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Learning Learning Drug Use ProblemDrug Use Problem
MOB6AMOB6A
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ObjectivesObjectives
��Describe model for developing interventionsDescribe model for developing interventions��Identify and evaluate sources of quantitative Identify and evaluate sources of quantitative
datadata��Understand the importance of studying provider Understand the importance of studying provider
and patient motivationsand patient motivations��Introduce qualitative research methodsIntroduce qualitative research methods��Develop instruments for field visitDevelop instruments for field visit
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Components of the Drug Use SystemComponents of the Drug Use System
Drug ImportsDrug ImportsLocal Local
ManufactureManufacture
Hospital or Hospital or Health CenterHealth Center
Private Physician or Private Physician or Other PractitionerOther Practitioner Pharmacist or Pharmacist or
Drug TraderDrug Trader
The Drug Supply The Drug Supply ProcessProcess
Provider and Provider and Consumer BehaviorConsumer Behavior
Illness PatternsIllness Patterns
++
PublicPublic
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Process of Changing Drug UseProcess of Changing Drug Use
1. EXAMINE1. EXAMINEMeasure Existing Measure Existing
PracticesPractices(Descriptive (Descriptive
Quantitative Studies) Quantitative Studies)
2. DIAGNOSE2. DIAGNOSEIdentify Specific Identify Specific
Problems & CausesProblems & Causes(In(In--depth Quantitative & depth Quantitative & Qualitative StudiesQualitative Studies))
3. TREAT3. TREATDesign & ImplementDesign & Implement
Interventions Interventions (Collect Data to (Collect Data to
Measure Outcomes)Measure Outcomes)
4. FOLLOW UP4. FOLLOW UPMeasure ChangesMeasure Changes
in Outcomes in Outcomes (Quantitative & (Quantitative &
Qualitative EvaluationQualitative Evaluation))improveimprove
interventionintervention
improveimprovediagnosisdiagnosis
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Changing Drug Use Problems:Changing Drug Use Problems:
1. Examine1. Examine
�� Identify drug use issue of interestIdentify drug use issue of interest�� highest clinical risk?highest clinical risk?�� widely used or expensive drugs?widely used or expensive drugs?�� easiest to correct?easiest to correct?
�� Collect data to describe practicesCollect data to describe practices�� in all subgroups or interestin all subgroups or interest�� most important prescribers?most important prescribers?�� high risk patients?high risk patients?
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�� Describe problem in detailDescribe problem in detail�� "gold standard" to assess quality?"gold standard" to assess quality?�� specific problem behaviorspecific problem behavior�� define important providers or patientsdefine important providers or patients
�� Identify determinants of the problemIdentify determinants of the problem�� knowledge and beliefsknowledge and beliefs�� cultural factors or peer practicescultural factors or peer practices�� patient demand and expectationspatient demand and expectations
�� Identify constraints to changeIdentify constraints to change�� economic constraintseconomic constraints�� drug supplydrug supply�� work environmentwork environment
Changing Drug Use Problems:Changing Drug Use Problems:
2. Diagnose2. Diagnose
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�� Select target and design interventionSelect target and design intervention�� which behaviors can be changed?which behaviors can be changed?�� feasible interventions?feasible interventions?�� costcost--effectiveness?effectiveness?�� personnel required?personnel required?
�� Pilot testPilot test�� acceptabilityacceptability�� effectivenesseffectiveness
�� Implement in stagesImplement in stages�� collect process and outcome datacollect process and outcome data
�� evaluate impactsevaluate impacts
Changing Drug Use Problems:Changing Drug Use Problems:
3. Treat3. Treat
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�� Evaluate success in relation to intended outcomesEvaluate success in relation to intended outcomes�� Was the intervention implemented as planned?Was the intervention implemented as planned?�� What changes occurredWhat changes occurred�� Was the intervention cost effective? transferable?Was the intervention cost effective? transferable?
�� Consider unintended negative outcomesConsider unintended negative outcomes�� Feedback resultsFeedback results
�� To managers and policymakersTo managers and policymakers�� To staffTo staff�� To providers and consumersTo providers and consumers
�� Use results to plan future activitiesUse results to plan future activities
Changing Drug Use Problems:Changing Drug Use Problems:
4. Follow4. Follow--upup
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Drug Use EncounterDrug Use Encounter
��Definition: the interaction between a provider Definition: the interaction between a provider and a patient when decisions are made about and a patient when decisions are made about which drugs to recommend or usewhich drugs to recommend or use
��Sites of drug use encountersSites of drug use encounters
Where the pill meets the patientWhere the pill meets the patient
––hospitalhospital––private practiceprivate practice––pharmacypharmacy––at homeat home
�� health centerhealth center�� traditional healertraditional healer�� drug sellerdrug seller
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Who is a Prescriber?Who is a Prescriber?OrOr Whose Behavior Do We Change?Whose Behavior Do We Change?
