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Session Guide

Learning About aDrug Use Problem

LEARNING ABOUT A DRUG USE PROBLEM SESSION GUIDE

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Learning about a Drug Use Problem

SESSION GUIDE

PURPOSE AND CONTENT

Individual drug use problems take place within a system of drug supply, andwithin a network of beliefs and motivations on the part of providers and patients.To change a problem behavior, we must learn about the behavior itself and alsoabout the determinants which underlie it.

OBJECTIVES[VA1]This unit will develop your ability to:

1. Describe a model for developing interventions.

2. Identify potential sources of data for learning about drug use problems, andevaluate their relative strengths and weaknesses.

3. Understand the importance of studying provider and patient motivations andincentives when developing a program to improve drug use.

4. Appreciate the role of qualitative research methods for learning about druguse behaviors.

5. Develop instruments for field visits.

PREPARATION

1. Read the Session Notes.

2. Complete Activity One: Potential Sources of Data on Drug Use .

It is important that these worksheets are completed, individually, before class sothat the results can be discussed in groups.


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FURTHER READINGS

1. International Network for Rational Use of Drugs, How to Use AppliedQualitative Methods to Design Drug Use Interventions, Working Draft 1996.

2. World Health Organization, Geneva, Qualitative Research for HealthProgrammes, WHO/MNH/PSF/94.3., 1994.

3. World Health Organization, Manual of Group Interview Techniques to Assessthe Needs of People with AIDS, WHO/GPH/TCO/HCS/95.2, 1995

4. World Health Organization & Management Sciences for Health, Guide forImproving the Diarrhoea Treatment Practices of Pharmacists and Lic ensedDrug Seller, WHO/CDD/93.43.

5. Folch-Lyon E, Trost J.F., Conducting Focus Group Sessions, Studies inFamily Planning, 1981, 12 (12), 443-449.


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Learning About a Drug Use Problem

SESSION NOTES

A. CHANGING DRUG USE PROBLEMS: AN OVERVIEW[VA2]

The process of identifying, understanding, and changing drug use problems issimilar to the process of diagnosing and treating a clinical illness.

[VA3]

Changing a Drug Use ProblemAn Overview of the Process

A logical series of activities and questions leads from initial identification of aproblem, diagnosis of its causes through implementation of an intervention to"treat" the problem, to evaluation of the outcomes of an intervention. Thisprocess includes:

1. EXAMINE1. EXAMINEMeasure ExistingMeasure Existing

PracticesPractices(Descriptive(Descriptive

Quantitative Studies)

2. DIAGNOSE2. DIAGNOSEIdentify SpecificIdentify Specific

Problems & CausesProblems & Causes(In-depth Quantitative(In-depth Quantitative& Qualitative Studies)& Qualitative Studies)

3. TREAT3. TREATDesign & ImplementDesign & Implement

InterventionsInterventions(Collect Data to(Collect Data to

Measure Outcomes )Measure Outcomes )

4. FOLLOW UP4. FOLLOW UPMeasure ChangesMeasure Changes

in Outcomes in Outcomes(Quantitative & Qualitative(Quantitative & Qualitative

Evaluation)Evaluation)

improvediagnosis

improveintervention


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[VA4]Examine : Measure Existing Practices

• Identify a priority drug use issue.

- Which potential problems carry the highest clinical risk?- Which involve expensive or widely used drugs?- Which are potentially the easiest to correct?

• Collect data to measure current practices.

- Which source of data will give you the best information?- How large a sample is necessary to get reliable information?- What are the groups of interest e.g., doctors and nurses or

public sector and mission facilities.

[VA5]Diagnose: Identify Specific Problems and Causes

• Describe in detail apparent problems in drug use.

- What specific practices are the problem?- What is an ideal practice?- Who are the most important providers, e.g., the influence

leaders in the community, or those with the best or worst practices?- Are there high risk patients, e.g., pregnant mothers or young

children?

• Identify the apparent causes of the problem.

- What social and cultural factors influence practices?- What do providers know and believe?- What do patients expect when they visit a provider?- How do economic constraints influence providers and patients?

• Identify constraints to change

- What economic factors prevent change?- What drug supply factors will hinder change?- What is the work environment?

[VA6]Treat: Design and Implement Interventions

• Select target behaviors to change, and design an intervention program.

- Which behaviors can be changed most cost effectively?


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- What are the possible economic consequences?- What are the most appropriate interventions, given their different

costs, complexities, and chances of success?- What personnel will be required, and what training will they need?

• Conduct pilot tests to determine the acceptability andeffectiveness of an intervention.

• Implement the intervention and collect data to measure changes.

- Is the intervention implemented as expected?- How are program impacts to be measured?- Are the data reliable?

[VA7]Follow Up: Measure Changes in Outcomes

• Evaluate the intervention's success.

- Was the intervention implemented as planned, e.g., the number ofeducational sessions or supervisory visits?

- What are the measurable changes, e.g., in knowledge, beliefs,patient satisfaction, clinical results, expenditures, etc.?

- How cost effective is the intervention compared to other strategies?- How generalizable are the results to other settings?

• Feed back results to program personnel, to providers, and toconsumers to encourage them to maintain and increasepositive changes.

• Use results to improve the impact of the program or to guide decisionsabout other problems to investigate.


