people go for medicines and where for advice  To give representative data, which can be generalised

23. WHO 23 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Additional qualitative data needed  To gain insight in problems as defined by various stakeholders  To find out what people think about existing source of information on drugs  To find out what drug information they need  To understand why problems occur

24. WHO 24 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Key quantitative methods  Weekly illness recalls = what people do in common health problems  Inventory of medicines in household cabinets and/or informal shops selling medicines in communities = popular medicines

25. WHO 25 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Key qualitative methods  Focus group discussions  Key informant interviews with variety of stakeholders

26. WHO 26 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Research methods: Individual level/community  Surveys  Inventory drug shops/medicine cabinets  common health problems  drug use practices  most popular medicines  sources of treatments  sources of info on drugs/therapy

27. WHO 27 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Research methods: Individual/Community level continued  Key informant interviews  Focus group discussions  common health problems and their treatment  perceived drug use problems  sources of drug information and therapy-advice  perceived adequacy of drug information and treatment advice  need for more info ?

28. WHO 28 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Research methods: Health institutions  review of records  structured observations of patient-health worker consultation  key informant interviews  simulated client visits pharmacies  exit interviews  drug prescription practices  perceived drug use problems  provision of drug information in health centres and pharmacies  existing IEC activities in the field of health  Messages on RDU

29. WHO 29 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Research methods: National level  content analysis of advertisements directed to consumers  sales statistics  key informant interviews  key messages on medicines in drug promotion  most commonly sold drugs  implementation NDP, regulation of drug promotion, activities to promote RDU

30. WHO 30 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Focus groups  Used widely in marketing research  Efficient way to collect information on a wide range of behaviours/ideas  Interactions stimulate people to give their views  But, best combined with individual interviews -- some things may not be shared in a group  Analysis can be difficult

31. WHO 31 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Focus groups: how to  Homogeneous groups in terms of age, sex, and/or socioeconomic status/ethnicity  6-10 participants  Skilled facilitator  Neutral venue  At least two discussions per category of respondents  Avoid uninvited onlookers

32. WHO 32 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Focus group content  Limit topics to four-five  Ensure natural progression from one topic to another  Ensure natural progression from general topic to specific aspects  Start with questions -- summarize into topics  Be flexible -- follow the flow of the discussion but make sure the topics are covered

33. WHO 33 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community How to analyse FGDs  Best to record on tape (ask for consent)  But, keep notes as well: non-verbal observations and who said what  Make extended notes  Capture exact words/local terms  Analyse according to the topics/questions asked and unexpected themes/issues that emerge.  Avoid quantifying-qualitative information

34. WHO 34 Investigating drug use patterns and identifying problems Promoting Rational Drug Use in the Community Activity 3: FGD on everyday medicine use  You are divided into four groups: younger women; middle-aged women; young men;middle-aged men  Focus is on every-day medicine use  Review the FGD guide: change/adapt  Select facilitator and rapporteur  Conduct FGD: one hour  Reflect on how it went  Write extended notes on the results