��physiciansphysicians��paramedicsparamedics��pharmacistspharmacists��injectionistsinjectionists��patientspatients
��clinical officersclinical officers��clinic attendantsclinic attendants��dispensersdispensers��drug sellersdrug sellers��relatives/friendsrelatives/friends
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How to Collect DataHow to Collect Data
�� Quantitative MethodsQuantitative Methods�� countscounts�� ratesrates�� classificationsclassifications�� What? or How Much?What? or How Much?
�� Qualitative MethodsQualitative Methods�� opinionsopinions�� descriptionsdescriptions�� observationsobservations�� Why? or How Strong?Why? or How Strong?
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Selecting Methods to Study Drug Selecting Methods to Study Drug UseUse
��Depends on:Depends on:��nature of the problemnature of the problem��objectives of collecting dataobjectives of collecting data�� resource availabilityresource availability�� time availabletime available
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Quantitative MethodsQuantitative Methods
�� Routine DataRoutine Data�� drug supply or consumption datadrug supply or consumption data�� morbidity and mortality reportsmorbidity and mortality reports
�� Record SystemsRecord Systems�� medical recordsmedical records�� pharmacy recordspharmacy records
�� Sample SurveysSample Surveys�� drug use encountersdrug use encounters�� provider interviewsprovider interviews�� patient & community interviewspatient & community interviews
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Types of Quantitative DataTypes of Quantitative Data
�� When collectedWhen collected�� retrospectiveretrospective�� prospectiveprospective
�� What levelWhat level�� aggregateaggregate�� patientpatient--specificspecific
�� Diagnosis informationDiagnosis information�� knownknown�� unknownunknown
�� Drug data Drug data �� detailed (name, dose, amount, duration)detailed (name, dose, amount, duration)�� nonnon--detailed (name only, if injection, etc.)detailed (name only, if injection, etc.)
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Where Can We Find Useful Where Can We Find Useful Quantitative Data?Quantitative Data?
��Administrative Offices, Medical StoresAdministrative Offices, Medical Stores��Clinical Treatment Areas & Medical Clinical Treatment Areas & Medical
Record DepartmentsRecord Departments��Health Facility PharmaciesHealth Facility Pharmacies��Private Pharmacies and Retail OutletsPrivate Pharmacies and Retail Outlets��HouseholdsHouseholds
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Data Available at District LevelData Available at District Level
��District OfficeDistrict Office�� data from routine health MISdata from routine health MIS�� morbidity and mortality reportsmorbidity and mortality reports�� previous drug use surveysprevious drug use surveys�� drug supply ordersdrug supply orders
��District StoresDistrict Stores�� drug supply ordersdrug supply orders�� stock cardsstock cards�� shipping and delivery receiptsshipping and delivery receipts
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Data Available at Health FacilitiesData Available at Health Facilities
��RetrospectiveRetrospective�� patient registerspatient registers�� treatment logstreatment logs�� pharmacy receiptspharmacy receipts�� medical recordsmedical records
��ProspectiveProspective�� observation of clinical encountersobservation of clinical encounters�� patient exit surveyspatient exit surveys�� inpatient surveysinpatient surveys
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Data From Drug EncountersData From Drug Encounters
�� FACILITYFACILITY
�� PATIENTPATIENT
�� PROVIDERPROVIDER
�� INTERACTIONINTERACTION
�� DRUGSDRUGS
�� ID, characteristics, equipment, drugs ID, characteristics, equipment, drugs availableavailable
�� ID, date, age, gender, symptoms ID, date, age, gender, symptoms knowledge, beliefs, attitudesknowledge, beliefs, attitudes
�� qualification, training, access to qualification, training, access to information, knowledge, beliefs, information, knowledge, beliefs, attitudesattitudes
�� exams, history, diagnosis, time spent, exams, history, diagnosis, time spent, explanation about illness, explanation explanation about illness, explanation about drugsabout drugs
�� brand, generic, strength, form, quantity, brand, generic, strength, form, quantity, duration, if dispensed, how labeled, duration, if dispensed, how labeled, cost, patient chargecost, patient charge
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Activity OneActivity One
Strengths and Weaknesses of Different Data Sources
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Qualitative MethodsQualitative Methods
�� These methods answer the question why. They These methods answer the question why. They provide insights into the reasons for behaviors.provide insights into the reasons for behaviors.
