Learning about a Drug Use

Problem
Trainers Guide

Learning about a Drug Use Problem

TRAINER'S GUIDE
OBJECTIVES
1.
2.
3.
4.
5.

Describe a model for developing interventions.

Identify and evaluate sources of quantitative data.
Understand the importance of studying provider and patient motivations.
Introduce qualitative research methods.
Develop instruments for field visits.

Total Time Required: 5 hours, 45 minutes

PREPARATION
1.
2.
3.
4.

Read the Session Notes.

Read Chapter 29, in Managing Drug Supply on investigating drug use (p. 430).
Complete Activity 1: Strengths and Weaknesses of Different Data Sources.
Select a specific problem or issue to be addressed in Activity 2: Designing
Qualitative Instruments.

TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

VISUAL AIDS
1. Title Slide
2. Objectives
3. Components of the Drug Use
System
4. An Overview of the Process of
Changing Drug Use
5. Changing Drug Use Problems:
1. Examine
6. Changing Drug Use Problems:
2. Diagnosis
7. Changing Drug Use Problems:
3. Treat
8. Changing Drug Use Problems:
4. Follow up
9. Drug Use Encounter
10. Who Is a Prescriber?
11. How to Collect Data
12. Selecting Methods to Study
Drug Use
13. Quantitative Methods
14. Types of Quantitative Data
15. Where Can We Find Useful
Quantitative Data?
16. Data Available at District Level
17. Data Available at Health
Facilities
18. Data from Drug Encounters
19. Activity 1: Strengths and
Weaknesses of Different Data
Sources
20. Qualitative Methods
21. In-Depth Interviews
22. In-Depth Interview: Key Points
23. In-Depth Interview: Strengths
and Weaknesses
24. Focus Group Discussions
25. Focus Groups Key Points
26. Focus Groups: Strengths and
Weaknesses
27. Structured Observations
28. Observations: Key Points
29. Observations: Strengths and
Weaknesses
30. Structured Questionnaires

31. Questionnaires: Key Points

32. Questionnaires: Strengths and
Weaknesses
33. Simulated Purchase Visits
34. Simulated Visits: Key Points
35. Simulated Visits: Strengths and
Weaknesses
36. Conclusion: Which Method to Use?
37. Activity 2: Designing Qualitative
Instruments
38. Activity 3: Preparing for a Field Visit

ORGANIZATION AND KEY POINTS OF SESSION

First Component
45 minutes

VAs 1-12

Overview of the Process of Changing Drug Use

This session introduces participants to an important model underlying the entire course
the cycle of changing behavior. After discussing the four steps of the cycle of
changing use, emphasize the importance of the first two steps in designing effective
interventions. Use an analogy to clinical medicine to describe these two steps. Step
One, measuring drug use, is like taking a patient history, signs, and symptoms. Step
Two, diagnosing the problem, is like determining etiology and the range of possible
therapies. After these two steps, it is possible to make an informed choice about an
intervention (therapy) that is likely to be effective.
Second Component
45 minutes
VAs 13-18
Sources of Quantitative Data about Drug Use
Participants receive a broad overview of the many kinds of quantitative data that is
possible to collect at various locations in the drug use system: central and district
administrative offices, health facilities, private pharmacies, and in the community.
Encourage participants to think broadly about the range of data available and how
different kinds of data can be used.
Narrow focus at the end of the session to the drug use encounter, and the types of
information it is possible to collect about patients, providers, their interaction, and the
drugs that are prescribe. Explain that the drug use indicator methodology taught in the
course captures only a small part of the possible variety of data about the drug use
encounter.
Third Component
60 minutes
VA 19
Activity 1: Strengths and Weaknesses of Different Data Sources
This activity will help participants think in more detail about the different types of data
available for studying a specific problem. Use of antibiotics is the problem used in the
activity, although this problem can be changed to make the activity fit better in a
particular setting.
Time usually allows for each group to complete only one of the four pages of the activity
in detail. Assign groups to think about specific pages.

