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Session Guide
Learning about a Drug Use Problem

PURPOSE AND CONTENT

OBJECTIVES
PREPARATION
FURTHER READINGS
SESSION NOTES
CONCLUSION
ICIUM POSTERS
ACTIVITIES
VISUAL AIDS
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PURPOSE AND CONTENT

Individual drug use problems take place within a system of drug supply, and within 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 also about the determinants which underlie it.

OBJECTIVES

This unit will develop your ability to:

Describe a model for developing interventions.

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

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

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

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 so that the results can be
discussed in groups.

FURTHER READINGS

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

World Health Organization, Geneva, Qualitative Research for Health Programmes,

WHO/MNH/PSF/94.3., 1994.

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

World Health Organization & Management Sciences for Health, Guide for Improving the
Diarrhoea Treatment Practices of Pharmacists and Licensed Drug Seller, WHO/CDD/93.43.

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

SESSION NOTES

CHANGING DRUG USE PROBLEMS: AN OVERVIEW

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

Changing a Drug Use Problem

A. An Overview of the Process

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

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.

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?

View locally or on the web at http://www.who.int/dap-icium/posters/1a2_txt.html

• 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?

Treat: Design and Implement Interventions

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

- Which behaviors can be changed most cost effectively?

- 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 and effectiveness 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?

Follow Up: Measure Changes in Outcomes

• Evaluate the intervention's success.

- Was the intervention implemented as planned, e.g., the number of educational

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 to consumers to encourage them to
maintain and increase positive changes.

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

B. COLLECTING DATA TO LEARN ABOUT DRUG USE

The first two steps in the cycle of treating a drug use

problem involve collecting data to learn about the exact
nature of the problem, and to find out some of its
underlying causes. We will focus our attention in this
session on the drug use encounter, a term which we use
to describe the period of interaction between a health
provider who is offering care (including pharmaceuticals)
and a patient who is seeking care. Drug use encounters
between health providers and patients 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 recommending and selecting therapies,
including:

• Physician • Nurse

• Clinical officer • Traditional healer

• Injectionist • Dresser /Attendant

• Pharmacist • Pharmacy clerk

• Shopkeeper • Trader • Patient • Relative or friend

Because these situations are so diverse, there are many quantitative

and qualitative methods for collecting data to learn about drug use
problems. The range of possible methods includes record reviews, prescription surveys, observations,
interviews, questionnaires, and so forth. The best method to use in a particular situation depends on:

• the nature of the problem

- how complex is the behavior involved?

- how much is known about the problem already?

• 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 for identifying problems of
inappropriate drug use and for learning about their underlying causes.

QUANTITATIVE METHODS

The type with which we are most familiar, quantitative data, are numeric data collected in the form of
counts, rates, or classifications. Quantitative data are very useful for finding out what behaviors are
happening in a given situation, and how often they are happening. These data can therefore be used to
identify specific problems or to measure the success of interventions to change these problems.

Opportunities for collecting quantitative data include:

• Routinely reported data -- the least costly alternative if data are already available, reliable, and
suitable to describe the problem being studied.

• Data gathered from record systems -- large samples of data can often be collected
retrospectively from medical or pharmacy record systems at relatively low cost. However the
quality of the data may be low since the data were often collected for other purposes.

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

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

TABLE 1: SOURCES OF QUANTITATIVE DATA ON DRUG USE

LOCATION OF DATA DATA SOURCES USEFUL FOR STUDYING

Public Sector RETROSPECTIVE: - aggregate patterns of drug

Administrative Offices, use and expenditures
Medical Stores - drug supply orders
- comparative use of drugs
- stock cards within therapeutic classes

- shipping and - comparative use by

delivery receipts different facilities or areas

Health Facility Clinical RETROSPECTIVE: - aggregate patterns of drug

Treatment Areas and
Medical Record - patient registers use and expenditures
Departments
- health worker logs - drug use per case, overall

- pharmacy receipts & by group (age, sex,

- medical records health problem, etc.)