�� Types of Qualitative MethodsTypes of Qualitative Methods�� InIn--depth interviewsdepth interviews�� Focus Group DiscussionsFocus Group Discussions�� Structured ObservationsStructured Observations�� Structured QuestionnairesStructured Questionnaires�� Simulated Purchase VisitsSimulated Purchase Visits
�� Qualitative methods require skilled trained data Qualitative methods require skilled trained data collectors. Data analysis is more difficult than for collectors. Data analysis is more difficult than for quantitative data. But the results can be very useful.quantitative data. But the results can be very useful.
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InIn--Depth InterviewsDepth Interviews
��Definition:Definition:��an extended discussion between a an extended discussion between a
respondent and an interviewer respondent and an interviewer based on a brief interview guide based on a brief interview guide that usually covers 10that usually covers 10--30 topics30 topics
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InIn--Depth Interview: Key PointsDepth Interview: Key Points
�� openopen--ended topics explored in depth rather than ended topics explored in depth rather than fixed questionsfixed questions
�� can target key informants, opinion leaders, or others can target key informants, opinion leaders, or others in special positionin special position
�� 55--10 interviews may be enough to get a feel for 10 interviews may be enough to get a feel for important issuesimportant issues
�� if target group is diverse, generally 5if target group is diverse, generally 5--10 interviews 10 interviews are held with each important subgroupare held with each important subgroup
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Seating arrangement?Seating arrangement?
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Strengths and WeaknessesStrengths and Weaknesses
�� StrengthsStrengths�� unexpected insights or new ideasunexpected insights or new ideas�� helps create trust between interviewer and respondenthelps create trust between interviewer and respondent�� less intrusive than questionnaireless intrusive than questionnaire�� useful with illiterate respondentsuseful with illiterate respondents
�� WeaknessesWeaknesses�� timetime--consuming compared to structured questionnaireconsuming compared to structured questionnaire�� data analysis can be difficultdata analysis can be difficult�� bias toward socially acceptablebias toward socially acceptable�� requires wellrequires well--trained interviewerstrained interviewers
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Focus Group DiscussionsFocus Group Discussions
��Definition:Definition:��a short (1 1/2 a short (1 1/2 -- 2 hour) discussion led by 2 hour) discussion led by
a moderator in which a small group of a moderator in which a small group of respondents (6respondents (6--10) talk in depth about a 10) talk in depth about a defined list of topics of interestdefined list of topics of interest
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��SmallSmall�� 55--11 people, promotes equal participation11 people, promotes equal participation
��HomogeneousHomogeneous�� common characteristics shared viewpointcommon characteristics shared viewpoint
��GuidedGuided�� led by moderator, topics kept in focusled by moderator, topics kept in focus
��InformalInformal�� free interaction, open sharing of ideasfree interaction, open sharing of ideas
��RecordedRecorded�� analysis at later time, notes kept by assistantanalysis at later time, notes kept by assistant
Focus Groups: Key PointsFocus Groups: Key Points
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Seating arrangement?Seating arrangement?
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Strengths and WeaknessesStrengths and Weaknesses
��StrengthsStrengths�� good at eliciting the beliefs and opinions of a good at eliciting the beliefs and opinions of a
groupgroup�� provides richness and depthprovides richness and depth�� easy and inexpensive to organizeeasy and inexpensive to organize
��WeaknessesWeaknesses�� need for skilled moderatorneed for skilled moderator�� do beliefs and opinions represent true feelings?do beliefs and opinions represent true feelings?
�� potential bias in analysispotential bias in analysis
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Structured ObservationsStructured Observations
��Definition:Definition:�� systematic systematic
observations by observations by trained observers of trained observers of a series of a series of encounters between encounters between health providers and health providers and patientspatients
.
