Learning about a Drug Use
Problem
Trainers Guide
Learning about a Drug Use Problem
TRAINER'S GUIDE
OBJECTIVES
1.
2.
3.
4.
5.
Describe a 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 visits.
Total Time Required: 5 hours, 45 minutes
PREPARATION
1.
2.
3.
4.
Read the Session Notes.
Read Chapter 29, in Managing Drug Supply on investigating drug use (p. 430).
Complete Activity 1: Strengths and Weaknesses of Different Data Sources.
Select a specific problem or issue to be addressed in Activity 2: Designing
Qualitative Instruments.
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
VISUAL AIDS
1. Title Slide
2. Objectives
3. Components of the Drug Use
System
4. An Overview of the Process of
Changing Drug Use
5. Changing Drug Use Problems:
1. Examine
6. Changing Drug Use Problems:
2. Diagnosis
7. Changing Drug Use Problems:
3. Treat
8. Changing Drug Use Problems:
4. Follow up
9. Drug Use Encounter
10. Who Is a Prescriber?
11. How to Collect Data
12. Selecting Methods to Study
Drug Use
13. Quantitative Methods
14. Types of Quantitative Data
15. Where Can We Find Useful
Quantitative Data?
16. Data Available at District Level
17. Data Available at Health
Facilities
18. Data from Drug Encounters
19. Activity 1: Strengths and
Weaknesses of Different Data
Sources
20. Qualitative Methods
21. In-Depth Interviews
22. In-Depth Interview: Key Points
23. In-Depth Interview: Strengths
and Weaknesses
24. Focus Group Discussions
25. Focus Groups Key Points
26. Focus Groups: Strengths and
Weaknesses
27. Structured Observations
28. Observations: Key Points
29. Observations: Strengths and
Weaknesses
30. Structured Questionnaires
31. Questionnaires: Key Points
32. Questionnaires: Strengths and
Weaknesses
33. Simulated Purchase Visits
34. Simulated Visits: Key Points
35. Simulated Visits: Strengths and
Weaknesses
36. Conclusion: Which Method to Use?
37. Activity 2: Designing Qualitative
Instruments
38. Activity 3: Preparing for a Field Visit
ORGANIZATION AND KEY POINTS OF SESSION
First Component
45 minutes
VAs 1-12
Overview of the Process of Changing Drug Use
This session introduces participants to an important model underlying the entire course
the cycle of changing behavior. After discussing the four steps of the cycle of
changing use, emphasize the importance of the first two steps in designing effective
interventions. Use an analogy to clinical medicine to describe these two steps. Step
One, measuring drug use, is like taking a patient history, signs, and symptoms. Step
Two, diagnosing the problem, is like determining etiology and the range of possible
therapies. After these two steps, it is possible to make an informed choice about an
intervention (therapy) that is likely to be effective.
Second Component
45 minutes
VAs 13-18
Sources of Quantitative Data about Drug Use
Participants receive a broad overview of the many kinds of quantitative data that is
possible to collect at various locations in the drug use system: central and district
administrative offices, health facilities, private pharmacies, and in the community.
Encourage participants to think broadly about the range of data available and how
different kinds of data can be used.
Narrow focus at the end of the session to the drug use encounter, and the types of
information it is possible to collect about patients, providers, their interaction, and the
drugs that are prescribe. Explain that the drug use indicator methodology taught in the
course captures only a small part of the possible variety of data about the drug use
encounter.
Third Component
60 minutes
VA 19
Activity 1: Strengths and Weaknesses of Different Data Sources
This activity will help participants think in more detail about the different types of data
available for studying a specific problem. Use of antibiotics is the problem used in the
activity, although this problem can be changed to make the activity fit better in a
particular setting.
Time usually allows for each group to complete only one of the four pages of the activity
in detail. Assign groups to think about specific pages.
In reporting, emphasize differences in reliability, in the ease of data collection, and in the
cost of obtaining the various types of data.
Fourth Component
45 minutes
VAs 20-26
Overview of In-Depth Qualitative Methods
Participants are introduced to two methods for in-depth qualitative assessment: in-depth
interviews and focus group discussions. Emphasize that the purpose of these
techniques is to stimulate respondents to talk at length about a set of issues, rather than
to answer specific questions.
In-depth interviews and focus group guides should be structured to encourage logical,
open discussions of a limited number of ideas, starting with a general question about an
idea then narrowing to specific issues through a series of problems.
Fifth Component
45 minutes
VAs 27-36
Overview of Semi-Structured Qualitative Methods
The semi-structured methods described are specific variations of more general
observation and questionnaire methods. These specific methods have been chosen
because they are especially useful in drug use studies.
Questionnaires are familiar to most participants. Focus attention on how questionnaire
can be used to measure attitudes and opinions, especially through the use of rating
scales and open-ended questions. Use the session evaluation form as an example of
an attitude questionnaire.
Highlight the importance of directly observing behavior during drug use encounters for
in-depth understanding of quality of care. Structured observation protocols and
simulated client visits are two useful observation methods. Encourage discussion about
the issue of bias on the part of the observer and also how the observer's presence
might affect normal behavior (Hawthorne Effect).
Sixth Component
75 minutes
VA 37
Activity 2: Designing Qualitative Instruments
This is a long activity during which participants prepare three draft data collection
instruments (in-depth interviews, observation form, patient exit interviews) to use during
the second field visit. All groups should develop instruments related to a single clinical
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
issue that is important in the local environment. Groups can use the examples in the
annexes (in the back of the Session Guide) as models for the instruments they develop.
Be sure that the groups adhere to the restrictions on length (one side of a sheet of
paper for the questionnaire and observational form, and three or four issues for the indepth interviews).
