1

Learning
Learning
Drug Use Problem
Drug Use Problem
MOB6A
MOB6A
Learning About Drug Use 2
Objectives
Objectives

Describe model for developing interventions
Describe model for developing interventions

Identify and evaluate sources of quantitative
Identify and evaluate sources of quantitative
data
data

Understand the importance of studying provider
Understand the importance of studying provider
and patient motivations
and patient motivations

Introduce qualitative research methods
Introduce qualitative research methods

Develop instruments for field visit
Develop instruments for field visit
Learning About Drug Use 3
Components of the Drug Use System
Components of the Drug Use System
Drug Imports Drug Imports
Local Local
Manufacture Manufacture
Hospital or Hospital or
Health Center Health Center
Private Physician or Private Physician or
Other Practitioner Other Practitioner
Pharmacist or Pharmacist or
Drug Trader Drug Trader
The Drug Supply The Drug Supply
Process Process
Provider and Provider and
Consumer Behavior Consumer Behavior
Illness Patterns Illness Patterns
+ +
Public Public
Learning About Drug Use 4
Process of Changing Drug Use
Process of Changing Drug Use
1. EXAMINE 1. EXAMINE
Measure Existing Measure Existing
Practices Practices
(Descriptive (Descriptive
Quantitative Studies) Quantitative Studies)
2. DIAGNOSE 2. DIAGNOSE
Identify Specific Identify Specific
Problems & Causes Problems & Causes
(In (In- -depth Quantitative & depth Quantitative &
Qualitative Studies Qualitative Studies) )
3. TREAT 3. TREAT
Design & Implement Design & Implement
Interventions Interventions
(Collect Data to (Collect Data to
Measure Outcomes) Measure Outcomes)
4. FOLLOW UP 4. FOLLOW UP
Measure Changes Measure Changes
in Outcomes in Outcomes
(Quantitative & (Quantitative &
Qualitative Evaluation Qualitative Evaluation) )
improve improve
intervention intervention
improve improve
diagnosis diagnosis
Learning About Drug Use 5
Changing Drug Use Problems: Changing Drug Use Problems:
1. Examine
1. Examine
Identify drug use issue of interest Identify 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 practices Collect data to describe practices
in all subgroups or interest in all subgroups or interest
most important prescribers? most important prescribers?
high risk patients? high risk patients?
Learning About Drug Use 6
Describe problem in detail Describe problem in detail
"gold standard" to assess quality? "gold standard" to assess quality?
specific problem behavior specific problem behavior
define important providers or patients define important providers or patients
Identify determinants of the problem Identify determinants of the problem
knowledge and beliefs knowledge and beliefs
cultural factors or peer practices cultural factors or peer practices
patient demand and expectations patient demand and expectations
Identify constraints to change Identify constraints to change
economic constraints economic constraints
drug supply drug supply
work environment work environment
Changing Drug Use Problems: Changing Drug Use Problems:
2. Diagnose
2. Diagnose
Learning About Drug Use 7
Select target and design intervention Select target and design intervention
which behaviors can be changed? which behaviors can be changed?
feasible interventions? feasible interventions?
cost cost- -effectiveness? effectiveness?
personnel required? personnel required?
Pilot test Pilot test
acceptability acceptability
effectiveness effectiveness
Implement in stages Implement in stages
collect process and outcome data collect process and outcome data
evaluate impacts evaluate impacts
Changing Drug Use Problems: Changing Drug Use Problems:
3. Treat
3. Treat
Learning About Drug Use 8
Evaluate success in relation to intended outcomes Evaluate success in relation to intended outcomes
Was the intervention implemented as planned? Was the intervention implemented as planned?
What changes occurred What changes occurred
Was the intervention cost effective? transferable? Was the intervention cost effective? transferable?
Consider unintended negative outcomes Consider unintended negative outcomes
Feedback results Feedback results
To managers and policymakers To managers and policymakers
To staff To staff
To providers and consumers To providers and consumers
Use results to plan future activities Use results to plan future activities
Changing Drug Use Problems: Changing Drug Use Problems:
4. Follow
4. Follow
-
-
up
up
Learning About Drug Use 9
Drug Use Encounter
Drug 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 use
which drugs to recommend or use

