Learning about drug use problem
- 1. 1 Learning about a DrugLearning about a Drug Use ProblemUse Problem
- 2. Learning about a Drug Use Problem 2 Learning about a Drug UseLearning about a Drug Use Problem: ObjectivesProblem: Objectives • Describe model for developing interventionsDescribe model for developing interventions • Identify and evaluate sources of quantitativeIdentify and evaluate sources of quantitative datadata • Understand the importance of studyingUnderstand the importance of studying provider and patient motivationsprovider and patient motivations • Introduce qualitative research methodsIntroduce qualitative research methods • Develop instruments for field visitDevelop instruments for field visit
- 3. Learning about a Drug Use Problem 3 Components of the Drug UseComponents of the Drug Use SystemSystem Drug ImportsDrug Imports LocalLocal ManufactureManufacture Hospital orHospital or Health CenterHealth Center Private Physician orPrivate Physician or Other PractitionerOther Practitioner Pharmacist orPharmacist or Drug TraderDrug Trader The Drug SupplyThe Drug Supply ProcessProcess Provider andProvider and Consumer BehaviorConsumer Behavior Illness PatternsIllness Patterns ++ PublicPublic
- 4. Learning about a Drug Use Problem 4 An Overview of the Process ofAn Overview of the Process of Changing Drug UseChanging Drug Use 1. EXAMINE1. EXAMINE Measure ExistingMeasure Existing PracticesPractices (Descriptive(Descriptive Quantitative Studies)Quantitative Studies) 2. DIAGNOSE2. DIAGNOSE Identify SpecificIdentify Specific Problems & CausesProblems & Causes (In-depth Quantitative(In-depth Quantitative & Qualitative Studies& Qualitative Studies)) 3. TREAT3. TREAT Design & ImplementDesign & Implement InterventionsInterventions (Collect Data to(Collect Data to Measure Outcomes)Measure Outcomes) 4. FOLLOW UP4. FOLLOW UP Measure ChangesMeasure Changes in Outcomesin Outcomes (Quantitative & Qualitative(Quantitative & Qualitative Evaluation)Evaluation) improveimprove interventionintervention improveimprove diagnosisdiagnosis
- 5. Learning about a Drug Use Problem 5 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?
- 6. Learning about a Drug Use Problem 6 • 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
- 7. Learning about a Drug Use Problem 7 • Select target and design interventionSelect target and design intervention – Which behaviors can be changed?Which behaviors can be changed? – Feasible interventions?Feasible interventions? – Cost-effectiveness?Cost-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
- 8. Learning about a Drug Use Problem 8 • 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 • Feed back resultsFeed back 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. Follow Up4. Follow Up
- 9. Learning about a Drug Use Problem 9 Drug Use EncounterDrug Use Encounter • Definition: the interaction between aDefinition: the interaction between a provider and a patient when decisions areprovider and a patient when decisions are made about which drugs to recommend ormade about which drugs to recommend or useuse • 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 – homehome – health centerhealth center – traditional healertraditional healer – drug sellerdrug seller
- 10. Learning about a Drug Use Problem 10 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
- 11. Learning about a Drug Use Problem 11 How to Collect DataHow to Collect Data • Quantitative MethodsQuantitative Methods – what? or how much?what? or how much? – countscounts – ratesrates – classificationsclassifications • Qualitative MethodsQualitative Methods – why? or how strong?why? or how strong? – opinionsopinions – descriptionsdescriptions – observationsobservations
- 12. Learning about a Drug Use Problem 12 Selecting Methods to Study DrugSelecting 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
- 13. Learning about a Drug Use Problem 13 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
- 14. Learning about a Drug Use Problem 14 Types of Quantitative DataTypes of Quantitative Data • When collectedWhen collected – RetrospectiveRetrospective – ProspectiveProspective • What levelWhat level – AggregateAggregate – Patient-specificPatient-specific • Diagnosis informationDiagnosis information – KnownKnown – UnknownUnknown • Drug dataDrug data – Detailed (name, dose, amount, duration)Detailed (name, dose, amount, duration) – Uondetailed (name only, if injection, etc.)Uondetailed (name only, if injection, etc.)