Support staff should enter the draft instruments in the computer and return the printed
drafts to the groups for editing the following day. After revisions, instruments should be
duplicated for use during the second field visit. Each team should use its own
instrument, as well as instruments developed by other groups for the remaining two
methods.
Seventh Component
30 minutes
VA 38
Activity 3: Preparing for a Field Visit
Describe the field sites that participants will visit the following day, and discuss
necessary logistics, such as assignment of teams to facilities and transportation
arrangements. Remind participants to bring the pages from the activity for Field Visit 1,
which they will need for debriefing.
The purpose of the field visit is to demonstrate to participants the wide variety of ways
they can learn about drug use in a new setting. Ideally each team should visit at lest one
public sector facility (hospital, health center, warehouse, district office) and at least one
private pharmacy. Team members should be encouraged to interview staff and patients,
examine different kinds of records and receipts, and observe the process of care in
different settings. Plan to spend about two to three hours in the field visit.
Slide 1
Learning about a Drug
Use Problem
Slide 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
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 3
Components of the Drug Use
System
Local
Manufacture
Drug Imports
The Drug Supply
Process
Provider and
Consumer Behavior
Hospital or
Health Center
Private Physician or
Other Practitioner
Illness Patterns
Pharmacist or
Drug Trader
Public
Learning about a Drug Use Problem
Emphasize that many types of data about drug use can be collected at any of the points
in the drug use system
Slide 4
An Overview of the Process of
Changing Drug Use
1. EXAMINE
Measure Existing
Practices
(Descriptive
Quantitative Studies)
4. FOLLOW UP
Measure Changes
in Outcomes
(Quantitative & Qualitative
Evaluation)
improve
diagnosis
improve
intervention
2. DIAGNOSE
Identify Specific
Problems & Causes
(In-depth Quantitative
& Qualitative Studies)
Studies)
3. TREAT
Design & Implement
Interventions
(Collect Data to
Measure Outcomes)
Learning about a Drug Use Problem
Move quickly around the cycle, and expand on details in the slides that follow. Make the
analogy to the process of clinical care.
Key points: Intervention orientation, interdisciplinary approach, and evidence-based
recommendation
7
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 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
Key point: Focus attention on a small number of issues, and use quantitative methods
to examine patterns of drug use.
Slide 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
Key points: What are major causes of problems? What are key barriers to change?
Slide 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
Key Points: Interventions depend on the causes refined during the diagnosis phase
Slide 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
Key Points: Follow-up completes the quality improvement cycle.
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
11
Slide 9
Drug Use Encounter
Definition: the interaction between a
provider and a patient when decisions are
made about which drugs to recommend or
use
Where the pill meets the patient
Sites of drug use encounters
hospital
private practice
pharmacy
home
health center
traditional healer
drug seller
Learning about a Drug Use Problem
Key Points: Drug use encounters are the main focus of attention for learning about
therapeutic decisions made by a variety of health providers.
Slide 10
Who Is a Prescriber?
Or Whose Behavior Do We Change?
Physicians
Paramedics
Pharmacists
Injectionists
Patients
Clinical officers
Clinic attendants
Dispensers
Drug sellers
Relatives/friends
Learning about a Drug Use Problem
10
Key Points: Interventions can target many different decision makers
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 11
How to Collect Data
Quantitative Methods
what? or how much?
counts
rates
classifications
Qualitative Methods
why? or how strong?
opinions
descriptions
observations
Learning about a Drug Use Problem
11
Key Points: Emphasize the primary objective of the quantitative method and qualitative
method
Slide 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
12
Key Points: Availability of different methods for studying drug use depending on the
situation.
13
Slide 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
13
Key Points: Many sources for quantitative data
Slide 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
14
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 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
15
Slide 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
16
Key Points: The importance of district level as sources of data on public sector drug
use.
15
Slide 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
17
Key Point: Different workers in health facilities are aware of different sources of data.
Slide 18
Data from Drug Encounters
FACILITY
ID, characteristics, equipment, drugs
available
ID, date, age, gender, symptoms
PATIENT
knowledge, beliefs, attitudes
qualification, training, access to
PROVIDER
information, knowledge, beliefs,
attitudes
INTERACTION exams, history, diagnosis, time spent,
explanation about illness, explanation
about drugs
DRUGS
brand, generic, strength, form, quantity,
duration, if dispensed, how labeled,
cost, patient charge
Learning about a Drug Use Problem
18
Key Points: Level of detail will depend on where and how data are collected
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 19
Activity One
Strengths and Weaknesses of
Different Data Sources
Learning About Drug Use
19
Slide 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
20
Key Point: Different participants may be aware of or have experience in the use of
qualitative methods.
17
Slide 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
21
Slide 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
22
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 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
23
Slide 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
19
24
Slide 25
Focus Groups: Key Points
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
Learning about a Drug Use Problem
25
Slide 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
26
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 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
27
Slide 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
28
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
21
Slide 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
29
Slide 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
30
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 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 5075 respondents from each
important subgroup
Learning about a Drug Use Problem
31
Key Points: Questionnaires are useful for many purposes. Here we emphasize using
them to measure attitudes, opinions, and beliefs, especially with rating scales and openended questions
Slide 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
23
32
Slide 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
33
Simulated purchases are a form of structured observations
Slide 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.
vs.
bloody diarrhea)
Learning about a Drug Use Problem
34
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.
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
25
Slide 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
35
Slide 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
36
TRAINERS GUIDE
LEARNING ABOUT A DRUG USE PROBLEM
Slide 37
Activity 2
Designing Qualitative
Instruments
Learning about a Drug Use Problem
37
Slide 38
Activity 3
Preparing for a Field Visit
Learning about a Drug Use Problem
27
38