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B. COLLECTING DATA TO LEARN ABOUT DRUG USE[VA8]

The first two steps in the cycle oftreating a drug use problem involvecollecting data to learn about theexact nature of the problem, and tofind out some of its underlyingcauses. We will focus our attentionin this session on the drug useencounter, a term which we use todescribe the period of interactionbetween a health provider who is offering care (including pharmaceuticals) and apatient who is seeking care. Drug use encounters between health providers andpatients can occur in many places including:

• Hospital inpatient units • Hospital outpatient clinics• Health centers • Private physicians' offices• Traditional healers' practices • Licensed pharmacies• Drug retail shops • Marketplace stalls

Drug use encounters may involve many different individuals in recommendingand selecting therapies, including:

[VA9]• Physician • Nurse• Clinical officer • Traditional healer• Injectionist • Dresser /Attendant• Pharmacist • Pharmacy clerk• Shopkeeper • Trader• Patient • Relative or friend

[VA10]Because these situations are so diverse, there aremany quantitative and qualitative methods forcollecting data to learn about drug use problems.The range of possible methods includes recordreviews, prescription surveys, observations, interviews, questionnaires, and soforth. The best method to use in a particular situation depends on:

[VA11]• the nature of the problem

- how complex is the behavior involved?- how much is known about the problem already?


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• the objectives of collecting data- is the objective describing a problem, measuring change, or

monitoring performance?- how much information is needed to choose among possible

interventions?

• the availability of resources- are technical experts available to assist in processing and

analyzing data?- is there an existing source of data?

• the time available- how much time can be spent in gathering data?- is there a need to demonstrate short-term change?

In general, two broad types of data, quantitative and qualitative, are useful foridentifying problems of inappropriate drug use and for learning about theirunderlying causes.

[VA12]QUANTITATIVE METHODSThe type with which we are most familiar, quantitative data, are numeric datacollected in the form of counts, rates, or classifications. Quantitative data arevery useful for finding out what behaviors are happening in a given situation, andhow often they are happening. These data can therefore be used to identifyspecific problems or to measure the success of interventions to change theseproblems.

Opportunities for collecting quantitative data include:

• Routinely reported data -- the least costly alternative if data arealready available, reliable, and suitable to describe the problembeing studied.

• Data gathered from record systems -- large samples of data canoften be collected retrospectively from medical or pharmacyrecord systems at relatively low cost. However the quality of thedata may be low since the data were often collected for otherpurposes.

• Sample surveys -- the most widely used method for collectinghealth data, surveys gather information, once or at multiple pointsin time, about a sample of people, health facilities, or events (e.g.,prescribing encounters).


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Table 1 lists some of the wide range of quantitative data sources that maybe useful in different situations for learning about drug use practices. It isclear that there are many possible ways to measure different aspects ofdrug use.

TABLE 1: SOURCES OF QUANTITATIVE DATA ON DRUG USELOCATION OFDATA

DATA SOURCES USEFUL FOR STUDYING

Public SectorAdministrativeOffices, MedicalStores

RETROSPECTIVE:- drug supply orders- stock cards- shipping and delivery receipts

- aggregate patterns of druguse and expenditures

- comparative use of drugswithin therapeutic classes

- comparative use by different facilities or areas

Health FacilityClinical TreatmentAreas and MedicalRecordDepartments

RETROSPECTIVE:- patient registers- health worker logs- pharmacy receipts- medical recordsPROSPECTIVE:- patient observations- patient exit surveys- inpatient surveys

- aggregate patterns of drug use and expenditures- drug use per case, overall & by group (age, sex, health problem, etc.)- provider-specific prescribing patterns- features of patient- prescriber interaction

Health FacilityPharmacies

RETROSPECTIVE:- pharmacy logs- prescriptions retained in pharmaciesPROSPECTIVE:- patient exit surveys- patient observations

- aggregate patterns of drug use and expenditures- dispensing practices- features of patient-

dispenser interaction

Pharmacies andRetail Drug Outlets

RETROSPECTIVE:- prescriptions retained in pharmaciesPROSPECTIVE:- customer exit surveys- customer observations- "simulated visits"

- private sector prescribing practices drug sales

without prescription- self-medication practices- features of customer- sales attendant interaction

Households RETROSPECTIVE:- family medical records- household surveysPROSPECTIVE:- household drug audits- family medical records

- total community drug use- care-seeking behavior- self-medication practices- family drug use- patient compliance


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TYPES OF QUANTITATIVE DATA[VA13] [VA14] [VA15]Quantitative data can be collected retrospectively (e.g. from stock cards) orprospectively. The data can be aggregate (e.g. monthly drug consumption)or patient specific (e.g. patient records). The diagnosis may be known orunknown depending on the purpose of the study. The drug data may bedetailed (e.g. name, does, amount, duration, cost) or non-detailed (e.g.name of drug only).[VA16]Data are likely to be available at the national, district and health facilitylevel. At the district level, data may be available at the district health office(routine health information system data, routine disease reports, previousdrug surveys or drug orders). At the district store, data on drug supplyorders, stock information and shipping delivery records may be usefulsources of information.[VA17]At health facilities both retrospective and prospective data are likely to beavailable. A range of information may be collected for each drug encounter.The data which could be collected is shown on Table 2.


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Table 2Data from Drug Encounters

• FacilityID EquipmentCharacteristics Drugs Available

• PatientID DateAge GenderSymptoms KnowledgeBeliefs Attitudes

ProviderQualification TrainingAccess to information KnowledgeBeliefs Attitudes

InteractionHistory ExamsDiagnosis Time spentExplanation about Explanation aboutIllness drugs

DrugsName Brand or GenericForm QuantityDuration If dispensedHow labeled CostPatient Charge

Activity One - will give you the opportunity to think about different sourcesof quantitative data, and their strengths and limitations. You should take thetime now to complete Activity One.


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C. QUALITATIVE METHODS TO LEARN ABOUT DRUG USE[VA18]

Quantitative methods describe drug use patterns, or pinpoint specificproblems that need attention. However, quantitative methods are usuallynot good for understanding why these patterns or problems exist.Qualitative techniques are better suited to examine underlying feelings,beliefs, attitudes, and motivations.