PROSPECTIVE: - provider-specific

- patient observations prescribing patterns

- patient exit surveys - features of patient-

- inpatient surveys prescriber interaction

Health Facility RETROSPECTIVE: - aggregate patterns of

 Pharmacies - pharmacy logs drug use and expenditures

- prescriptions retained in - dispensing practices

pharmacies
- features of patient-dispenser
PROSPECTIVE: interaction

- patient exit surveys

- patient observations

Pharmacies and Retail RETROSPECTIVE: - private sector prescribing

Drug Outlets
- prescriptions retained practices drug sales without
prescription
in pharmacies
- self-medication practices
PROSPECTIVE:
- features of customer-
- customer exit surveys
sales attendant interaction
- customer observations

- "simulated visits"

Households RETROSPECTIVE: - total community drug use

- family medical records - care-seeking behavior

- household surveys - self-medication practices

PROSPECTIVE: - family drug use

- household drug audits - patient compliance

- family medical records

Types of Quantitative Data

Quantitative data can be collected retrospectively (e.g. from stock cards) or prospectively. The data can be
aggregate (e.g. monthly drug consumption) or patient specific (e.g. patient records). The diagnosis may be
known or unknown depending on the purpose of the study. The drug data may be detailed (e.g. name, does,
amount, duration, cost) or non-detailed (e.g. name of drug only).

Data are likely to be available at the national, district and health facility level. At the district level, data may
be available at the district health office (routine health information system data, routine disease reports,
previous drug surveys or drug orders). At the district store, data on drug supply orders, stock information
and shipping delivery records may be useful sources of information.

At health facilities both retrospective and prospective data are likely to be available. A range of information
may be collected for each drug encounter. The data which could be collected is shown on Table 2.

Table 2

Data from Drug Encounters

Facility

ID Equipment

Characteristics Drugs Available

Patient

ID Date
Age Gender

Symptoms Knowledge

Beliefs Attitudes

Provider

Qualification Training

Access to information Knowledge

Beliefs Attitudes

Interaction

History Exams

Diagnosis Time spent

Explanation about Explanation about

Illness drugs

Drugs

Name Brand or Generic

Form Quantity

Duration If dispensed

How labeled Cost

Patient Charge

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

C. QUALITATIVE METHODS TO LEARN ABOUT DRUG USE

Quantitative methods describe drug use patterns, or pinpoint specific problems that need attention.
However, quantitative methods are usually not 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 their behavior. Qualitative methods often
involve trained interviewers or observers. However, managers and policy makers can use qualitative
methods to assess the factors that underlie a problem so that they can decide how to try to solve it.
Managers themselves do not need to know how to carry out qualitative techniques, but only what these
techniques are and how they may be useful.

Some common methods to collect qualitative data on drug use include: in-depth interviews, focus groups,
structured observations, structured questionnaires, and simulated patient visits. These methods, and their
strengths and weaknesses, are described briefly below. Examples of instruments used in each of these
methods are included in the annexes to this session. Anyone interested in knowing more should read the
INRUD manual How to Use Applied Qualitative Methods to Design Drug Use Interventions or consult another
reference accepting the use of these techniques.

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

In-depth Interviews

Overview:

• an extended discussion between a respondent

and an interviewer based on a brief interview
guide that might cover between 10-30 topics

• the interview is guided by a list of open-ended

topics rather than a set of fixed questions, and
the respondent is continually probed to provide
more depth and detail on these topics

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

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

Scope:

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

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

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 considered inappropriate

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

An example of an in-depth interview guide designed to be used with health workers to investigate treatment
of ARI is included in Annex 1.

Focus Group Discussion (FGD)

Overview:

• moderated discussion about a defined set of topics among a small number of

participants (usually 6-10) who share key characteristics like age, gender, or job
 • focus groups typically last for 1-2 hours, and
the conversation is usually recorded so that
details can be reviewed later

• participants talk under the guidance of a

moderator who keeps the discussion focused,
ensures that everyone participates, and tries to
encourage the participants to discuss topics in-
depth

• an assistant, who does not take part in the discussion, takes notes about 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 atmosphere encourages open,

free-flowing conversation

Scope:

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

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

Strengths:

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

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

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

• can be very useful in anticipating responses to or misunderstanding about

educational materials prepared for an intervention

Weaknesses:

• because participants are not chosen randomly and because only a few groups are
held, opinions and attitudes may not represent the larger population

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

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

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

• some discussions may distort or exaggerate feelings of certain participants, or they

may be dominated by a few strong-willed individuals

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

Structured Observations of Patient Encounters.