In reporting, emphasize differences in reliability, in the ease of data collection, and in the
cost of obtaining the various types of data.
Fourth Component
45 minutes
VAs 20-26
Overview of In-Depth Qualitative Methods
Participants are introduced to two methods for in-depth qualitative assessment: in-depth
interviews and focus group discussions. Emphasize that the purpose of these
techniques is to stimulate respondents to talk at length about a set of issues, rather than
to answer specific questions.
In-depth interviews and focus group guides should be structured to encourage logical,
open discussions of a limited number of ideas, starting with a general question about an
idea then narrowing to specific issues through a series of problems.
Fifth Component
45 minutes

VAs 27-36

Overview of Semi-Structured Qualitative Methods

The semi-structured methods described are specific variations of more general
observation and questionnaire methods. These specific methods have been chosen
because they are especially useful in drug use studies.
Questionnaires are familiar to most participants. Focus attention on how questionnaire
can be used to measure attitudes and opinions, especially through the use of rating
scales and open-ended questions. Use the session evaluation form as an example of
an attitude questionnaire.
Highlight the importance of directly observing behavior during drug use encounters for
in-depth understanding of quality of care. Structured observation protocols and
simulated client visits are two useful observation methods. Encourage discussion about
the issue of bias on the part of the observer and also how the observer's presence
might affect normal behavior (Hawthorne Effect).
Sixth Component
75 minutes
VA 37
Activity 2: Designing Qualitative Instruments
This is a long activity during which participants prepare three draft data collection
instruments (in-depth interviews, observation form, patient exit interviews) to use during
the second field visit. All groups should develop instruments related to a single clinical

TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

issue that is important in the local environment. Groups can use the examples in the
annexes (in the back of the Session Guide) as models for the instruments they develop.
Be sure that the groups adhere to the restrictions on length (one side of a sheet of
paper for the questionnaire and observational form, and three or four issues for the indepth interviews).
Support staff should enter the draft instruments in the computer and return the printed
drafts to the groups for editing the following day. After revisions, instruments should be
duplicated for use during the second field visit. Each team should use its own
instrument, as well as instruments developed by other groups for the remaining two
methods.
Seventh Component
30 minutes
VA 38
Activity 3: Preparing for a Field Visit
Describe the field sites that participants will visit the following day, and discuss
necessary logistics, such as assignment of teams to facilities and transportation
arrangements. Remind participants to bring the pages from the activity for Field Visit 1,
which they will need for debriefing.
The purpose of the field visit is to demonstrate to participants the wide variety of ways
they can learn about drug use in a new setting. Ideally each team should visit at lest one
public sector facility (hospital, health center, warehouse, district office) and at least one
private pharmacy. Team members should be encouraged to interview staff and patients,
examine different kinds of records and receipts, and observe the process of care in
different settings. Plan to spend about two to three hours in the field visit.

Slide 1

Learning about a Drug

Use Problem

Slide 2

Learning about a Drug Use

Problem: Objectives
Describe model for developing interventions
Identify and evaluate sources of quantitative
data
Understand the importance of studying
provider and patient motivations
Introduce qualitative research methods
Develop instruments for field visit

Learning about a Drug Use Problem

TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

Slide 3

Components of the Drug Use

System
Local
Manufacture

Drug Imports

The Drug Supply

Process

Provider and
Consumer Behavior

Hospital or
Health Center

Private Physician or
Other Practitioner

Illness Patterns

Pharmacist or
Drug Trader

Public

Learning about a Drug Use Problem

Emphasize that many types of data about drug use can be collected at any of the points
in the drug use system
Slide 4