Qualitative methods are based on talking to people, or observing theirbehavior. Qualitative methods often involve trained interviewers orobservers. However, managers and policy makers can use qualitativemethods to assess the factors that underlie a problem so that they candecide how to try to solve it. Managers themselves do not need to knowhow to carry out qualitative techniques, but only what these techniques areand how they may be useful.

Some common methods to collect qualitative data on drug use include: in-depth interviews, focus groups, structured observations, structuredquestionnaires, and simulated patient visits. These methods, and theirstrengths and weaknesses, are described briefly below. Examples ofinstruments used in each of these methods are included in the annexes tothis session. Anyone interested in knowing more should read the INRUDmanual How to Use Applied Qualitative Methods to Design Drug UseInterventions or consult another reference appected the use of thesetechniques.

However, in order to change problems effectively, we often need to find outmore about why they are happening. For this purpose, it is helpful to collectqualitative data about the problem in the form of descriptions, ratings,observations, or some other less easily quantifiable form. These qualitativedata allow us to look in more depth at a problem in order to understand itscauses and possible strategies for changing it. Although qualitative dataare not collected as numbers, the content of the data may be organized andanalyzed later according to a structured coding system.


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[VA19]In-depth Interviews

Overview:• an extended discussion

between a respondent andan interviewer based on abrief interview guide thatmight cover between 10-30topics

• the interview is guided by alist of open-ended topics rather than a set of fixed questions, and therespondent is continually probed to provide more depth and detail onthese topics

• issues of interest to the respondent are allowed to emerge as thefocus of the discussion

• often completed with key informants, who may be opinion leaders orother people in a special personal or professional position who areexpected to provide insights into the perspective of a group

[VA20]Scope:

• A few (5-10) in-depth interviews with people who reflect the feelingsof a particular group will often be enough to get a feel for theimportant issues

• if the target population is diverse, generally 5-10 interviews would beheld with members of each important subgroup

[VA21]Strengths:

• helps establish trust between the interviewer and respondent.• can be particularly useful with less educated or illiterate respondents,

and in cultural groups where abrupt, direct questioning is consideredinappropriate

• can generate unexpected insights or new ideas and information,because the topics covered depend on the opinions and feelings ofthe respondent

Weaknesses:• time-consuming compared to more structured questionnaires• analysis of large amounts of open-ended data can be difficult,• key informants may say what is socially acceptable or what they

believe the interviewer wants to hear• interviewers must be well-trained to avoid bias and well-informed

about the material discussedAn example of an in-depth interview guide designed to be used with healthworkers to investigate treatment of ARI is included in Annex 1.


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Focus Group Discussion (FGD)[VA22]

Overview:• moderated discussion

about a defined set oftopics among a smallnumber of participants(usually 6-10) who sharekey characteristics likeage, gender, or job

• focus groups typically last for 1-2 hours, and the conversation isusually recorded so that details can be reviewed later

• participants talk under the guidance of a moderator who keeps thediscussion focused, ensures that everyone participates, and tries toencourage the participants to discuss topics in-depth

• an assistant, who does not take part in the discussion, takes notesabout the topics discussed, points of agreement and disagreement,and the non-verbal interactions of the participants

• an informal location (e.g., restaurant) and a relaxed atmosphereencourages open, free-flowing conversation

[VA23]Scope:

• the number of FGDs conducted depends on the target population; ifthe target population is homogeneous, fewer groups are needed, butif the population is diverse, generally 2-4 groups would be held foreach important subgroup

• subgroups are usually defined on the basis of factors like: urban-rurallocation; level of prescriber training; type and size of health facility; oreven quality of previous practices (e.g., health workers who followstandard treatment norms vs. those who do not)

[VA24]Strengths:

• useful in finding out how people behave and why they behave asthey do

• inexpensive to conduct and quick to organize; often the entireprocess of planning, recruiting participants, holding discussions, andanalyzing data can take place in as little as 2-3 weeks

• the exchange of ideas and the support of other participantsencourage participants to express feelings and beliefs

• can be very useful in anticipating responses to or misunderstandingabout educational materials prepared for an intervention


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Weaknesses:• because participants are not chosen randomly and because only a

few groups are held, opinions and attitudes may not represent thelarger population

• the success of focus groups depends on the skill of the moderator inencouraging meaningful discussion among participants

• the analysis of focus group data can be very subjective and highlyinfluenced by the biases of the analyst

• FGDs are good at finding out the direction of behavior, but they onlyindicate frequency of behavior in very general terms

• some discussions may distort or exaggerate feelings of certainparticipants, or they may be dominated by a few strong-willedindividuals

An example of a moderator's guide for a focus group study examiningtreatment of ARI in public health facilities is included in Annex 2.

STRUCTURED OBSERVATIONS OF PATIENT ENCOUNTERSOverview:

• systematic observations bytrained observers of a series ofencounters between healthproviders and patients

• data can be recorded as a list ofobserved behaviors andimpressions, or by scoring eachinteraction on a predeterminedset of indicators and scales

• in a typical study, a trained observer would first get to know thehealth providers to be observed, and would introduce a non-threatening reason for the observations, in order to make theirbehavior as natural as possible

• observers sometimes keep a diary to record their feelings about thesetting being observed and features of patients or providers thatseem related to observed practices


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[VA26]Scope:

• observation studies vary greatly in scope• if we want to quantify the frequency of certain behaviors, the number

of encounters observed needs to be rather large, at least 30 or morein each category of interest

• if we want to understand the typical features of clinical episodes, afew days' observation in five or six carefully selected settings mightbe enough

Strengths:[VA27]

• FGD’s are the only feasible way to learn systematically about whathappens during the complex interactions between persons seekingcare and medical providers

• they are the best method to study issues like patient demand, theinfluence of sales attendants on customers' selection of products, orthe quality of communication between prescribers and patients

• because health providers are seen in their working environment,observers can gain insights about behavior that are impossible for anoutsider to obtain

Weaknesses:• presence of observers may cause shifts towards socially appropriate

behavior; however, in many settings observers "blend in" over time• observation studies require skilled observers, who can make people

feel at ease, and also be careful and unbiased in reporting theirobservations

• observation is less useful when the behaviors of interest occurinfrequently or for only a subgroup of encounters (e.g., for specificage groups or diagnoses)

Examples of forms that were designed for structured observation ofepisodes of clinical care for malaria patients, and quality of drug dispensingin health facilities are included in Annex 3.