 Overview:

• systematic observations by trained observers of a series of

encounters between health providers and patients

• data can be recorded as a list of observed behaviors and

impressions, or by scoring each interaction on a
predetermined set of indicators and scales

• in a typical study, a trained observer would first get to know

the health providers to be observed, and would introduce a non-threatening reason
for the observations, in order to make their behavior as natural as possible

• observers sometimes keep a diary to record their feelings about the setting being
observed and features of patients or providers that seem related to observed
practices

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 more in each category of interest

• if we want to understand the typical features of clinical episodes, a few days'

observation in five or six carefully selected settings might be enough

Strengths:

• FGD’s are the only feasible way to learn systematically about what happens during
the complex interactions between persons seeking care and medical providers

• they are the best method to study issues like patient demand, the influence of sales
attendants on customers' selection of products, or the 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 an outsider 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 their observations

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

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

STRUCTURED QUESTIONNAIRES

Overview:

• questionnaires contain a fixed set of items that are asked to a large sample of
respondents selected according to strict rules to represent a larger population

• questionnaires are usually administered by interviewers trained to collect this kind

of information in a standardized way.
 • can focus on material that is factual, such as what respondents know, or on factors
that are harder to quantify like attitudes, opinions, or beliefs

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

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

Scope:

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

• if the target population has several subgroups with potentially different levels of
knowledge, attitudes, or opinions, then the sample would usually include at least 50-
75 randomly selected persons from each subgroup

• the required sample size depends on the nature of the target population, how the
sample is drawn, the desired degree of accuracy, and available resources

Strengths:

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

managers and respondents

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

• questionnaire surveys are the best method to find out: (1) the frequency of specific
behaviors; (2) the relative strength of different attitudes 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

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

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

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

SIMULATED PATIENT VISITS

Overview

• a research assistant, who has been prepared in advance

to present a standardized complaint, visits a health facility
or pharmacy seeking treatment

• the objective of the simulated visit is to determine how a

sample of providers will react to this fixed scenario; what
questions they ask, what examinations they carry out; what treatments they
 recommend; what advice they give

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

• simulated visits are frequently used to examine practices in private pharmacies,

where it is more common for customers to seek advice and treatment without
extensive physical examination

Scope

• since simulated visit surveys are used to gather quantitative information, they are
usually carried out with samples of 30 or more health providers

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 or teaching hospital settings

• particularly useful when combined with provider interviews, in order to contrast

knowledge and reported behavior with actual practice

Weaknesses

• behavior is measured only in response to the scenario presented, and not in

response to the range of situations presented by real patients

• research assistants can vary widely in their ability to present a standard scenario,
and to accurately remember details of the encounter

• some managers and researchers find it an ethical problem to present false

information to providers in this way

Examples of two scenarios that could be used to examine treatment for different types of ARI at private
drug retail outlets using simulated patient visits 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 patients method. These were:

Evaluation of provider-client interaction in the distribution of oral contraceptives by private drug outlets in
Ghana using the simulated client method; Arhinful DK, Ofori-Adjei D.  View locally   or Access on the Web at:
http://www.who.int/dap-icium/posters/1b1_fin.html

Undercover careseekers: simulated clients in the study of health provider behavior in developing countries;
Madden IM, Quick JD, Ross-Degnan D, Kafle KK View locally  or Access on the Web http://www.who.int/dap-
icium/posters/1b4_text.html

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

CONCLUSION

Which method to use:

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

In general it is better to combine quantitative and qualitative methods. Also you should try to use multiple
methods to "triangulate" findings. Each method used can look at different aspects of a problem.
Involving social scientists who have expertise in qualitative methods often has major benefits!

ICIUM Posters

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

The impact of three forms of educational interventions on dispensing practices, Ameyaw MM, Ofori-Adjei D.
View locally  or access on the web at  http://www.who.int/dap-icium/posters/2b1_txt1.html

Improving rational prescribing of physicians: an educational approach for acute diarrhoea in children in
Jakarta, Gani L, Tangkilisan A, Pujilestari L. View locally  or access on the web at http://www.who.int/dap-
icium/posters/2b2_text.html

Prescribing audit with feedback intervention in six regional hospitals and Mulago Referral Teaching
Hospital, Uganda, Ogwal-Okeng JW, Anokbonggo WW, Birungi H, View locally or access on the web at
http://www.who.int/dap-icium/posters/2C3_Text.html