An Overview of the Process of

Changing Drug Use
1. EXAMINE
Measure Existing
Practices
(Descriptive
Quantitative Studies)
4. FOLLOW UP
Measure Changes
in Outcomes
(Quantitative & Qualitative
Evaluation)

improve
diagnosis

improve
intervention

2. DIAGNOSE
Identify Specific
Problems & Causes
(In-depth Quantitative
& Qualitative Studies)
Studies)

3. TREAT
Design & Implement
Interventions
(Collect Data to
Measure Outcomes)
Learning about a Drug Use Problem

Move quickly around the cycle, and expand on details in the slides that follow. Make the
analogy to the process of clinical care.
Key points: Intervention orientation, interdisciplinary approach, and evidence-based
recommendation
7

TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

Slide 5

Changing Drug Use Problems:

1. Examine
Identify drug use issue of interest
Highest clinical risk?
Widely used or expensive drugs?
Easiest to correct?

Collect data to describe practices

In all subgroups or interest
Most important prescribers?
High-risk patients?

Learning about a Drug Use Problem

Key point: Focus attention on a small number of issues, and use quantitative methods
to examine patterns of drug use.
Slide 6

Changing Drug Use Problems:

2. Diagnose
Describe problem in detail
Gold standard to assess quality?
Specific problem behavior
Define important providers or patients

Identify determinants of the problem

Knowledge and beliefs
Cultural factors or peer practices
Patient demand and expectations

Identify constraints to change

Economic constraints
Drug supply
Work environment
Learning about a Drug Use Problem

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

Slide 7

Changing Drug Use Problems:

3. Treat
Select target and design intervention

Which behaviors can be changed?

Feasible interventions?
Cost-effectiveness?
Personnel required?

Pilot test
Acceptability
Effectiveness

Implement in stages
Collect process and outcome data
Evaluate impacts
Learning about a Drug Use Problem

Key Points: Interventions depend on the causes refined during the diagnosis phase
Slide 8

Changing Drug Use Problems:

4. Follow Up
Evaluate success in relation to intended outcomes
Was the intervention implemented as planned?
What changes occurred
Was the intervention cost-effective? Transferable?

Consider unintended negative outcomes

Feed back results
To managers and policymakers
To staff
To providers and consumers

Use results to plan future activities

Learning about a Drug Use Problem

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

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LEARNING ABOUT A DRUG USE PROBLEM

11

Slide 9

Drug Use Encounter

Definition: the interaction between a
provider and a patient when decisions are
made about which drugs to recommend or
use
Where the pill meets the patient
Sites of drug use encounters

hospital
private practice
pharmacy
home

health center
traditional healer
drug seller

Learning about a Drug Use Problem

Key Points: Drug use encounters are the main focus of attention for learning about
therapeutic decisions made by a variety of health providers.
Slide 10

Who Is a Prescriber?
Or Whose Behavior Do We Change?

Physicians
Paramedics
Pharmacists
Injectionists
Patients

Clinical officers
Clinic attendants
Dispensers
Drug sellers
Relatives/friends

Learning about a Drug Use Problem

10

Key Points: Interventions can target many different decision makers

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LEARNING ABOUT A DRUG USE PROBLEM

Slide 11

How to Collect Data

Quantitative Methods
what? or how much?
counts
rates
classifications

Qualitative Methods
why? or how strong?
opinions
descriptions
observations

Learning about a Drug Use Problem

11

Key Points: Emphasize the primary objective of the quantitative method and qualitative
method
Slide 12

Selecting Methods to Study Drug

Use
Depends on
Nature of the problem
Objectives of collecting data
Resource availability
Time available

Learning about a Drug Use Problem

12

Key Points: Availability of different methods for studying drug use depending on the
situation.
13

Slide 13

Quantitative Methods
Routine Data
Drug supply or consumption data
Morbidity and mortality reports

Record Systems
Medical records
Pharmacy records

Sample Surveys

Drug use encounters

Provider interviews
Patient & community interviews

Learning about a Drug Use Problem

13

Key Points: Many sources for quantitative data

Slide 14

Types of Quantitative Data

When collected
Retrospective
Prospective

What level
Aggregate
Patient-specific

Diagnosis information
Known
Unknown

Drug data
Detailed (name, dose, amount, duration)
Uondetailed (name only, if injection, etc.)
Learning about a Drug Use Problem

