Methodology issue in the evaluation of the quality

Journal of Advanced Nursing, 1997, 25, 753–759

Methodological issues in the evaluation of thequality of public health nursing: a case study ofthe maternal and child health centres inHong Kong

Dr Sheila Twinn PhD BA PGCEA RN RSCN RHV

Senior Lecturer, Department of Nursing, Faculty of Medicine, The Chinese University ofHong Kong, Shatin, Hong Kong

Accepted for publication 19 April 1996

TWINN S. (1997) Journal of Advanced Nursing 25, 753–759Methodological issues in the evaluation of the quality of public health nursing:a case study of the maternal and child health centres in Hong Kong.The demand for the evaluation of the quality of patient and client care hasincreased in public health nursing as in all disciplines of nursing. In Hong Kongthis demand led to the development of a collaborative study with theDepartment of Health to evaluate the quality of public health nursing in thematernal and child health centres. A multiple case study design was developedto undertake the research using both qualitative and quantitative methods ofdata collection. The findings from the study demonstrated not only implicationsfor clinical practice which have been reported elsewhere, but alsomethodological issues for the evaluation of care. These findings indicate threemajor issues for consideration. The first issue is that of the cultural context ofcare which includes perceptions of care such as demands on the service andexpectations of care. The second issue is the use of health data, including boththe methods of recording as well as the sources of data. The final issue is that ofthe method of data collection, in particular the implications of the use oflanguage in data collection tools. The findings suggest that both the use ofprofessional language and the need for translation have implications for datacollection methods. Indeed in the author’s view the development ofmethodologies for the evaluation of care must address culturally specific issues,particularly where English is not the first language of subjects in the study. Inaddition the use the use of language in the method of data collection highlightsmore general issues raised by the use of translation in the collection andanalysis of qualitative data.

level include the growth of consumerism and increasingINTRODUCTION

expectations amongst patients and clients. The legislationof individual countries such as the National Health ServiceThe demand for the evaluation of health care has arisen

at both an international and local level in response to a and Community Care Act 1990 in the United Kingdom(UK) has also contributed to this demand since therange of different factors. These factors include policy

documents from organisations such as the World Health legislation requires providers to measure the quality ofcare.Organisation (WHO), in which health care providers of

member states are required to evaluate the quality of care Although authors such as Griffiths (1995) argue the slowdevelopment of outcome measurement in the evaluation(Roemer & Montoya-Aguilar 1988). Factors at a more local

753© 1997 Blackwell Science Ltd

S. Twinn

of nursing care, the extent to which outcomes have been developmental screening programs, health advice andcounselling and more general advice about child rearingdeveloped within the process of quality assurance varies

amongst the different disciplines of nursing. Generally practice and family health.The centres are extremely well used with #92% of fam-nursing in the community is less well developed than the

acute sector. Some authors (Zlotnick 1992, Barriball & ilies with young children accessing the service (DoH 1994).Indeed an average attendance at a clinic session is aroundMackenzie 1993) attribute this phenomenon to the diffi-

culties of measuring the quality of nursing care in the com- 200 children. Evidence such as this highlights once morethe cultural dichotomy present in the provision of healthmunity. In particular these difficulties relate to defining

standards in practice and the role played by factors outside care. It was from this background that a study was devel-oped collaboratively with the public health nursing div-the domain of nursing in determining the quality of care.ision of the Department of Health in Hong Kong. The aimof the study was to evaluate the effectiveness of care pro-

Public health nursingvided by the maternal and child health centres in meetingthe needs of families with young children.The situation in public health nursing, a discipline of nurs-

ing in the community, is perhaps more complex, withdifficulties in identifying appropriate outcome measures

THE STUDYbeing clearly acknowledged (Zlotnick & Gould 1993,Goodwin 1994). Despite these complexities the demand Three objectives were identified to meet this aim. The first

was to establish the extent to which the centres met thefor quality care measures in public health nursing remainsand Hong Kong is no exception in demanding high quality health needs of women, infants and young children, the

second to identify practitioners’ and clients’ perceptionsservice provision from public health nursing. However,the implications of the evaluation process for different cul- of care provided by the centre and lastly to develop a set

of tools to measure the effectiveness of nursing care in thetural groups within this discipline of nursing provides animportant focus for consideration. centres. In order to achieve these objectives a case study

design was developed using the interpretation of the meth-odology proposed by Yin (1994). Yin differentiates

BACKGROUND TO THE STUDYbetween the use of a single and multiple case studyapproach and for this particular study it was decided thatAlthough Hong Kong has been a British colony since 1842,

#98% of the 6·5 million population are Chinese and con- a multiple study was most appropriate, using bothquantitative and qualitative methods of data collection.tinue to retain traditional Chinese cultural values (Lau &