ARI Case management training for appropriate use of antibiotics: the Nicaragua case, Carries GA, Saenz CJ,
Hugh View locally or access on the web at  http://www.who.int/dap-icium/posters/2D1_TXT.html

Interactional group discussion: an innovative behavioral intervention to reduce the use of injections in public
health facilities, Hadiyono IEP. Suryawati S. Danu SS, Sunartono, Santoso B, Presenter: Hadiyono JEP View
locally or access on the web at http://www.who.int/dap-icium/posters/2d2_text.html

2D-3. Impact evaluation of self-monitoring of drug use indicators in health facilities: experiences from
Gunungkidul, Indonesia, Sunartono, Danminto, Suryawati S, Prawitasari J, Bimo, Santoso B [Not yet up]View
locally or access on the web at http://www.who.int/dap-icium/posters/2D3_TXT.html

Rational drug use in rural health units of Uganda: effect of national standard treatment guidelines on
rational drug use, Kafuko JM, Zirabamuzaale C. Bagenda D View locally or access on the web at 
http://www.who.int/dap-icium/posters/2f3_text.html

Other posters can be viewed on the WHO ICIUM site: http://www.who.int/dap-icium/

ACTIVITIES:

ACTIVITY TWO: Designing Qualitative Instruments

This activity is designed to give you practice in designing qualitative instruments.

ACTIVITY THREE: Preparing for a Field Visit

This activity is designed to prepare you for the field visit which will take place on the day following this
session. This will give you an opportunity to put into practice what you have learned in this session.

ACTIVITY ONE

Potential Sources of Data on Drug Use

Rationale

There are many different ways to learn about drug use patterns and problems. 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 be collected about the behavior
of individual health providers or consumers of drugs. Each type of data can be useful in understanding the
nature of a problem and identifying its underlying causes.

This exercise will help you to think about the strengths and weaknesses of different kinds of data. We will
consider both quantitative sources which can answer the question "What is the frequency and scope of the
problem?" and qualitative 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 of overuse of antibiotics in your country. In the spaces provided at the right of the
table, write down (1) what kinds of useful data you might gather from each source that could help you
understand the problem of injection overuse, and (2) some possible advantages and/or limitations of this
particular source of data for answering your questions.

When evaluating the advantages and limitations of the data, consider factors 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 antibiotic Prescribing Practices five
possible sources of data, including "previous surveys of antibiotic practice." From this source, we might
obtain the following useful information: historical rates of antibiotic use by health facility or geographic area,
and possibly use of antibiotics by factors like health problem or age. The advantages of using historical
survey data are that they are already collected and have no additional cost. However, limitations include not
being able to control exactly which data have been collected or from where, not knowing whether current
practices have changed, and having no patient-specific or provider-specific information. It would also
usually not be possible to learn about dosing of antibiotics.

ACTIVITY ONE - WORKSHEET

Quantitative Sources of Data to Learn about antibiotic Use

DATA SOURCE TYPE OF INFORMATION ADVANTAGES/

AVAILABLE LIMITATIONS

A. Antibiotic Supply or Aggregate Consumption

Drug import records    

manufacturing records

Facility drug supply    

orders/ delivery receipts

Pharmacy stock cards/    

pharmacy ledger book

Pharmacy sales    
receipts/patient co-
payment records

Community household    
drug use surveys
 Other (describe):    

DATA SOURCE TYPE OF INFORMATION ADVANTAGES/

AVAILABLE LIMITATIONS

B. Antibiotic Prescribing Practice

Previous surveys of    
antibiotic practices

Clinical record books    

provider treatment logs

Prescription receipts &    

pharmacy dispensing
records

Patient medical records    

Observations of treatment    
episodes

Other (describe):    

DATA SOURCE TYPE OF INFORMATION ADVANTAGES/

AVAILABLE LIMITATIONS

C. Prevalence of Health Problems Requiring Injections

Routine data from    

health information
system

Patient registers &    

treatment logs
 Patient exit interviews    

Community morbidity    
surveys

Other (describe):    

DATA SOURCE TYPE OF INFORMATION ADVANTAGES/

AVAILABLE LIMITATIONS

D. Community Use    

Household drug use    

surveys

Records of private    
practitioners

Observations at private    
pharmacies

Other (describe):    

ACTIVITY TWO

Designing 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 our understanding of a problem. Although these methods often involve
social scientists, it is also possible for managers and decision-makers to use them effectively.