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TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

Slide 15

Where Can We Find Useful

Quantitative Data?
Administrative offices, medical stores
Clinical treatment areas and medical
record departments
Health facility pharmacies
Private pharmacies and retail outlets
Households

Learning about a Drug Use Problem

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Slide 16

Data Available at District Level

District office

Data from routine health MIS

Morbidity and mortality reports
Previous drug use surveys
Drug supply orders

District stores

Drug supply orders

Stock cards
Shipping and delivery receipts
Learning about a Drug Use Problem

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

15

Slide 17

Data Available at Health

Facilities
Retrospective

Patient registers
Treatment logs
Pharmacy receipts
Medical records

Prospective
Observation of clinical encounters
Patient exit surveys
Inpatient surveys
Learning about a Drug Use Problem

17

Key Point: Different workers in health facilities are aware of different sources of data.
Slide 18

Data from Drug Encounters

FACILITY

ID, characteristics, equipment, drugs

available
ID, date, age, gender, symptoms
PATIENT
knowledge, beliefs, attitudes

qualification, training, access to

PROVIDER
information, knowledge, beliefs,
attitudes
INTERACTION exams, history, diagnosis, time spent,
explanation about illness, explanation
about drugs
DRUGS
brand, generic, strength, form, quantity,
duration, if dispensed, how labeled,
cost, patient charge
Learning about a Drug Use Problem

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

TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

Slide 19

Activity One

Strengths and Weaknesses of

Different Data Sources

Learning About Drug Use

19

Slide 20

Qualitative Methods
These methods answer the question why. They
provide insights into the reasons for behaviors.
Types of qualitative methods

In-depth interviews
Focus group discussions
Structured observations
Structured questionnaires
Simulated purchase visits

Qualitative methods require trained data collectors.

Data analysis is more difficult, but the results can be
very useful.
Learning about a Drug Use Problem

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

17

Slide 21

In-Depth Interviews
Definition:
An extended discussion
between a respondent
and an interviewer
based on a brief
interview guide that
usually covers 10-30
topics

Learning about a Drug Use Problem

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Slide 22

In-Depth Interview: Key Points

Open-ended topics explored in depth rather
than fixed questions
Can target key informants, opinion leaders,
or others in special position
5-10 interviews may be enough to get a feel
for important issues
If target group is diverse, generally 5-10
interviews are held with each important
subgroup
Learning about a Drug Use Problem

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TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

Slide 23

In-Depth Interview: Strengths

and Weaknesses
Strengths

Unexpected insights or new ideas

Helps create trust between interviewer and respondent
Less intrusive than questionnaire
Useful with illiterate respondents

Weaknesses

Time-consuming compared with structured questionnaire

Data analysis can be difficult
Bias toward socially acceptable or expected responses
Requires well-trained interviewers

Learning about a Drug Use Problem

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Slide 24

Focus Group Discussions

Definition:
A short (1 1/2 - 2
hour) discussion led
by a moderator in
which a small group
of respondents (6-10)
talk in depth about a
defined list of topics
of interest

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24

Slide 25

Focus Groups: Key Points

Small
5-11 people, promotes equal participation

Homogeneous
Common characteristics, shared viewpoint

Guided
Led by moderator, topics kept in focus

Informal
Free interaction, open sharing of ideas

Recorded
Analysis at later time, notes kept by assistant
Learning about a Drug Use Problem

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Slide 26

Focus Groups:
Strengths and Weaknesses
Strengths
Elicits the beliefs and opinions of a group
Provides richness and depth
Easy and inexpensive to organize

Weaknesses
Need for skilled moderator
Do beliefs and opinions represent true feelings?
Potential bias in analysis

Learning about a Drug Use Problem

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TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

Slide 27

Structured Observations
Definition:
Systematic
observations by
trained observers of
a series of
encounters between
health providers and
patients