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STRUCTURED QUESTIONNAIRES[VA28]Overview:

• questionnaires contain a fixed set of items that are asked to a largesample of respondents selected according to strict rules to representa larger population

• questionnaires are usually administered by interviewers trained tocollect this kind of information in a standardized way.

• can focus on material that is factual, such as what respondentsknow, or on factors that are harder to quantify like attitudes, opinions,or beliefs

• in contrast to an in-depth interview, all questions are identified inadvance, and each respondent is asked precisely the samequestions

• answers are often limited to a fixed set of response categories; ifquestions are open-ended, they are coded later according to fixedcriteria

[VA29]Scope:

• questionnaire surveys usually include at least 50-75 respondentsfrom the target population

• if the target population has several subgroups with potentiallydifferent levels of knowledge, attitudes, or opinions, then the samplewould usually include at least 50-75 randomly selected persons fromeach subgroup

• the required sample size depends on the nature of the targetpopulation, how the sample is drawn, the desired degree ofaccuracy, and available resources

[VA30]Strengths:

• questionnaires are familiar and understandable to most people,including health managers and respondents

• skills required to develop survey forms, design samples, collect andprocess data, and analyze results are often locally available

• questionnaire surveys are the best method to find out: (1) thefrequency of specific behaviors; (2) the relative strength of differentattitudes and opinions; (3) characteristics of the target population

Weaknesses:• attitudes and opinions are often difficult to quantify• people will sometimes give an answer when asked a direct question,

even if the question is irrelevant or if none of the responses apply• many respondents tend to answer what they feel interviewers expect

to hear


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• results are sensitive to which questions are asked, and how they areworded

• for populations that are not homogeneous, the samples needed arelarge, requiring many interviewers or a long period of time to collectthe data

An example of a brief structured questionnaire designed to survey patientsatisfaction with treatment at a health facility is included in Annex 4.

SIMULATED PATIENT VISITS

[VA31]Overview

• a research assistant, who hasbeen prepared in advance topresent a standardizedcomplaint, visits a healthfacility or pharmacy seekingtreatment

• the objective of the simulatedvisit is to determine how asample of providers will reactto this fixed scenario; what questions they ask, what examinationsthey carry out; what treatments they recommend; what advice theygive

• details of the standard scenario can be systematically varied (e.g.watery vs. bloody diarrhea) to see how the responses of healthproviders change

• simulated visits are frequently used to examine practices in privatepharmacies, where it is more common for customers to seek adviceand treatment without extensive physical examination

[VA32]Scope

• since simulated visit surveys are used to gather quantitativeinformation, they are usually carried out with samples of 30 or morehealth providers

[VA33]Strengths

• simulated patient surveys are relatively quick and easy to organize,and the data are simple to analyze

• very good method for studying practices in the private retail sector,although simulated visits have also been used in out-patient orteaching hospital settings

• particularly useful when combined with provider interviews, in orderto contrast knowledge and reported behavior with actual practice


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Weaknesses• behavior is measured only in response to the scenario presented,

and not in response to the range of situations presented by realpatients

• research assistants can vary widely in their ability to present astandard scenario, and to accurately remember details of theencounter

• some managers and researchers find it an ethical problem to presentfalse information to providers in this way

Examples of two scenarios that could be used to examine treatment fordifferent types of ARI at private drug retail outlets using simulated patientvisits and a form to collect the data from these visits are included in Annex 5.

At the ICIUM conference reports were given of the use of simulated patientsmethod. These were:Evaluation of provider-client interaction in the distribution of oralcontraceptives by private drug outlets in Ghana using the simulated clientmethod; Arhinful DK, Ofori-Adjei Dhttp://www.who.ch/programmes/dap/icium/posters/1b1_fin.html

Undercover careseekers: simulated clients in the study of health providerbehavior in developing countries; Madden IM, Quick JD, Ross-Degnan D,Kafle KK http://www.who.ch/programmes/dap/icium/posters/1b4_text.html

Such a brief introduction to qualitative methodologies is clearly not enoughto understand them fully or to learn to use them effectively. But by usingthese techniques expertise can be gained.

[VA34]CONCLUSIONWhich method to use:

The best method to use will depend on the nature of the problem, what theobjectives of collecting the data are, what resources and time are availableand what the local capacity and experience of studying drug use.

In general it is better to combine quantitative and qualitative methods. Alsoyou should try to use multiple methods to "triangulate" findings. Eachmethod used can look at different aspects of a problem.

Involving social scientists who have expertise in qualitative methods oftenhas major benefits!