Sites of drug use encounters
Sites of drug use encounters
Where the pill meets the patient Where the pill meets the patient
hospital hospital
private practice private practice
pharmacy pharmacy
at home at home
health center health center
traditional healer traditional healer
drug seller drug seller
Learning About Drug Use 10
Who is a Prescriber?
Who is a Prescriber?
Or
Or
Whose Behavior Do We Change?
Whose Behavior Do We Change?

physicians
physicians

paramedics
paramedics

pharmacists
pharmacists

injectionists
injectionists

patients
patients

clinical officers
clinical officers

clinic attendants
clinic attendants

dispensers
dispensers

drug sellers
drug sellers

relatives/friends
relatives/friends
Learning About Drug Use 11
How to Collect Data
How to Collect Data
Quantitative Methods Quantitative Methods
counts counts
rates rates
classifications classifications
What? or How Much? What? or How Much?
Qualitative Methods Qualitative Methods
opinions opinions
descriptions descriptions
observations observations
Why? or How Strong? Why? or How Strong?
Learning About Drug Use 12
Selecting Methods to Study Drug
Selecting Methods to Study Drug
Use
Use

Depends on:
Depends on:

nature of the problem
nature of the problem

objectives of collecting data
objectives of collecting data

resource availability
resource availability

time available
time available
Learning About Drug Use 13
Quantitative Methods
Quantitative Methods
Routine Data Routine Data
drug supply or consumption data drug supply or consumption data
morbidity and mortality reports morbidity and mortality reports
Record Systems Record Systems
medical records medical records
pharmacy records pharmacy records
Sample Surveys Sample Surveys
drug use encounters drug use encounters
provider interviews provider interviews
patient & community interviews patient & community interviews
Learning About Drug Use 14
Types of Quantitative Data
Types of Quantitative Data
When collected When collected
retrospective retrospective
prospective prospective
What level What level
aggregate aggregate
patient patient- -specific specific
Diagnosis information Diagnosis information
known known
unknown unknown
Drug data Drug data
detailed (name, dose, amount, duration) detailed (name, dose, amount, duration)
non non- -detailed (name only, if injection, etc.) detailed (name only, if injection, etc.)
Learning About Drug Use 15
Where Can We Find Useful
Where Can We Find Useful
Quantitative Data?
Quantitative Data?

Administrative Offices, Medical Stores

Administrative Offices, Medical Stores

Clinical Treatment Areas & Medical

Clinical Treatment Areas & Medical
Record Departments
Record Departments

Health Facility Pharmacies

Health Facility Pharmacies

Private Pharmacies and Retail Outlets

Private Pharmacies and Retail Outlets

Households
Households
Learning About Drug Use 16
Data Available at District Level
Data Available at District Level

District Office
District Office
data from routine health MIS data from routine health MIS
morbidity and mortality reports morbidity and mortality reports
previous drug use surveys previous drug use surveys
drug supply orders drug supply orders

District Stores
District Stores
drug supply orders drug supply orders
stock cards stock cards
shipping and delivery receipts shipping and delivery receipts
Learning About Drug Use 17
Data Available at Health Facilities
Data Available at Health Facilities

Retrospective
Retrospective
patient registers patient registers
treatment logs treatment logs
pharmacy receipts pharmacy receipts
medical records medical records

