Trainer's Guide
Implementing a Drug Use Indicators Study

1. Identify the importance of drug use indicators.

2. Identify steps to be taken in preparing and implementing a drug use indicators study.

3. Understand the strengths and weaknesses of different methods of sampling and data collection.

4. Understand how to analyze drug use practice in a given setting using the drug use indicators.

5. Present the results of a drug use indicator study.

1. Read the Session Notes.
2. Become familiar with the WHO Manual, "How to Investigate Drug Use in Health Facilities." WHO/DAP 93.1
3. Review the slide set included with this module to become familiar with how they illustrate field work during and indicators study.

1. Objectives
2. Types of Drug Use Studies
3. Prescribing Indicators
4. Patient care Indicators
5. Facility Indicators
6. Steps in an Indicator Study
7. Scope of the Indicators Study
8. Indicator Sampling Methods
9. Preparing for a Survey (1)
10. Preparing for a Survey (2)
11. Preparing for a Survey (3)
12. Undertaking the Survey: Preparation
13. Undertaking the Survey: Field Activities
14. Simple Prescribing Indicators Form
15. Detailed Prescribing Indicators Form
16. Prescription 1
17. Prescription 2
18. Prescription 3
19. Prescription 4
20. Prescription 5
21. Prescription 6
22. Patient Care Indicators Form
23. Health Facility Summary Form
24. Facility Indicator Reporting Form
25. Indicators Consolidation Form
26. Graphs of Indicators Data(1)
27. Graphs of Indicators Data(2)
28. Graphs of Indicators Data(3)
29. Graphs of Indicators Data(4)
30. Steps in an Indicator Study: Summary
31. Conclusion
32. Lot Quality Sampling Procedure (optional)
33. LQA's Sampling Table (optional)

ORGANIZATION AND KEY COMPONENTS OF SESSION

First Component

· (60 minutes) 2 VA 's 1-5

Introduction to indicator studies, definitions

At the beginning of the session warn participants that this is a demanding session but one that will give them practical skills that will be useful to them in their future professional lives. In this component provide a brief history of how the indicators came to be developed by INRUD and WHO. Mention the Lancet article, which can be used to confirm that the indicators and methods are internationally recognized.

For the types of drug use studies give examples of the different studies that have been done in different countries.

For the definitions use the WHO manual and quote examples and controversies. For average numbers of drugs mention the examples of co-trimoxazole, and of rifampicin and isoniazid. For injections, comment "if it hurts it’s an injection." For generics discuss the cases of paracetemol (panadol) and aspirin (Acetyl Salicylic Acid ASA). For the EDL or formulary, discuss the need to define in advance what would be an acceptable list. For the patient care indicators, point out that consulting time may be affected by interruptions. For dispensing time suggest the WHO indicator may not be the most useful indicator. A more careful indicator might be dispensing communication time, which is the time the patient is actually communicating with the dispenser after the prescribed drugs have been collected. For facility indicators, point out that there must be a decision made in advance as to which EDL or Formulary would be acceptable.

Second Component

· (15 minutes) 2 No VA's, Use Slides

Use slides from indicator studies in different countries to demonstrate how an indicator study is actually undertaken. Allow comments about the different sites. Point out the range of sources of data, and that in any study different methods may be needed to undertake the study.

Third Component

· (45 minutes) 2 VA's 6-12

Scope, sampling and preparing for an indicator study

Refer to pages 25-31 of the WHO manual to discuss the scope and sampling issues for a survey. Point out that the type of survey will depend on who will use the information and the purpose of the survey. For sampling characterize the most common situation in which 20 facilities are surveyed with 30 prescriptions or observations, which gives results with confidence intervals of ± 7,5% for the entire sample. For an individual facility with 100 prescriptions or observations, the confidence interval would be ± 10%.

Use the VA Steps in an Indicator Study to list out the different steps that are required. Then refer to Chapter 4, pages 32-38, for the different steps of undertaking an indicator study.

When discussing training of field workers refer to Table 5 on Page 35, which describes how the enumerators can be trained. Stress how important it is to conduct field practice to gain shared experience in conducting such surveys.

Fourth Component

· (45 minutes) 2 VA's 14-21

Collecting Prescribing Data

When you review the two data collection forms, highlight that the detailed form is used when field workers are not knowledgeable while the simple prescribing indicators form requires more sophisticated field workers such as pharmacists, nurses, or medical students.

When reviewing the prescriptions refer back to the definitions on Pages 13 and 14 with the explanations on pages 15 and 16. For prescription 4, the final line of the prescription is an instruction to pulverize all of the drugs and put them in separate packets of mixed drugs.

Fifth Component

· (90 minutes) Activity One

Data Collection and Entry

For this activity participants will be given examples of individual case notes and a patient register. Ask participants to select 12 prescriptions from each set of records thus collecting a total of 30 records (including the six prescriptions already coded in the class exercise). For the patient records a simple random selection method can be used; for the patient register, systematic or multistage sampling can be used. For the patient register point out that some of the attendances are reattendances or referrals, and that these should not be included. Also problems occur when it is not possible to interpret or read illegible writing. Before starting there should be agreement on whether the next or the previous records would be used when the selected record is unsuitable for whatever reason. For the data analysis refer to pages 39-41 on which a filled form is completed and the formulas are explained.

For the calculation of the values it is always necessary to check the results as errors are often made in that the denominator varies for different indicators. As this is a long activity it may be useful to take the lunch break during the activity

 

Sixth Component

· (30 minutes) 2 VA's 22-25

Collecting Patient Care and Facility Indicators

Go over the forms that will be used and revisit the definitions of these indicators. Refer to Pages 42 to 44 which have a demonstration form completed and the formulas explained. Point out that the consolidation form on Page 73 has a column labeled "Impartial information" should be used for availability of EDL or formulary.

Seventh Component

· (45 minutes) Activity Two

Presenting results at a facility

For this activity each group should be assigned a facility and prepare to present a commentary on the results of a survey. Use a role-play format to allow two randomly selected groups to present their results. With this format the difficult questions raised by participants can be discussed. Common questions relate to workload and drug supply issues. Use this opportunity to discuss how important cultural sensitivity is when making criticisms. Give advice about starting with a positive comment, and encouraging the facility staff to give their won interpretation of the data from their facility.

Eighth Component

· (30 minutes) 2 VA's 26-29

Reporting an Indicator study

For this component a short lecture is given on how to present the results. Focus on reporting at district level. The key points to emphasize is that in any indicator study there are usually a few (2-3) good facilities, a few (2-3) problem facilities, and that most (14-16) are average. However the average may still be unacceptable e.g. short dispensing times or low patient understanding. The issue of the "gold standard" of performance needs to be discussed in this stage of the session. Point out that work is being done in Nigeria by Ambrose Isah to begin to address this issue.

Ninth Component

· (30 minutes) 2 VA's 30-31

Logistic Planning for Field Work and Conclusion

Use this component to recap the different steps in conducting a survey by focussing on what will happen during the practical field visit, which will happen the next day.

When concluding point out that the method presented has been tested and used in many different countries and that it is now the standard method.

Conclude by recognizing that this has been a long and demanding session but it is a crucial component of the course.

Back to top | Back to Table of Contents