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ICIUM Posters

A number of studies presented at the ICIUM meeting demonstrate the use of thetechniques described in this module. These include:

The impact of three forms of educational interventions on dispensing practices,Ameyaw MM, Ofori-AdjeiD, http://www.who.ch/programmes/dap/icium/posters/2B1_TXT1.html,

Improving rational prescribing of physicians: an educational approach for acutediarrhoea in children in Jakarta, Gani L, Tangkilisan A, Pujilestari L,http://www.who.ch/programmes/dap/icium/posters/2b2_text.html,

Prescribing audit with feedback intervention in six regional hospitals and MulagoReferral Teaching Hospital, Uganda, Ogwal-Okeng JW, Anokbonggo WW,Birungi H, http://www.who.ch/programmes/dap/icium/posters/2C3_Text.html

ARI Case management training for appropriate use of antibiotics: the Nicaraguacase, Carries GA, Saenz CJ, Hughhttp://www.who.ch/programmes/dap/icium/posters/2D1,_TXT.html

Interactional group discussion: an innovative behavioral intervention to reducethe use of injections in public health facilities, Hadiyono IEP. Suryawati S. DanuSS, Sunartono, Santoso B, Presenter: Hadiyono JEPhttp://www.who.ch/programmes/dap/icium/posters/2d2_text.html

2D-3. Impact evaluation of self-monitoring of drug use indicators in healthfacilities: experiences from Gunungkidul, Indonesia, Sunartono, Danminto,Suryawati S, Prawitasari J, Bimo, Santoso B [Not yet up]

Rational drug use in rural health units of Uganda: effect of national standardtreatment guidelines on rational drug use, Kafuko JM, Zirabamuzaale C.Bagenda D http://www.who.ch/programmes/dap/icium/posters/2f3_text.html

Other posters can be viewed on the WHO ICIUM site:http://www.who.org/programmes/dap/icium/posters/-txt.html


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ACTIVITY TWO: Designing Qualitative InstrumentsThis activity is designed to give you practice in designing qualitativeinstruments.

ACTIVITY THREE: Preparing for a Field VisitThis activity is designed to prepare you for the field visit which will takeplace on the day following this session. This will give you an opportunity toput into practice what you have learned in this session.


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ACTIVITY ONEPotential Sources of Data on Drug Use

Rationale

There are many different ways to learn about drug use patterns andproblems. Ministries of Health, drug regulatory agencies, drug companies,and private organizations all routinely collect information about drug supply,about disease prevalence, or about the use of drugs. Data may also becollected about the behavior of individual health providers or consumers ofdrugs. Each type of data can be useful in understanding the nature of aproblem and identifying its underlying causes.

This exercise will help you to think about the strengths and weaknesses ofdifferent kinds of data. We will consider both quantitative sources which cananswer the question "What is the frequency and scope of the problem?" andqualitative sources which can answer the question "Why is it happening?"

Instructions

Examine the sources of data listed in the four parts of the Worksheet .Imagine that you want to learn about the frequency and causes ofoveruse of antibiotics in your country . In the spaces provided at theright of the table, write down (1) what kinds of useful data you might gatherfrom each source that could help you understand the problem of injectionoveruse, and (2) some possible advantages and/or limitations of thisparticular source of data for answering your questions.

When evaluating the advantages and limitations of the data, considerfactors like:

• how relevant the data are for learning about antibiotics;• how easy it is to collect this kind of data in your country;• the amount of time and the cost to collect and process the data;• the overall reliability of this type of data.

For example, Part B. of the Worksheet lists under the heading of antibioticPrescribing Practices five possible sources of data, including "previoussurveys of antibiotic practice." From this source, we might obtain thefollowing useful information: historical rates of antibiotic use by healthfacility or geographic area, and possibly use of antibiotics by factors likehealth problem or age. The advantages of using historical survey data arethat they are already collected and have no additional cost. However,limitations include not being able to control exactly which data have beencollected or from where, not knowing whether current practices have


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changed, and having no patient-specific or provider-specific information. Itwould also usually not be possible to learn about dosing of antibiotics.


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ACTIVITY ONE - WORKSHEETQuantitative Sources of Data to Learn about antibiotic Use

DATASOURCE

TYPE OF INFORMATION AVAILABLE

ADVANTAGES/LIMITATIONS

A. Antibiotic Supply or Aggregate Consumption

Drug import recordsmanufacturingrecords

Facility drug supplyorders/ deliveryreceipts

Pharmacy stockcards/ pharmacyledger book

Pharmacy salesreceipts/patientcopayment records

Communityhousehold druguse surveys

Other (describe):


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DATA SOURCE TYPE OF INFORMATION AVAILABLE


B. Antibiotic Prescribing Practice

Previous surveys ofantibiotic practices

Clinical record booksprovider treatmentlogs

Prescription receipts& pharmacydispensing records

Patient medicalrecords

Observations oftreatment episodes

Other (describe):


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DATASOURCE



C. Prevalence of Health Problems Requiring Injections

Routine data fromhealth informationsystem

Patient registers &treatment logs

Patient exitinterviews

Communitymorbidity surveys

Other (describe):


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DATASOURCE



D. Community Use

Household drug usesurveys

Records of privatepractitioners

Observations atprivate pharmacies

Other (describe):


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ACTIVITY TWODesigning Qualitative Instruments

Rationale

There are different ways to learn about the factors that underlie drug use.Qualitative methods can be useful tools for gathering data to fill in ourunderstanding of a problem. Although these methods often involve socialscientists, it is also possible for managers and decision-makers to use themeffectively.

This exercise will help you to become more familiar with one of thequalitative methods for collecting data about drug use. You will develop abrief instrument that will be used to collect data during our second fieldvisit.. You must focus attention on essential information, and consider howitems must be phrased to communicate effectively both with the respondentand the person administering the instrument.

Instructions

During this exercise, we will develop three brief instruments to collectqualitative data about a specific local drug use problem. The group as awhole will be given a locally relevant target problem. For example, we mightfocus attention on polypharmacy, or the unnecessary use of multiple drugs.All of the instruments should be aimed at determining the factors underlyingthe problem, details about specific behaviors involved, or constraints tochanging these problem behaviors.

Each group will be assigned one method, and will develop a very briefinstrument that can be used to collect data about the target problem. Besure your instrument focuses on relevant issues. You should not plan tocollect a large amount of data that does not provide useful information.