This exercise will help you to become more familiar with one of the qualitative methods for collecting data
about drug use. You will develop a brief instrument that will be used to collect data during our second field
visit.. You must focus attention on essential information, and consider how items must be phrased to
communicate effectively both with the respondent and the person administering the instrument.

Instructions
During this exercise, we will develop three brief instruments to collect qualitative data about a specific local
drug use problem. The group as a whole will be given a locally relevant target problem. For example, we
might focus attention on polypharmacy, or the unnecessary use of multiple drugs. All of the instruments
should be aimed at determining the factors underlying the problem, details about specific behaviors involved,
or constraints to changing these problem behaviors.

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

Note: During the field work, the instrument you develop will be used by other 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 to collect 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 relevant to the target problem.

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 to administer. In that amount of time it is not possible to discuss much
more than 2-3 major topics in some depth, so plan accordingly. Include suggested probe questions, but
remember that the in-depth interview is a flexible tool and will be administered differently with every
respondent.

Groups 2 & 5: Structured Observation

You should develop a structured observation form to collect information during the clinical encounter
between prescriber and patient. Remember to focus your attention on aspects of the clinical interaction that
are relevant to understanding 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 during an interview with a patient who
is exiting from the health facility after receiving care. Remember to focus your attention during the interview
on aspects of patient knowledge, belief, attitudes, or experience that are relevant 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. One member of your group who speaks the local language should translate
your form when it is finished. Be aware that it is often difficult to express concepts in the same way in two
different languages.

ACTIVITY THREE

Preparing for a Field Visit

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

1. Decide who your group leader will be for this visit. Your group leader will be
expected to introduce the members of the group, explain the purpose 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 will use Worksheets
2 and 3 from the session on the Field Visit to guide your work. These are similar to
the worksheets you used in Activity One, but they ask you to record different
information. Take a look at these worksheets now. Your group should meet and
decide what data they are likely to find at the facility to be visited. Decide within the
group how you will divide up the work.

During the visit you will not actually be required to collect the data in any systematic way, but you should be
prepared to report on the different sources of data available.

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

For observational data, identify which interactions you might be able to observe, 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 such data collection, and what methods
could be used. At the facility, ask possible target respondents (doctors, paramedics, dispensers, patients) if
they would be willing to participate and discuss what arrangements would need to be made.

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

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

SAMPLE IN-DEPTH INTERVIEW GUIDE ON TREATMENT OF ARI

ANNEX 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 of children in this
community. I am interested in knowing your views about ARI and how it is managed. It would be
very helpful if we could spend some time together to discuss this issue.

3. General Background:

Could you please tell me what your position is in this clinic and for how long you have worked
here?

Probe: - educational background

- age

- marital status

4. Interview Topics:

Clinic Experience
 Can we talk for a while about your work in the clinic? How many patients do you treat in an
average day and what kind of problems do they 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 ARI

I would like to talk some more about respiratory infections in children. Could you please tell me
how respiratory infections usually present themselves 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

SAMPLE IN-DEPTH INTERVIEW GUIDE ON TREATMENT OF ARI

ANNEX 1

Interview for Prescribers (Continued)

Treatment

How would you usually treat a child who has a mild respiratory infection?

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 Antibiotics

I would like to talk some more about the use of antibiotics in treating respiratory infections in
different children. What factors determine whether 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 mild ARI 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 were there 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.]

SAMPLE FGD GUIDE ON TREATMENT OF ARI

ANNEX 2

FGD for Prescribers

1. Introduction

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

Ground Rules

a. 60-90 minutes (tape recorded -- observer and note taker)

b. Speak clearly and only one participant at a time

c. Important that everyone participate

d. No right or wrong answers

e. Maintain confidence in own opinions

f. Assure anonymity and confidentiality

 2. Diagnosis

Can we talk about how you diagnose different kinds of ARI? In your experience, how do prescribers
distinguish simple cough from other kinds of respiratory 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 Cough

Let'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 Expectation

I would like to know more about patients and how they feel about the treatment they usually
receive for ARI. Do patients usually come to the health 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?

