Learning about a Drug Use Problem

1. Learning about a Drug Use Problem

2. 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 Learning about a Drug Use Problem

3. Local Drug Imports Manufacture The Drug Supply Process Provider and + Consumer Behavior Private Physician or Hospital or Pharmacist or Other Practitioner Health Center Drug Trader Illness Patterns Public Components of the Drug Use System Learning about a Drug Use Problem

4. 1. EXAMINE Measure Existing Practices (Descriptive Quantitative Studies) 4. FOLLOW UP improve diagnosis 2. DIAGNOSE Measure Changes Identify Specific in Outcomes Problems & Causes (Quantitative & Qualitative (In-depth Quantitative Evaluation) & Qualitative Studies) improve intervention 3. TREAT Design & Implement Interventions (Collect Data to Measure Outcomes) An Overview of the Process of Changing Drug Use Learning about a Drug Use Problem

5. Changing Drug Use Problems:1. 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? Learning about a Drug Use Problem

6. Changing Drug Use Problems:2. 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 Learning about a Drug Use Problem

7. Changing Drug Use Problems:3. 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 Learning about a Drug Use Problem

8. Changing Drug Use Problems:4. 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 • Feed back results • To managers and policymakers • To staff • To providers and consumers • Use results to plan future activities Learning about a Drug Use Problem

9. 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 health center traditional healer drug seller Drug Use Encounter Where the pill meets the patient • hospital • private practice • pharmacy • home Learning about a Drug Use Problem

10. Physicians Paramedics Pharmacists Injectionists Patients Clinical officers Clinic attendants Dispensers Drug sellers Relatives/friends Who Is a Prescriber?Or Whose Behavior Do We Change? Learning about a Drug Use Problem

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

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

13. 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 Learning about a Drug Use Problem

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

15. Where Can We Find Useful Quantitative Data? • Administrative offices, medical stores • Clinical treatment areas and medical record departments • Health facility pharmacies • Private pharmacies and retail outlets • Households Learning about a Drug Use Problem

16. 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 Learning about a Drug Use Problem

17. Data Available at Health Facilities • Retrospective • Patient registers • Treatment logs • Pharmacy receipts • Medical records • Prospective • Observation of clinical encounters • Patient exit surveys • Inpatient surveys Learning about a Drug Use Problem

18. 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 Data from Drug Encounters Learning about a Drug Use Problem

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

20. 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 trained data collectors. Data analysis is more difficult, but the results can be very useful. Learning about a Drug Use Problem

21. 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 Learning about a Drug Use Problem

22. 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 Learning about a Drug Use Problem

23. 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 with structured questionnaire • Data analysis can be difficult • Bias toward socially acceptable or expected responses • Requires well-trained interviewers Learning about a Drug Use Problem

24. 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 Learning about a Drug Use Problem

25. 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 Focus Groups: Key Points Learning about a Drug Use Problem

26. Focus Groups: Strengths and Weaknesses • Strengths • Elicits 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 Learning about a Drug Use Problem

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

28. Observations: Key Points • To prepare for study, observer should— • Introduce nonthreatening 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 Learning about a Drug Use Problem

29. 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 Learning about a Drug Use Problem

30. 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 ? ? ? ? ? ? ? Learning about a Drug Use Problem

31. 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 Learning about a Drug Use Problem

32. 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 Learning about a Drug Use Problem

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

34. 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) Learning about a Drug Use Problem

35. Simulated Visits:Strengths 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? Learning about a Drug Use Problem

36. Conclusion:Which 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 Learning about a Drug Use Problem

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

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