Note: During the field work, the instrument you develop will be used byother groups, so be sure that it is clear and easy to implement.

Groups 1 & 4: In-depth Interview

You should develop a short in-depth interview guide that can be used tocollect information from a district medical officer, a health facility manager,or another person responsible for management of health services.Remember to focus your attention on gathering information that is relevantto the target problem.


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You can use Annex One in this session as a model from which to begin.You should plan your interview to take an average of 20-30 minutes toadminister. In that amount of time it is not possible to discuss much morethan 2-3 major topics in some depth, so plan accordingly. Includesuggested probe questions, but remember that the in-depth interview is aflexible tool and will be administered differently with every respondent.

Groups 2 & 5: Structured Observation

You should develop a structured observation form to collect informationduring the clinical encounter between prescriber and patient. Remember tofocus your attention on aspects of the clinical interaction that are relevant tounderstanding the target problem.

You can use Annex Three in this session as a model from which to begin.The form you develop must fit on one side of a piece of paper.

Groups 3 & 6: Structured Questionnaire

You should develop a structured questionnaire to collect information duringan interview with a patient who is exiting from the health facility afterreceiving care. Remember to focus your attention during the interview onaspects of patient knowledge, belief, attitudes, or experience that arerelevant to understanding the target problem.

You can use Annex Four in this session as a model from which to begin.The form you develop must fit on one side of a piece of paper. Onemember of your group who speaks the local language should translate yourform when it is finished. Be aware that it is often difficult to expressconcepts in the same way in two different languages.


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ACTIVITY THREEPreparing for a Field Visit

Tomorrow you will be visiting a number of local health facilities. Thepurpose of these visits is both to observe what the system of care is like inthis area, and also to identify possible sources of quantitative andqualitative data to investigate drug use.

1. Decide who your group leader will be for this visit. Your group leaderwill be expected to introduce the members of the group, explain thepurpose of the visit, and express thanks at the end of the visit.

2. Each group will be assigned to visit one or more facilities. You willuse Worksheets 2 and 3 from the session on the Field Visit to guideyour work. These are similar to the worksheets you used in ActivityOne, but they ask you to record different information. Take a look atthese worksheets now. Your group should meet and decide whatdata they are likely to find at the facility to be visited. Decide withinthe group how you will divide up the work.

During the visit you will not actually be required to collect the data in anysystematic way, but you should be prepared to report on the differentsources of data available.

For quantitative data, look at a number of samples of the different datasources that exist. What kind of information does the data contain? Doesthe data appear to be systematically kept and reliable? Can you think of away that the data could be sampled?

For observational data, identify which interactions you might be able toobserve, and during the visit, try to determine how this could best be done.

For other kinds of qualitative data, discuss who would be involved in suchdata collection, and what methods could be used. At the facility, askpossible target respondents (doctors, paramedics, dispensers, patients) ifthey would be willing to participate and discuss what arrangements wouldneed to be made.

After the field visit, groups should be prepared to present the range of datasources identified during the visit. You should also be prepared to discussdifficulties that you observed in collecting the data.

Remember : the purpose of this visit is to identify the range of datasources which would be available. You will have an opportunity toactually collect, analyze, and present data during the next field trip .


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SAMPLE IN-DEPTH INTERVIEW GUIDE ON TREATMENT OF ARIANNEX 1

Interview for Prescribers

1. Introduction:[interviewer name and general affiliation]

2. Purpose of Interview:I know that respiratory infection is one of the common health problems ofchildren in this community. I am interested in knowing your views aboutARI and how it is managed. It would be very helpful if we could spendsome time together to discuss this issue.

3. General Background:Could you please tell me what your position is in this clinic and for howlong you have worked here?

Probe: - educational background- age- marital status

4. Interview Topics:Clinic ExperienceCan we talk for a while about your work in the clinic? How manypatients do you treat in an average day and what kind of problems dothey have?

Probe: - number of patients are under the age of five- subjective prevalence of respiratory infections- importance of respiratory infections in under-fives

Diagnosis of ARII would like to talk some more about respiratory infections in children.Could you please tell me how respiratory infections usually presentthemselves in children in this community?

Probe: - key signs and symptoms- different forms of presentation- subjective organization of diagnoses- relative prevalence of severe vs. mild ARI

How do you know if a child has a serious respiratory infection?

Probe: - key history questions- physical examinations performed- importance of lab examination


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SAMPLE IN-DEPTH INTERVIEW GUIDE ON TREATMENT OF ARIANNEX 1

Interview for Prescribers (Continued)

Treatment

How would you usually treat a child who has a mild respiratoryinfection?

Probe:- number of drugs prescribed for typical case- names of specific drugs prescribed- use of injections- when is treatment varied- treatment of severe vs. mild respiratory infection

Use of AntibioticsI would like to talk some more about the use of antibiotics in treatingrespiratory infections in different children. What factors determinewhether you give an antibiotic or not?

Probe : - influence of personal experience- mothers expectations- practices of peers- essential drug list- knowledge of standard treatment guidelines

Cost of Treatment (Medications)

How much does it cost on the average to treat a typical case of mildARI in a child?

Probe: - knowledge of cost of different drugs- cost of severe case- problems with ability to pay for some patients/mothers

5. Wrap-up:[Thanks to respondent for time and willingness to participate]

Do you have anything to add to what was already discussed or werethere important topics which were not covered?

Probe:- treatment of ARI- use of antibiotics- anything in general about health care in this facility or in district

[Close interview with thanks.]


