Drug and Therapeutics Committee Session 8. Understanding the Problems

Drug and Therapeutics
Session 8. Understanding the Problems
Associated with Medicine Use—
Qualitative Methods
 Introduction
 Applying qualitative methods to medicine use
 Qualitative methods
Focus group discussions
In-depth interviews
Structured observations
Structured questionnaires
 Activities
 Summary
Introduction (1)
 Quantitative study methods identify presence of
medicine use problems
 Indicator studies
 Aggregate data: DDD, ABC, VEN
 Record review and DUE
 What else is needed to plan an intervention?
 Need to know why the problem exists, that is,
qualitative methods
Introduction (2)
 Four qualitative study methods
Focus group discussions
In-depth interviews
Structured observations
Applying Qualitative Methods (1)
 Complement results of a quantitative study
 Explore a topic about which little is known
 Provide background data before
developing training materials for a planned
educational intervention and for
developing managerial and regulatory
Applying Qualitative Methods (2)
Example of using qualitative methods
 Prescribing by brand name was very popular at the
district hospital. Despite numerous interventions
including face-to-face discussions, in-service education,
policy and procedures changes, physicians continued to
prescribe by brand name.
 Using qualitative methods, investigators discovered that
physicians were receiving educational “benefits” from
pharmaceutical companies in exchange for
theicorrected once the reasons for the medicine use
behavior became known.
Some Factors Influencing
Medicine Use
of Industry
Workload &
With Peers
Authority &
Focus Group Discussions (1)
 A short discussion (1–2 hours) led by a
moderator in which a small groups of
respondents (6–10) talk in depth about topics of
 A trained moderator leads the discussion and
encourages participants to reveal underlying
opinions, attitudes, and reasons for the problem
being studied
 The discussion is recorded and analyzed to
identify key themes and issues
Focus Group Discussions (2)
 6–10 participants who share similar
characteristics (e.g., age, gender, type of work)
 Locale convenient to participants and one in
which they will feel comfortable
 Number of focus groups discussions should be
sufficient to gain the views of all the various
target groups involved in the medicine use
 Moderator and recorder must be skilled and
Focus Group Discussions (3)
 Advantages
 Relatively cheap and easy to organize
 Identifies a range of beliefs and ideas
 Disadvantages
 Group may not represent the larger population
 Success depends on the skill of the moderator
In-depth Interview (1)
 An extended discussion between a respondent
and an trained interviewer (who is
knowledgeable about the topic) based on a
brief interview guide that usually covers 10–20
 The interview is flexible and often unstructured
 The questions are open ended to encourage
the interviewee to talk at length on the topic of
 5–10 interviews with each important subgroup,
often opinion leaders and key informants
In-depth Interview (2)
 Advantages
 Can develop trust between interviewer and
 Possible to probe deeper and therefore gain
unexpected insights or new ideas
 Can reveal unsought, but significant, data
 Disadvantages
 Generates lots of data and analysis may be
difficult and time consuming
 Interviewees may give answers they think the
interviewer wants to hear
Structured Observation (1)
 Systematic observations by trained observers of
a series of encounters between health providers
and patients
 Observers record in structured manner behaviors
and impressions they witness during the
encounters or they record a score for each
observed interaction
 Data may be recorded as coded indicators and
scales or lists of behaviors and events, and then
frequency of behaviors may be calculated
Structured Observation (2)
 To prepare for the study, the observer should
provide a nonthreatening explanation and spend
time “blending in”
 At least 30 encounters should be observed to
calculate the frequency of behaviors
 At least 10 sites should be visited to observe
Structured Observation (3)
 Advantages
 Best way to study the complex provider-patient
interactions, including patient demand and quality of
 Can learn about provider behavior in natural setting
 Data on actual—rather than reported—behavior collected
 Disadvantages
 Observed providers may modify their behavior because
of observer’s presence
 Requires skilled, patient observers
 Inappropriate for infrequent behaviors
Structured Questionnaire (1)
 A fixed set of questions asked to a large sample of
respondents selected according to strict rules to
represent a larger population
 The questions have a fixed set of responses or
options to collect the desired information in a
standard way from all respondents
 The questionnaire may be administered by an
interviewer or filled out alone by the respondent
Structured Questionnaire (2)
 At least 50–75 respondents from each target
 Respondents chosen randomly
 Training and supervision of interviewers required
 Questions asked in a standardized way; no
leading questions
Structured Questionnaire (3)
 Advantages
 Best for measuring strength and frequency of
attitudes, beliefs, knowledge, and population
 Can generalize to a wider population
 Disadvantages
 Does not uncover the unexpected
 Sensitive to the way questions are phrased leading to
possible bias; respondents may answer even when
they have no true opinion
 Large surveys are expensive
Activity 1
 What qualitative methods can be used to
investigate the reasons underlying a particular
 What questions should be asked in—
 An in-depth interview with a prescriber?
 A questionnaire with an exiting patient?
 What activities should be observed during the—
 Consultation
 Dispensing process
 Group work followed by plenary discussion
Activity 2
 Antibiotic consumption in your hospital is high and
often unnecessary, according to a recent prescription
 Each group will develop one qualitative instrument to
investigate the reasons underlying antibiotic overuse
 In-depth interview with prescribers
 Structured interviews with exiting patients
 Structured observation of the consultation
 Each group to role-play based on the instrument
 During each role-play, everyone to note the following:
 Was the instrument clear?
 Did the instrument detect an underlying motive?
 Before an intervention can be designed to correct
poor practice or irrational use of medicines, need
to know why that behavior is occurring
 Qualitative methods should be used to investigate
the behavior from different perspectives and with
regard to different actors (e.g., patients, staff)
 Triangulation of results using different methods
should be done to identify the major reasons
underlying a particular behavior