- 15. Learning about a Drug Use Problem 15 Where Can We Find UsefulWhere Can We Find Useful Quantitative Data?Quantitative Data? • Administrative offices, medical storesAdministrative offices, medical stores • Clinical treatment areas and medicalClinical treatment areas and medical record departmentsrecord departments • Health facility pharmaciesHealth facility pharmacies • Private pharmacies and retail outletsPrivate pharmacies and retail outlets • HouseholdsHouseholds
- 16. Learning about a Drug Use Problem 16 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
- 17. Learning about a Drug Use Problem 17 Data Available at HealthData Available at Health FacilitiesFacilities • 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
- 18. Learning about a Drug Use Problem 18 Data from Drug EncountersData from Drug Encounters • FACILITYFACILITY • PATIENTPATIENT • PROVIDERPROVIDER • INTERACTIONINTERACTION • DRUGSDRUGS • ID, characteristics, equipment, drugsID, characteristics, equipment, drugs availableavailable • ID, date, age, gender, symptomsID, date, age, gender, symptoms knowledge, beliefs, attitudesknowledge, beliefs, attitudes • qualification, training, access toqualification, training, access to information, knowledge, beliefs,information, knowledge, beliefs, attitudesattitudes • exams, history, diagnosis, time spent,exams, history, diagnosis, time spent, explanation about illness, explanationexplanation 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
- 19. Learning about a Drug Use Problem 19 Activity 1Activity 1 Strengths and Weaknesses of Different Data Sources
- 20. Learning about a Drug Use Problem 20 Qualitative MethodsQualitative Methods • These methods answer the question why. TheyThese 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 – In-depth interviewsIn-depth interviews – Focus group discussionsFocus group discussions – Structured observationsStructured observations – Structured questionnairesStructured questionnaires – Simulated purchase visitsSimulated purchase visits • Qualitative methods require trained data collectors.Qualitative methods require trained data collectors. Data analysis is more difficult, but the results can beData analysis is more difficult, but the results can be very useful.very useful.
- 21. Learning about a Drug Use Problem 21 In-Depth InterviewsIn-Depth Interviews • Definition:Definition: An extended discussionAn extended discussion between a respondentbetween a respondent and an interviewerand an interviewer based on a briefbased on a brief interview guide thatinterview guide that usually covers 10-30usually covers 10-30 topicstopics
- 22. Learning about a Drug Use Problem 22 In-Depth Interview: Key PointsIn-Depth Interview: Key Points • Open-ended topics explored in depth ratherOpen-ended topics explored in depth rather than fixed questionsthan fixed questions • Can target key informants, opinion leaders,Can target key informants, opinion leaders, or others in special positionor others in special position • 5-10 interviews may be enough to get a feel5-10 interviews may be enough to get a feel for important issuesfor important issues • If target group is diverse, generally 5-10If target group is diverse, generally 5-10 interviews are held with each importantinterviews are held with each important subgroupsubgroup
- 23. Learning about a Drug Use Problem 23 In-Depth Interview: StrengthsIn-Depth Interview: Strengths and Weaknessesand 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 – Time-consuming compared with structured questionnaireTime-consuming compared with structured questionnaire – Data analysis can be difficultData analysis can be difficult – Bias toward socially acceptable or expected responsesBias toward socially acceptable or expected responses – Requires well-trained interviewersRequires well-trained interviewers
- 24. Learning about a Drug Use Problem 24 Focus Group DiscussionsFocus Group Discussions • Definition:Definition: A short (1 1/2 - 2A short (1 1/2 - 2 hour) discussion ledhour) discussion led by a moderator inby a moderator in which a small groupwhich a small group of respondents (6-10)of respondents (6-10) talk in depth about atalk in depth about a defined list of topicsdefined list of topics of interestof interest
- 25. Learning about a Drug Use Problem 25 • SmallSmall – 5-11 people, promotes equal participation5-11 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
- 26. Learning about a Drug Use Problem 26 Focus Groups:Focus Groups: Strengths and WeaknessesStrengths and Weaknesses • StrengthsStrengths – Elicits the beliefs and opinions of a groupElicits the beliefs and opinions of a group – 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
- 27. Learning about a Drug Use Problem 27 Structured ObservationsStructured Observations • Definition:Definition: SystematicSystematic observations byobservations by trained observers oftrained observers of a series ofa series of encounters betweenencounters between health providers andhealth providers and patientspatients .
