Learning About a Drug Use Problem

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Learning About a Drug Use Problem
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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

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Components of the Drug Use System
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An Overview of the Process of Changing Drug Use
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Changing Drug Use Problems1. 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?

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Changing Drug Use Problems2. 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

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Changing Drug Use Problems3. 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

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Changing Drug Use Problems4. 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

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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

• hospital
• private practice
• pharmacy
• at home

• health center
• traditional healer
• drug seller

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Who is a Prescriber?Or Whose Behavior Do We
Change?

• physicians
• paramedics
• pharmacists
• injectionists
• patients

• clinical officers
• clinic attendants
• dispensers
• drug sellers
• relatives/friends

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How to Collect Data

• Quantitative Methods
• counts
• rates
• classifications
• What? or How Much?

• Qualitative Methods
• opinions
• descriptions
• observations
• Why? or How Strong?

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Selecting Methods to Study Drug Use

• Depends on
• nature of the problem
• objectives of collecting data
• resource availability
• time available

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Quantitative Methods

• Routine Data
• 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

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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.)

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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

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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
• drug supply orders
• stock cards
• shipping and delivery receipts

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Data Available at Health Facilities

• Retrospective
• patient registers
• treatment logs
• pharmacy receipts
• medical records
• Prospective
• observation of clinical encounters
• patient exit surveys
• inpatient surveys

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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

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Activity One
Strengths and Weaknesses of Different Data Sources
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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.

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In-Depth Interviews

• Definition
• an extended discussion between a respondent and
  an interviewer based on a brief interview guide
  that usually covers 10-30 topics

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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

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In-Depth Interview Strengths and Weaknesses

• Strengths
• 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

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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

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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
  

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Focus Groups Strengths and Weaknesses

• Strengths
• 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

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Structured Observations

• Definition
• systematic observations by trained observers of a
  series of encounters between health providers and
  patients

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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

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Observations Strengths and Weaknesses

• Strengths
• 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

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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

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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 50-75 respondents from each
  important subgroup

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Questionnaires Strengths and Weaknesses

• Strengths
• 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

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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

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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)

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Simulated VisitsStrengths and Weaknesses

• Strengths
• 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?

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ConclusionWhich 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

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Activity 2
Designing Qualitative Instruments
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Activity 3
Preparing for a Field Visit