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Observations: Key PointsObservations: Key Points
�� to prepare for study, observer should:to prepare for study, observer should:�� introduce nonintroduce non--threatening explanationthreatening explanation�� spend enough time to "blend in"spend enough time to "blend in"
�� data can be recorded as:data can be recorded as:�� coded indicators and scalescoded indicators and scales�� list of behaviors and eventslist of behaviors and events�� diary of observer's impressionsdiary 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 to count frequency of behaviors, at least 30 cases in each
categorycategory�� to understand typical features, a few cases in 5to understand typical features, a few cases in 5--6 settings 6 settings
may be enoughmay be enough
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Strengths and WeaknessesStrengths and Weaknesses��StrengthsStrengths
�� best way to study the complex providerbest way to study the complex provider--patient patient interactionsinteractions
�� can learn about provider behavior in its natural can learn about provider behavior in its natural settingsetting
�� best way to learn about patient demand, quality best way to learn about patient demand, quality of communicationof communication
��WeaknessesWeaknesses�� behavior may not be natural because of behavior may not be natural because of
observer's presenceobserver's presence�� requires skilled, patient observersrequires skilled, patient observers
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Structured QuestionnairesStructured Questionnaires
��Definition:Definition:
�� a fixed set of items asked a fixed set of items asked to a large sample of to a large sample of respondents selected respondents selected according to strict rules to according to strict rules to represent a larger represent a larger populationpopulation
? ? ?? ? ?
?
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Questionnaires: Key PointsQuestionnaires: Key Points
��Nature of questionsNature of questions�� useful for attitudes, opinions, and beliefs as well useful for attitudes, opinions, and beliefs as well
as factsas facts�� questions always asked in a standardized wayquestions always asked in a standardized way�� can have fixed or opencan have fixed or open--ended responsesended responses
��Sample sizeSample size�� depends on target population, type of sampling, depends on target population, type of sampling,
desired accuracy, and available resourcesdesired accuracy, and available resources�� usually at least 50usually at least 50--75 respondents from each 75 respondents from each
important subgroupimportant subgroup
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�� StrengthsStrengths�� best to study frequency of knowledge, attitudes, population best to study frequency of knowledge, attitudes, population
characteristicscharacteristics�� familiar to managers and respondentsfamiliar to managers and respondents�� required skills often locally availablerequired skills often locally available
�� WeaknessesWeaknesses�� attitudes often difficult to quantifyattitudes often difficult to quantify�� respondents often answer a direct question even if they respondents often answer a direct question even if they
have no true opinionhave no true opinion�� results sensitive to which questions are asked and wordingresults sensitive to which questions are asked and wording�� large surveys can be expensivelarge surveys can be expensive
Strengths and WeaknessesStrengths and Weaknesses
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Simulated Purchase VisitsSimulated Purchase Visits
��Definition:Definition:
�� a research assistant, prepared in a research assistant, prepared in advance to present a standard advance to present a standard complaint, visit providers complaint, visit providers seeking treatment in seeking treatment in order to determine order to determine their practicestheir practices
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Simulated Visits: Key PointsSimulated Visits: Key Points
��usually sample 30+ providersusually sample 30+ providers��collect data on many aspects of practicecollect data on many aspects of practice
�� historyhistory--takingtaking�� examinationexamination�� treatmenttreatment�� adviceadvice
��frequently used to examine practices in frequently used to examine practices in private pharmaciesprivate pharmacies
��scenario can be varied (e.g. watery vs. scenario can be varied (e.g. watery vs. bloody diarrhea)bloody diarrhea)
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��StrengthsStrengths�� can compare knowledge & reported practice with can compare knowledge & reported practice with
actual practiceactual practice�� relatively quick & easy to conductrelatively quick & easy to conduct�� data are simple to analyzedata are simple to analyze
��WeaknessesWeaknesses�� response may be specific to the scenario response may be specific to the scenario
presentedpresented�� research assistants can vary widely in reliabilityresearch assistants can vary widely in reliability�� impact on morbidity records?impact on morbidity records?
Strengths and WeaknessesStrengths and Weaknesses
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Conclusion:Conclusion:Which Method to Use?Which Method to Use?
��Best method depends on:Best method depends on:
��nature of the problemnature of the problem��objectives of collecting dataobjectives of collecting data��available resources and timeavailable resources and time�� local capacity and experiencelocal capacity and experience
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Use of multiple methodsUse of multiple methods
�� Quantitative + qualitativeQuantitative + qualitative�� Triangulate findingsTriangulate findings�� Each method can look Each method can look
at different aspect at different aspect of a problemof a problem
ProblemProblem
FGDFGD
Obser
Obser
--va
tion
vatio
n
InterInter--viewview
In dic aIn dic a --to rsto rs
Quest
Quest
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Activity 2Activity 2
Designing Qualitative Instruments
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Activity 3Activity 3
Preparing for a Field Visit