- 28. Learning about a Drug Use Problem 28 Observations: Key PointsObservations: Key Points • To prepare for study, observer should—To prepare for study, observer should— – Introduce nonthreatening explanationIntroduce nonthreatening 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 eachTo count frequency of behaviors, at least 30 cases in each categorycategory – To understand typical features, a few cases in 5-6 settingsTo understand typical features, a few cases in 5-6 settings may be enoughmay be enough
- 29. Learning about a Drug Use Problem 29 Observations:Observations: Strengths and WeaknessesStrengths and Weaknesses • StrengthsStrengths – Best way to study the complex provider-patientBest way to study the complex provider-patient interactionsinteractions – Can learn about provider behavior in its naturalCan learn about provider behavior in its natural settingsetting – Best way to learn about patient demand, quality ofBest way to learn about patient demand, quality of communicationcommunication • WeaknessesWeaknesses – Behavior may not be natural because ofBehavior may not be natural because of observer's presenceobserver's presence – Requires skilled, patient observersRequires skilled, patient observers – Not useful for infrequent behaviorsNot useful for infrequent behaviors
- 30. Learning about a Drug Use Problem 30 Structured QuestionnairesStructured Questionnaires • DefinitionDefinition A fixed set of itemsA fixed set of items asked to a largeasked to a large sample ofsample of respondentsrespondents selected accordingselected according to strict rules toto strict rules to represent a largerrepresent a larger populationpopulation ? ? ? ? ? ? ? ? ? ? ? ? ? ?
- 31. Learning about a Drug Use Problem 31 Questionnaires: Key PointsQuestionnaires: Key Points • Nature of questionsNature of questions – Useful for attitudes, opinions, and beliefs as wellUseful 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 open-ended responsesCan have fixed or open-ended 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 50–75 respondents from eachUsually at least 50–75 respondents from each important subgroupimportant subgroup
- 32. Learning about a Drug Use Problem 32 • StrengthsStrengths – Best to study frequency of knowledge, attitudes,Best to study frequency of knowledge, attitudes, population characteristicspopulation characteristics – 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 evenRespondents often answer a direct question even if they have no true opinionif they have no true opinion – Results sensitive to which questions are askedResults sensitive to which questions are asked and wordingand wording – Large surveys can be expensiveLarge surveys can be expensive Questionnaires:Questionnaires: Strengths and WeaknessesStrengths and Weaknesses
- 33. Learning about a Drug Use Problem 33 Simulated Purchase VisitsSimulated Purchase Visits • Definition:Definition: A research assistant,A research assistant, prepared in advanceprepared in advance to present a standardto present a standard complaint, visitscomplaint, visits providers seekingproviders seeking treatment in order totreatment in order to determine theirdetermine their practicespractices
- 34. Learning about a Drug Use Problem 34 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 – History-takingHistory-taking – ExaminationExamination – TreatmentTreatment – AdviceAdvice • Frequently used to examine practices inFrequently 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)
- 35. Learning about a Drug Use Problem 35 • StrengthsStrengths – Can compare knowledge & reported practice withCan 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 scenarioResponse may be specific to the scenario presentedpresented – Research assistants can vary widely in reliabilityResearch assistants can vary widely in reliability – Ethical problem?Ethical problem? Simulated Visits:Simulated Visits: Strengths and WeaknessesStrengths and Weaknesses
- 36. Learning about a Drug Use Problem 36 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 • Use multiple methodsUse multiple methods – Quantitative qualitativeQuantitative qualitative – ““Triangulate” findingsTriangulate” findings – Each method can look at different aspects of aEach method can look at different aspects of a problemproblem
- 37. Learning about a Drug Use Problem 37 Activity 2Activity 2 Designing Qualitative Instruments
- 38. Learning about a Drug Use Problem 38 Activity 3Activity 3 Preparing for a Field Visit
Editor's Notes
- #6: Key point: focus attention on a small number of issues, and use quantitative methods to examine patterns of drug use.
- #7: Key points: What are major causes of problems? What are key barriers to change?
- #8: Key Points: Interventions depend on the causes refined during the diagnosis phase
- #9: Key Points: Follow-up completes the quality improvement cycle.
- #10: Key Points: Drug use encounters are the main focus of attention for learning about therapeutic decisions made by a variety of health providers.
- #11: Key Points: Interventions can target many different decision makers
- #12: Key Points: Primary objective of quantitative method Primary objective of qualitative method
- #13: Key Points: Availability of different methods for studying drug use depending on the situation.
- #14: Key Points: Many sources for quantitative data
- #17: Key Points: The importance of district level as sources of data on public sector drug use.
- #18: Key Point: Different workers in health facilities are aware of different sources of data.
- #19: Key Points: level of detail will depend on where and how data are collected
- #21: Key Point: Different participants may be aware of or have experience in the use of qualitative methods.
- #29: Key Points: Observations can introduce bias in the behaviors of the persons observed, and efforts must be made to desensitize the process before beginning to record data
- #32: Key Points: Questionnaires are useful for many purposes. Here we emphasize using them to measure attitudes, opinions, and beliefs, especially with rating scales and open-ended questions
- #34: Simulated purchases are a form of structured observations
- #35: Key Points: Because the scenario is standardized, the method only measures a limited range of behavior. Varying the scenario systematically can illustrate behavior in responses to a range of likely situations.