h

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