Prospective
Prospective
observation of clinical encounters observation of clinical encounters
patient exit surveys patient exit surveys
inpatient surveys inpatient surveys
Learning About Drug Use 18
Data From Drug Encounters
Data From Drug Encounters
FACILITY FACILITY
PATIENT PATIENT
PROVIDER PROVIDER
INTERACTION INTERACTION
DRUGS DRUGS
ID, characteristics, equipment, drugs ID, characteristics, equipment, drugs
available available
ID, date, age, gender, symptoms ID, date, age, gender, symptoms
knowledge, beliefs, attitudes knowledge, beliefs, attitudes
qualification, training, access to qualification, training, access to
information, knowledge, beliefs, information, knowledge, beliefs,
attitudes attitudes
exams, history, diagnosis, time spent, exams, history, diagnosis, time spent,
explanation about illness, explanation explanation about illness, explanation
about drugs about drugs
brand, generic, strength, form, quantity, brand, generic, strength, form, quantity,
duration, if dispensed, how labeled, duration, if dispensed, how labeled,
cost, patient charge cost, patient charge
Learning About Drug Use 19
Activity One
Activity One
Strengths and Weaknesses of
Different Data Sources
Learning About Drug Use 20
Qualitative Methods
Qualitative 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 Methods Types of Qualitative Methods
In In- -depth interviews depth interviews
Focus Group Discussions Focus Group Discussions
Structured Observations Structured Observations
Structured Questionnaires Structured Questionnaires
Simulated Purchase Visits Simulated 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.
Learning About Drug Use 21
In
In
-
-
Depth Interviews
Depth 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 10
that usually covers 10
-
-
30 topics
30 topics
Learning About Drug Use 22
In
In
-
-
Depth Interview: Key Points
Depth Interview: Key Points
open open- -ended topics explored in depth rather than ended topics explored in depth rather than
fixed questions fixed questions
can target key informants, opinion leaders, or others can target key informants, opinion leaders, or others
in special position in special position
5 5- -10 interviews may be enough to get a feel for 10 interviews may be enough to get a feel for
important issues important issues
if target group is diverse, generally 5 if target group is diverse, generally 5- -10 interviews 10 interviews
are held with each important subgroup are held with each important subgroup
Learning About Drug Use 23
Seating arrangement?
Seating arrangement?
Learning About Drug Use 24
Strengths and Weaknesses
Strengths and Weaknesses
Strengths Strengths
unexpected insights or new ideas unexpected insights or new ideas
helps create trust between interviewer and respondent helps create trust between interviewer and respondent
less intrusive than questionnaire less intrusive than questionnaire
useful with illiterate respondents useful with illiterate respondents
Weaknesses Weaknesses
time time- -consuming compared to structured questionnaire consuming compared to structured questionnaire
data analysis can be difficult data analysis can be difficult
bias toward socially acceptable bias toward socially acceptable
requires well requires well- -trained interviewers trained interviewers
Learning About Drug Use 25
Focus Group Discussions
Focus 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 (6
respondents (6
-
-
10) talk in depth about a
10) talk in depth about a
defined list of topics of interest
defined list of topics of interest
Learning About Drug Use 26

Small
Small
5 5- -11 people, promotes equal participation 11 people, promotes equal participation

Homogeneous
Homogeneous
common characteristics shared viewpoint common characteristics shared viewpoint

Guided
Guided
led by moderator, topics kept in focus led by moderator, topics kept in focus

Informal
Informal
free interaction, open sharing of ideas free interaction, open sharing of ideas

Recorded
Recorded
analysis at later time, notes kept by assistant analysis at later time, notes kept by assistant
Focus Groups: Key Points
Focus Groups: Key Points
Learning About Drug Use 27
Seating arrangement?
Seating arrangement?
Learning About Drug Use 28
Strengths and Weaknesses
Strengths and Weaknesses

Strengths
Strengths
good at eliciting the beliefs and opinions of a good at eliciting the beliefs and opinions of a
group group
provides richness and depth provides richness and depth
easy and inexpensive to organize easy and inexpensive to organize

Weaknesses
Weaknesses
need for skilled moderator need for skilled moderator
do beliefs and opinions represent true feelings? do beliefs and opinions represent true feelings?
potential bias in analysis potential bias in analysis
Learning About Drug Use 29
Structured Observations
Structured 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
patients patients
.
Learning About Drug Use 30
Observations: Key Points
Observations: Key Points
to prepare for study, observer should: to prepare for study, observer should:
introduce non introduce non- -threatening explanation threatening 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 scales coded indicators and scales
list of behaviors and events list of behaviors and events
diary of observer's impressions 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 to count frequency of behaviors, at least 30 cases in each
category category
to understand typical features, a few cases in 5 to understand typical features, a few cases in 5- -6 settings 6 settings
may be enough may be enough
Learning About Drug Use 31
Strengths and Weaknesses
Strengths and Weaknesses

