Trainer's GuideLearning About a

Drug Use Problem

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Learning about a Drug Use Problem

TRAINER'S GUIDE

OBJECTIVES1. Describe a model for developing interventions.

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

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

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

5. Draft qualitative data collection instruments for field visits.

6. Prepare for field visit.

PREPARATION

1. Read the Session Notes.2. MDS Chapter on Investigating Drug Use, Chapter 29, p 430.3. Complete Activity One: Potential Sources of Data on Drug Use4. Select a specific problem or issue to be addressed in Activity Two:

Designing Qualitative Instruments

VISUAL AIDS

1. Title Slide2. Objectives3. Components of the Drug

Use System4. An Overview of the

Process of Changing Drug Use

5. Changing Drug Use Problems: Examine

6. Changing Drug Use Problems: Diagnosis

7. Changing Drug Use Problems: Treat

8. Changing Drug Use Problems: Follow-up

9. Drug Use Encounter10.Who is a Prescriber11.How to Collect Data12.Selecting Methods to

Study Drug Use13.Quantitative Methods

1

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

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 One20.Qualitative Methods21. In-Depth Interviews:

Definition22. In-Depth Interview: Key

Points23. In-Depth Interview:

Strengths and Weaknesses

24.Focus Group: Discussions

25.Focus Group: Key Points26.Focus Groups: Strengths

and Weaknesses27.Structured Observations28.Observations: Key

Points29.Observations: Strengths

and Weaknesses30.Structured Questionnaires31.Questionnaires: Key Points32.Structured Questionnaires:

Strengths and Weaknesses33.Simulated Purchase Visits34.Simulated Purchase Visits:

Key Points35.Simulated Purchase Visits:

Strengths and Weaknesses36.Conclusion37.Activity Two38.Activity Three

2

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

ORGANIZATION AND KEY POINTS OF SESSIONFirst Component

(45 minutes) VA 's 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) VA 's 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 's 19

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 in the activity in detail. Assign groups to think about specific pages.

3

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

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) VA 's 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) VA 's 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 observational methods. Encourage discussion about the issue of bias, on the part of the observer and also how the observer's presence during normal behavior.

Sixth Component (75 minutes) VA 37

Designing Qualitative Instruments

This is a long activity during which participants prepare three draft data

4

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

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 issue that is important in the local environment. Groups can use the examples in the annexes as models for the instruments they develop.

Be sure that the groups adhere to the restrictions on length (1 side of a sheet of paper for the questionnaire and observational form, and 3-4 issues for the in-depth 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 Three: 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 2-3 hours in the field visit.

5

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 1

6

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 2

7

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 3

Emphasize that many types of data about drug use can be collected at any of the points in the drug use system

8

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 4

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 of interest:

Intervention orientationInterdisciplinary approachEvidence-based recommendation

9

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 5

Key point: focus attention on a small number of issues, and use quantitative methods to examine patterns of drug use.

10

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 6

Key points:What are major causes of problems?What are key barriers to change?

11

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 7

Key Points:Interventions depend on the causes refined during the diagnosis phase

12

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 8

Key Points:Follow-up completes the quality improvement cycle.

13

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 9

Key Points:Drug use encounters are the main focus of attention for learning about therapeutic decisions made by a variety of health providers.

14

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 10

Key Points:Interventions can target many different decision-makers

15

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 11

Key Points:Primary objective of quantitative methodPrimary objective of qualitative method

16

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 12

Key Points:Availability of different methods for studying drug use depending on the situation.

17

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 13

Key Points:Many sources for quantitative data

18

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 14

19

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 15

20

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 16

Key Points:The importance of district level as sources of data on public sector drug use.

21

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 17

Key Point:Different workers in health facilities are aware of different sources of data.

22

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 18

Key Points:level of detail will depend on where and how data are collected

23

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 19

24

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 20

Key Point:Different participants may be aware of or have experience in the use of qualitative methods.

25

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 21

26

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 22

27

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 23

28

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 24

29

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 25

30

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 26

31

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 27

32

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 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

33

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 29

34

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 30

35

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 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 open-ended questions

36

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 32

37

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 33

Simulated purchases are a form of structured observations

38

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 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.

39

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 35

40

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 36

41

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 37

42

LEARNING ABOUT A DRUG USE PROBLEM TRAINER'S GUIDE

Slide 38

43