Learning about a Drug Use Problem

27

Slide 28

Observations: Key Points

To prepare for study, observer should
Introduce nonthreatening explanation
Spend enough time to "blend in"

Data can be recorded as

Coded indicators and scales
List of behaviors and events
Diary of observer's impressions

Observation studies vary in scope

To count frequency of behaviors, at least 30 cases in each
category
To understand typical features, a few cases in 5-6 settings
may be enough
Learning about a Drug Use Problem

28

Key Points: Observations can introduce bias in the behaviors of the persons observed,
and efforts must be made to desensitize the process before beginning to record data

21

Slide 29

Observations:
Strengths and Weaknesses
Strengths
Best way to study the complex provider-patient
interactions
Can learn about provider behavior in its natural
setting
Best way to learn about patient demand, quality of
communication

Weaknesses
Behavior may not be natural because of
observer's presence
Requires skilled, patient observers
Not useful for infrequent behaviors
Learning about a Drug Use Problem

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Slide 30

Structured Questionnaires
Definition
A fixed set of items
asked to a large
sample of
respondents
selected according
to strict rules to
represent a larger
population

? ?
?
? ? ?
? ?? ??
?
? ?
Learning about a Drug Use Problem

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TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

Slide 31

Questionnaires: Key Points

Nature of questions
Useful for attitudes, opinions, and beliefs as well
as facts
Questions always asked in a standardized way
Can have fixed or open-ended responses

Sample size
Depends on target population, type of sampling,
desired accuracy, and available resources
Usually at least 5075 respondents from each
important subgroup
Learning about a Drug Use Problem

31

Key Points: Questionnaires are useful for many purposes. Here we emphasize using
them to measure attitudes, opinions, and beliefs, especially with rating scales and openended questions
Slide 32

Questionnaires:
Strengths and Weaknesses
Strengths
Best to study frequency of knowledge, attitudes,
population characteristics
Familiar to managers and respondents
Required skills often locally available

Weaknesses
Attitudes often difficult to quantify
Respondents often answer a direct question even
if they have no true opinion
Results sensitive to which questions are asked
and wording
Large surveys can be expensive
Learning about a Drug Use Problem

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32

Slide 33

Simulated Purchase Visits

Definition:
A research assistant,
prepared in advance
to present a standard
complaint, visits
providers seeking
treatment in order to
determine their
practices

Learning about a Drug Use Problem

33

Simulated purchases are a form of structured observations

Slide 34

Simulated Visits: Key Points

Usually sample 30+ providers
Collect data on many aspects of practice

History-taking
Examination
Treatment
Advice

Frequently used to examine practices in

private pharmacies
Scenario can be varied (e.g., watery vs.
vs.
bloody diarrhea)
Learning about a Drug Use Problem

34

Key Points: Because the scenario is standardized, the method only measures a limited
range of behavior. Varying the scenario systematically can illustrate behavior in
responses to a range of likely situations.

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LEARNING ABOUT A DRUG USE PROBLEM

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Slide 35

Simulated Visits:
Strengths and Weaknesses
Strengths
Can compare knowledge & reported practice with
actual practice
Relatively quick & easy to conduct
Data are simple to analyze

Weaknesses
Response may be specific to the scenario
presented
Research assistants can vary widely in reliability
Ethical problem?
Learning about a Drug Use Problem

35

Slide 36

Conclusion:
Which Method to Use?
Best method depends on

Nature of the problem

Objectives of collecting data
Available resources and time
Local capacity and experience

Use multiple methods

Quantitative qualitative
Triangulate findings
Each method can look at different aspects of a
problem
Learning about a Drug Use Problem

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TRAINERS GUIDE

LEARNING ABOUT A DRUG USE PROBLEM

Slide 37

Activity 2

Designing Qualitative
Instruments

Learning about a Drug Use Problem

37

Slide 38

Activity 3

Preparing for a Field Visit

Learning about a Drug Use Problem

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38