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SAMPLE FGD GUIDE ON TREATMENT OF ARIANNEX 2

FGD for Prescribers

1. Introduction[5 minutes: narrative welcoming participants, describing reasons fordiscussion, and setting up the general ground rules for the session]

Ground Rulesa. 60-90 minutes (tape recorded -- observer and note taker)b. Speak clearly and only one participant at a timec. Important that everyone participated. No right or wrong answerse. Maintain confidence in own opinionsf. Assure anonymity and confidentiality

2. DiagnosisCan we talk about how you diagnose different kinds of ARI? In yourexperience, how do prescribers distinguish simple cough from other kinds ofrespiratory illness?

Probe:- Do they depend mostly on clinical features or on laboratory investigations?

- What are some of the distinguishing clinical signs?- What are some of the investigations requested?- What are the common types of ARI seen in this area?- What are some of the signs of a severe respiratory problem?

3. Treatment of CoughLet's talk now about the treatment of ARI at health centers. Can you tell

me some of the drugs that are commonly prescribed to treat ARI?Probe - Are different drugs prescribed for different respiratory problems?

- How do you know which kinds of drugs to prescribe?- Does everyone treat these problems in the same way?- Are some drugs quicker or more powerful than others in treating severe ARI?

4. Patient ExpectationI would like to know more about patients and how they feel about thetreatment they usually receive for ARI. Do patients usually come to thehealth center expecting to get a certain type of treatment?Probe:- Do they show a clear preference for certain kinds of treatment?

- What do they do if they do not get what they expect?- Have you ever tried to convince a patient to accept a treatment they did not want?- Were you able to convince them?- What did you say to convince them?


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SAMPLE FGD GUIDE ON TREATMENT OF ARIANNEX 2

FGD for Prescribers (Continued)

5. Patient Attitudes Towards Specific DrugsI would like to know some more about how patients feel about thedifferent drugs they receive for ARI? For example, how do patients feelabout antibiotics?

Probe:- Do patients know about specific types or brands of antibiotics?

- Do they prefer tablets or injections?- Do they use other remedies/drugs for treating cough?- What are some of these other remedies?- Why do you think they use these remedies/drugs?

6. PolypharmacyI know that many doctors prefer to treat ARI with a number of differentdrugs at the same time. What is your opinion on using multiple drugs totreat ARI?

Probe: - For what type of patients are multiple drugs usually needed?- Is this situation common?- Under what circumstances do you feel that multiple drug therapy is justified?

7. Wrap-up[10 minutes: narrative thanking participants for their help, reviewingsome of the key issues discussed, asking if there were any importantpoints that were not mentioned, and closing group]


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EXAMPLE OF STRUCTURED OBSERVATION FORMSANNEX 3

MALARIA TREATMENT ENCOUNTER OBSERVATION FORM

IDENTIFYING INFORMATION: Sequence #: Date:

Health Facility: _________________________________

Patient Age: < 5 _____ 5-12 ____ > 12 _____ Sex: ______

Provider Type: Doctor _____ CMO _____ Nurse _____

DIAGNOSTIC COMMUNICATION: Prescriber Patient Not Asks Volunteers Discussed

Length of current problem episode? Presence of: fever

headache? malaise? muscle weakness? loss of appetite? chills? vomiting? metal taste in mouth?

Patient mentions malaria? Got previous treatment for this episode? Any previous drugs taken this episode? Last time treated for malaria? Name of drug used to treat last time? ____Patient finished last course of treatment?

EXAMINATION Does NotYes No Apply

Temperature measured? Patient touched for fever? Pulse felt? Sclera of eye examined? Tongue examined? Listens to chest? Palpates abdomen?


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EXAMPLE OF STRUCTURED OBSERVATION FORMSANNEX 3continued

TREATMENTDoes Not

Yes No ApplyInjection given (If injection) Sterile technique followed Advised lab test? Advised exam at different facility? ____Advised return visit if not better?

COMMUNICATION Does NotYes No Apply

Patient asks for:injection? chloroquine? ofantrine?

Provider explains how to use drugs? Provider offers advice on malaria prevention? Provider offers nutrition advice?

PROVIDER-PATIENT INTERACTION Does NotYes No Apply

Patient greets prescriber? Prescriber greets patient? Friendly conversation? Provider gives reassurance to patient? Patient encouraged to describe problem freely? Doctor listens to responses? Provider ends encounter abruptly? Patient appears to want more information?

WRAP-UP

Observer: Length of consultation (mins):

Notes:


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EXAMPLE OF BRIEF STRUCTURED QUESTIONNAIRE

ANNEX 4

PATIENT SATISFACTION SURVEYAdult Patients Exiting Health Facility

1. What is the main illness / complaint for which you came here today toseek treatment?

2. When did you first experience the symptoms of the illness / complaint?

3. What you first felt the symptoms of this illness, what did you do?

4. Is this your first visit to this health facility for this illness?( ) Yes ( ) No

5. Were you told the name of your illness today by the person who treatedyou?( ) Yes ( ) No

If yes: What did the doctor tell you your illness was?

If no: Did you ask the doctor the name of your illness?( ) Yes ( ) No

6. Were you physically examined by the person who treated you?( ) Yes ( ) No

7. Do you feel you had the chance to fully explain your illness to the personwho treated you?( ) Yes ( ) No

8. How many medicines were prescribed for you?

9. How many medicines did you receive from this facility?


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EXAMPLE OF BRIEF STRUCTURED QUESTIONNAIRE

ANNEX 4

PATIENT SATISFACTION SURVEYAdult Patients Exiting Health Facilitycontinued

If patient received medicines, ask to see them, and ask for each drug:

Would you please tell me how you will take this drug?

Name of drug Correct Incorrect

1. __________________________________ ( ) ( )2. __________________________________ ( ) ( )3. __________________________________ ( ) ( )4. __________________________________ ( ) ( )5. __________________________________ ( ) ( )

10. Were you given a prescription so that you could buy a drug outside thisfacility?

If yes: How many drugs were prescribed to buy? __________

11. Were you given an injection during this visit?( ) Yes ( ) No

12. How satisfied are you with your care in this facility today?

Would you say you are very satisfied, a little satisfied, a littledissatisfied, or very dissatisfied?

