Transcript Learning About a Drug Use Problem

Learning about a Drug
Use Problem
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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
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Components of the Drug Use
System
Local
Manufacture
Drug Imports
The Drug Supply
Process
Provider and
Consumer Behavior
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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)
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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
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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
• Feed back 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
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hospital
private practice
pharmacy
home
– health center
– traditional healer
– drug seller
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Who Is a Prescriber?
Or Whose Behavior Do We Change?
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Physicians
Paramedics
Pharmacists
Injectionists
Patients
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Clinical officers
Clinic attendants
Dispensers
Drug sellers
Relatives/friends
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How to Collect Data
• Quantitative Methods
– what? or how much?
– counts
– rates
– classifications
• Qualitative Methods
– why? or how strong?
– opinions
– descriptions
– observations
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Selecting Methods to Study Drug
Use
• Depends on—
– Nature of the problem
– Objectives of collecting data
– Resource availability
– Time available
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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
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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)
– Uondetailed (name only, if injection, etc.)
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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
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Data Available at District Level
• District office
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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
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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 1
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 trained data collectors.
Data analysis is more difficult, but the results can be
very useful.
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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
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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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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 with structured questionnaire
Data analysis can be difficult
Bias toward socially acceptable or expected responses
Requires well-trained interviewers
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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
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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
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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 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
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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
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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
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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
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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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