Strengths
Strengths
best way to study the complex provider best way to study the complex provider- -patient patient
interactions interactions
can learn about provider behavior in its natural can learn about provider behavior in its natural
setting setting
best way to learn about patient demand, quality best way to learn about patient demand, quality
of communication of communication

Weaknesses
Weaknesses
behavior may not be natural because of behavior may not be natural because of
observer's presence observer's presence
requires skilled, patient observers requires skilled, patient observers
Learning About Drug Use 32
Structured Questionnaires
Structured 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
population population
?
?
?
?
? ?
?
Learning About Drug Use 33
Questionnaires: Key Points
Questionnaires: Key Points

Nature of questions
Nature of questions
useful for attitudes, opinions, and beliefs as well useful for attitudes, opinions, and beliefs as well
as facts as facts
questions always asked in a standardized way questions always asked in a standardized way
can have fixed or open can have fixed or open- -ended responses ended responses

Sample size
Sample size
depends on target population, type of sampling, depends on target population, type of sampling,
desired accuracy, and available resources desired accuracy, and available resources
usually at least 50 usually at least 50- -75 respondents from each 75 respondents from each
important subgroup important subgroup
Learning About Drug Use 34
Strengths Strengths
best to study frequency of knowledge, attitudes, population best to study frequency of knowledge, attitudes, population
characteristics characteristics
familiar to managers and respondents familiar to managers and respondents
required skills often locally available required skills often locally available
Weaknesses Weaknesses
attitudes often difficult to quantify attitudes 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 opinion have no true opinion
results sensitive to which questions are asked and wording results sensitive to which questions are asked and wording
large surveys can be expensive large surveys can be expensive
Strengths and Weaknesses
Strengths and Weaknesses
Learning About Drug Use 35
Simulated Purchase Visits
Simulated 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 practices their practices
Learning About Drug Use 36
Simulated Visits: Key Points
Simulated Visits: Key Points

usually sample 30+ providers
usually sample 30+ providers

collect data on many aspects of practice
collect data on many aspects of practice
history history- -taking taking
examination examination
treatment treatment
advice advice

frequently used to examine practices in
frequently used to examine practices in
private pharmacies
private pharmacies

scenario can be varied (e.g. watery vs.
scenario can be varied (e.g. watery vs.
bloody diarrhea)
bloody diarrhea)
Learning About Drug Use 37

Strengths
Strengths
can compare knowledge & reported practice with can compare knowledge & reported practice with
actual practice actual practice
relatively quick & easy to conduct relatively quick & easy to conduct
data are simple to analyze data are simple to analyze

Weaknesses
Weaknesses
response may be specific to the scenario response may be specific to the scenario
presented presented
research assistants can vary widely in reliability research assistants can vary widely in reliability
impact on morbidity records? impact on morbidity records?
Strengths and Weaknesses
Strengths and Weaknesses
Learning About Drug Use 38
Conclusion:
Conclusion:
Which Method to Use?
Which Method to Use?

Best method depends on:

Best method depends on:

nature of the problem
nature of the problem

objectives of collecting data
objectives of collecting data

available resources and time
available resources and time

local capacity and experience
local capacity and experience
Learning About Drug Use 39
Use of multiple methods
Use of multiple methods
Quantitative + qualitative Quantitative + qualitative
Triangulate findings Triangulate findings
Each method can look Each method can look
at different aspect at different aspect
of a problem of a problem
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Learning About Drug Use 40
Activity 2
Activity 2
Designing Qualitative
Instruments
Learning About Drug Use 41
Activity 3
Activity 3
Preparing for a Field Visit