Download Learning About a Drug Use Problem

Learning About a Drug
Use Problem
1
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 Drug Use
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Components of the Drug Use
System
Local
Manufacture
Drug Imports
The Drug Supply
Process
Provider and
Consumer Behavior
+
Hospital or
Health Center
Illness Patterns
Private Physician or
Other Practitioner
Pharmacist or
Drug Trader
Public
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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
2. DIAGNOSE
Identify Specific
Problems & Causes
(In-depth Quantitative
& Qualitative Studies)
improve
intervention
3. TREAT
Design & Implement
Interventions
(Collect Data to
Measure Outcomes)
Learning About Drug Use
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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?
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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
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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
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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
• Feedback results
– To managers and policymakers
– To staff
– To providers and consumers
• Use results to plan future activities
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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
–at home
– health center
– traditional healer
– drug seller
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Who is a Prescriber?
Or Whose Behavior Do We Change?
•
•
•
•
•
physicians
paramedics
pharmacists
injectionists
patients
•
•
•
•
•
clinical officers
clinic attendants
dispensers
drug sellers
relatives/friends
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How to Collect Data
• Quantitative Methods
– counts
– rates
– classifications
– What? or How Much?
• Qualitative Methods
– opinions
– descriptions
– observations
– Why? or How Strong?
Learning About Drug Use
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Selecting Methods to Study Drug
Use
• Depends on:
– nature of the problem
– objectives of collecting data
– resource availability
– time available
Learning About Drug Use
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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 Drug Use
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Types of Quantitative Data
• When collected
– retrospective
– prospective
• What level
– aggregate
– patient-specific
• Diagnosis information
– known
– unknown
• Drug data
– detailed (name, dose, amount, duration)
– non-detailed (name only, if injection, etc.)
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Where Can We Find Useful
Quantitative Data?
• Administrative Offices, Medical Stores
• Clinical Treatment Areas & Medical
Record Departments
• Health Facility Pharmacies
• Private Pharmacies and Retail Outlets
• Households
Learning About Drug Use
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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
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Data Available at Health
Facilities
• Retrospective
–
–
–
–
patient registers
treatment logs
pharmacy receipts
medical records
• Prospective
– observation of clinical encounters
– patient exit surveys
– inpatient surveys
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Data From Drug Encounters
• FACILITY
• ID, characteristics, equipment, drugs
available
• PATIENT
• ID, date, age, gender, symptoms
knowledge, beliefs, attitudes
• PROVIDER
• qualification, training, access to
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
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Activity One
Strengths and Weaknesses of
Different Data Sources
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Qualitative Methods
• These methods answer the question why. They
provide insights into the reasons for behaviors.
• Types of Qualitative Methods
–
–
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In-depth interviews
Focus Group Discussions
Structured Observations
Structured Questionnaires
Simulated Purchase Visits
• Qualitative methods require skilled trained data
collectors. Data analysis is more difficult than for
quantitative data. But the results can be very useful.
Learning About Drug Use
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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 Drug Use
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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
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In-Depth Interview: Strengths
and Weaknesses
• Strengths
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–
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unexpected insights or new ideas
helps create trust between interviewer and respondent
less intrusive than questionnaire
useful with illiterate respondents
• Weaknesses
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time-consuming compared to structured questionnaire
data analysis can be difficult
bias toward socially acceptable or expected responses
requires well-trained interviewers
Learning About Drug Use
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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
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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 Drug Use
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Focus Groups:
Strengths and Weaknesses
• Strengths
– good at eliciting 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
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Structured Observations
• Definition:
– systematic
observations by
trained observers of
a series of
encounters between
health providers and
patients
.
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Observations: Key Points
• to prepare for study, observer should:
– introduce non-threatening 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
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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 Drug Use
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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
?
?
?
? ? ?
?
?
?
?
?
?
?
?
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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
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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 Drug Use
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Simulated Purchase Visits
• Definition:
– a research assistant,
prepared in advance
to present a standard
complaint, visit
providers seeking
treatment in order to
determine their
practices
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Simulated Visits: Key Points
• usually sample 30+ providers
• collect data on many aspects of practice
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history-taking
examination
treatment
advice
• frequently used to examine practices in
private pharmacies
• scenario can be varied (e.g. watery vs.
bloody diarrhea)
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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?
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Conclusion:
Which Method to Use?
• Best method depends on:
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–
–
–
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
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Activity 2
Designing Qualitative
Instruments
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Activity 3
Preparing for a Field Visit
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