Very Little Little VerySatis. ( ) Satis. ( ) Dissat. ( ) Dissat. ( )

If a little dissatisfied or very dissatisfied: Could please tell me thethings that you are not satisfied with?

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13. Would you visit this health facility again in case of an illness like theone that brought you here today?

( ) Yes ( ) No

14. What are your suggestions for improving care in this facility?

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EXAMPLE OF SIMULATED PATIENT SCENARIOS AND FORMANNEX 5

SCENARIOS FOR SIMULATED PATIENT VISITS FOR ARI TREATMENT

SCENARIO 1 Two-Year Old Child with Simple Cough and Cold, and aDemanding Parent

SCENARIO: An assessor will present herself as the parent of a two-yearold female child who has had a cough and cold for the last twodays and wanted to buy a bottle of COUGHSUP syrup for thisproblem. COUGHSUP will be identified from key-informantinterviews as one of the more commonly reported dangerouscough and cold syrups being used locally. Care will be takenbeforehand to assure that the assessor uses terms to describethe cough and cold. Other than these facts, no information willbe presented unless asked for by the pharmacy attendant.

In response to questioning, the assessor will provide thefollowing information:

Child's condition: Describe the child as having cough andfever, running nose and not sleeping properly.

Child's cough: Describe as dry (without any sputum), and notassociated with wheezing or any breathing problem.

Has a prescription: Does not have one.

Any medicine Taken: Not any so far.

Why the product was needed: The assessor will respond thatshe used the product last time for a similar condition, and itworked without any problems.

Whether the assessor will consider an alternative product:The assessor will respond that she will consider an alternativeonly if it is better.

ACTIONS: The assessor will take note mentally of:

(1) any questions that the pharmacy attendant asksbefore making a recommendation, including anydiscussion on why the product was needed andconsiderations on an alternative product;


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(2) any explanation about the product finallyrecommended; and,

(3) any advice about how to treat the cough andcold episode.

Any product that is finally recommended should be purchasedin the quantities offered.


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ANNEX 5EXAMPLE OF SIMULATED PATIENT SCENARIOS AND FORM

SCENARIOS FOR SIMULATED PATIENT VISITS FOR ARI TREATMENT(Continued)

SCENARIO 2: Two-Year Old Child with Suspected Pneumonia and aPassive Parent

SCENARIO: An assessor will present herself as the parent of a two-yearold female child who has had cough and fast breathing for thelast one day. Care will be taken beforehand to assure that theassessor uses emic terms to describe the fast breathing. Theassessor will ask the person who waits on her for advice about(1) what illness the child is having and (2) what products arebest to treat this condition. Other than these facts, noinformation will be presented unless asked for by thepharmacy attendant.

In response to questioning, the assessor will provide thefollowing information:

Child's condition: Describe the child as having cough, fastbreathing, no chest in-drawing, and fever.

Has a prescription: Does not have one.

Any medicine Taken: Not taken so far.

ACTIONS: The assessor will take note mentally of:

(1) any questions that the pharmacy attendantasks before making a recommendation,

(2) any explanations about the productsrecommended, and

(3) any other advice about how to treat the fastbreathing episode.

Record the diagnosis made in the "Any Comments" section ofthe Survey Form.

Any products that are recommended should be purchased inthe quantities offered.


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ANNEX 5EXAMPLE OF SIMULATED PATIENT SCENARIOS AND FORM

SCENARIOS FOR SIMULATED PATIENT VISITS FOR ARI TREATMENT

Assessor Name: Date:

Outlet Name Time:

Type of Outlet:

1. Did the drug seller ask: Yes No

a. The age of the child? ( ) ( )b. If child has fast/difficult breathing? ( ) ( )c. If child is able to drink? ( ) ( )d. If child is abnormally sleepy/hard to wake? ( ) ( )e. If child had any convulsions? ( ) ( )f. If child is having fever? ( ) ( )g. Any other advice (describe):

2. Which products were purchased? Write 'NONE' if no purchase.

NAME & PACKAGE SIZE UNITS PRICE

a.___________________________ ____________ ________

b.___________________________ ____________ ________

c.___________________________ ____________ ________

d.___________________________ ____________ ________

3. Describe below the advice given to you on how to take drugs.

DOSE: FREQUENCY: DURATION:teaspoonful/ times per day number of daystab/capsule

Drug a. __________ __________ __________

Drug b. __________ __________ __________

Drug c. __________ __________ __________

Drug d. __________ __________ __________ANNEX 5


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EXAMPLE OF SIMULATED PATIENT SCENARIOS AND FORMSCENARIOS FOR SIMULATED PATIENT VISITS FOR ARI TREATMENT

4. What explanations were given about the drugs purchased?

DRUG SELLER DESCRIBED Drug a. Drug b. Drug c. Drug d.

What drug does

Cautions, side effects

5. Which of the following did the pharmacy attendant advise? (Check asmany as needed)

a. Visit health worker now ( )b. Visit health worker if breathing is fast/difficult ( )c. Visit health worker if child is not able to drink ( )d. Visit health worker if no improvement for two days ( )e. Take full course of the drug purchased ( )f. Continue to give fluids and foods as usual ( )g. Continue to breast feed frequently ( )h. Keep the child warm ( )i. Any other advice (describe)

6. Comments:

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Documents

Session Guide - World Health Organizationarchives.who.int/PRDUC2004/RDUCD/Acrobat_Files/SG_Acrobat_File… · 3. World Health Organization, Manual of Group Interview Techniques to