SAMPLE FGD GUIDE ON TREATMENT OF ARI

ANNEX 2

FGD for Prescribers (Continued)

5. Patient Attitudes Towards Specific Drugs

I would like to know some more about how patients feel about the different drugs they receive
for ARI? For example, how do patients feel about 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. Polypharmacy

I know that many doctors prefer to treat ARI with a number of different drugs at the same time.
What is your opinion on using multiple drugs to treat 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, reviewing some of the key issues
discussed, asking if there were any important points that were not mentioned, and closing group]

Example of Structured Observation Forms

ANNEX 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 Not

Yes No Apply

Temperature measured?

Patient touched for fever?

Pulse felt?

Sclera of eye examined?

Tongue examined?

Listens to chest?

Palpates abdomen?

Example of Structured Observation Forms

ANNEX 3

continued

TREATMENT

Does Not

Yes No Apply

Injection given

(If injection) Sterile technique followed

Advised lab test?

Advised exam at different facility? ____

Advised return visit if not better?

COMMUNICATION Does Not

Yes 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 Not

Yes 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:

Example of Brief Structured Questionnaire

ANNEX 4
 PATIENT SATISFACTION SURVEY

Adult Patients Exiting Health Facility

1. What is the main illness / complaint for which you came here today to seek 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 treated you?

( ) 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 person who treated you?

( ) Yes ( ) No

8. How many medicines were prescribed for you?

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

Example of Brief Structured Questionnaire

ANNEX 4

PATIENT SATISFACTION SURVEY

Adult Patients Exiting Health Facility

continued

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 this facility?

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 little dissatisfied, or very
dissatisfied?

Very Little Little Very

Satis. ( ) Satis. ( ) Dissat. ( ) Dissat. ( )

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

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Would you visit this health facility again in case of an illness like the one that brought
you here today?

( ) Yes ( ) No

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

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________
 ________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

EXAMPLE OF SIMULATED PATIENT SCENARIOS AND FORM

ANNEX 5

SCENARIOS FOR SIMULATED PATIENT VISITS FOR ARI TREATMENT

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

SCENARIO: An assessor will present herself as the parent of a

two-year old female child who has had a cough and cold for
the last two days and wanted to buy a bottle of COUGHSUP
syrup for this problem. COUGHSUP will be identified from key-
informant interviews as one of the more commonly reported
dangerous cough and cold syrups being used locally. Care will
be taken beforehand to assure that the assessor uses terms to
describe the cough and cold. Other than these facts, no
information will be presented unless asked for by the
pharmacy attendant.

In response to questioning, the assessor will provide the

following information:

Child's condition: Describe the child as having cough and fever,

running nose and not sleeping properly.

Child's cough: Describe as dry (without any sputum), and not

associated 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 that
she used the product last time for a similar condition, and it
 worked without any problems.

Whether the assessor will consider an alternative product: The

assessor will respond that she will consider an alternative only
if it is better.

ACTIONS: The assessor will take note mentally of:

(1) any questions that the pharmacy

attendant asks before making a
recommendation, including any
discussion on why the product was
needed and considerations on an
alternative product;

(2) any explanation about the product

finally recommended; and,

(3) any advice about how to treat the

cough and cold episode.

Any product that is finally recommended should be purchased

in the quantities offered.

ANNEX 5

EXAMPLE 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 a Passive Parent

SCENARIO: An assessor will present herself as the parent of a

two-year old female child who has had cough and fast
breathing for the last one day. Care will be taken beforehand to
assure that the assessor uses emic terms to describe the fast
breathing. The assessor will ask the person who waits on her
for advice about (1) what illness the child is having and (2)
what products are best to treat this condition. Other than these
facts, no information will be presented unless asked for by the
pharmacy attendant.

In response to questioning, the assessor will provide the

following information:

Child's condition: Describe the child as having cough, fast

breathing, 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
 attendant asks
before making a
recommendation,

(2) any
explanations
about the
products
recommended,
and

(3) any other

advice about how
to treat the fast
breathing
episode.

Record the diagnosis made in the "Any Comments" section of

the Survey Form.

Any products that are recommended should be purchased in

the quantities offered.

ANNEX 5

EXAMPLE 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 days

tab/capsule

Drug a. __________ __________ __________

Drug b. __________ __________ __________

Drug c. __________ __________ __________

Drug d. __________ __________ __________

ANNEX 5

EXAMPLE OF SIMULATED PATIENT SCENARIOS AND FORM

SCENARIOS 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 as many 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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