Kuan 1988). However, the influence of the British colonial The use of a multiple case study design requires theresearcher to identify an appropriate number of cases forsystem is witnessed in the structure of health care pro-

vision where the legitimised system is that of a western the study. In this study, because of its collaborative nature,the number of cases were determined jointly with themodel. Alongside this approach to care the use of tra-

ditional Chinese medicine continues, with individuals fre- Department of Health. Subsequently, following consider-ations of service provision, one maternal and child healthquently accessing both forms of care (Lee & Cheung 1989,

Hedley et al. 1990), perhaps reflecting a dichotomy of cul- centre from each of the four health regions of the Territorywas selected as a case study. In each of the case studiestural values in the Territory. This situation is likely to be

exacerbated when Hong Kong returns to Chinese sover- the unit of analysis consisted of four different groups ofindividuals: clients, nurses, doctors and administrativeeignty in 1997. An indication of the outcome of this

approach to care is, however, reflected by the health indi- personnel. Because of resource implications and the inter-ests of the researchers the study focused on clients’ andces of the Territory which for example has an Infant

Mortality Rate (IMR) of 4·7 per 1000 live births in 1993 nursing staff ’s perception of the service.(DoH 1994).

Nursing practice presents a similar pattern adopting aData collection

western philosophy and approach to care in both the acutesector and nursing in the community. Public health nurs- The data collection consisted of four stages within each of

the case studies. However, prior to data collection aing, the most well established nursing service in the com-munity sector, was initially modelled directly on the briefing visit was carried out to each of the study centres

in order to explain the study and provide the opportunityhealth visiting service provided in the UK (DoH 1992).Public health nurses participate in a range of nursing for staff to ask questions. The researchers considered this

process important for two reasons. Firstly generally littlepractice, of which the maternal and child health centresprovide an important focus. These centres provide free research had been undertaken in nursing in Hong Kong,

and secondly because of the possible concerns respon-heath care to antenatal women and children up to the ageof five. The provision of care includes immunisation and dents associate with the purpose of evaluation research

754 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759

Public health nursing in Hong Kong

(Tones & Tilford 1994). This second reason was included Cantonese as a first language, being the parent ofthe child, the child having no known abnormality and theparticularly important since the informal feedback given

to one of the researchers during the early stages of parent having attended the centre and been interviewedby the nursing staff on at least four occasions. Using thesethe study clearly demonstrated some concern amongst

practitioners as to the purpose of the study. criteria 8 clients were interviewed from each of the fourcentres providing a sample of 32 informants, two of whomwere fathers. The interviews, carried out in Cantonese,Epidemiological survey

The first stage of data collection involved an epidemiological were translated into English and transcribed. Although asmall sample, the informants came from a range of socioe-survey of women and children living within the catchment

area of the study centres. This proved very time consuming conomic groups and provided a range of different percep-tions of the service. Interestingly only one client refusedas no readily accessible data sources were maintained. Data

such as immunisation rates are collected on a Territory wide to participate in the study, stating that she had insufficienttime to be interviewed.basis and only include those children attending the maternal

and child health centres. Child protection data is collected The criteria used for selecting the purposive sample ofnurses included factors such as professional qualifications,from the perspective of the perpetrator rather than the

abused child, contributing to the difficulty of identifying the perceptions of service provision, years of professionalexperience and perceived attitudes to practice. The codedlocation of children at risk of being abused.

Although the nursing staff collect other health data which questionnaires were used to select participants meetingthese criteria. In each of the four centres, four nurses wereare entered into the child’s record, there was no computeriz-

ation of records nor systematic method of maintaining con- selected for interview and all agreed to participate, givinga total of 16 informants. Although informants were givensistency of the type of data entered onto the records. This

situation demanded a manual search of the records and due the choice of being interviewed in Cantonese or English,all but three of the sample elected to be interviewed into the high attendance rates at the centres a systematic sam-

pling method was used with every tenth record being Cantonese. The interviews were transcribed and translatedinto English where necessary.sampled. This method of sampling provided data on socioe-

conomic factors, including housing, and some crude dataon health factors such as health during pregnancy, father’s

Analysishealth and the perinatal health of the baby.

Data analysis consisted of two stages consistent with themethodology suggested by Yin (1994). The first stage

Questionnairefocused on the data collected in the individual case study,using descriptive statistics to analyse the quantitative dataThe second stage of the study involved a coded confiden-

tial questionnaire consisting of closed and open questions and content analysis to analyse the qualitative data obtainedfrom the interviews and questionnaires. The second stageadministered to a total population sample of 42 qualified

nursing staff within each of the study centres, including involved a cross case analysis of these data to enable patternmatching and the development of policy implications. Themidwives, enrolled nurses, registered nurses and nursing

officers. 41 of these nurses completed the questionnaire findings from the data analysis demonstrated the signifi-cance of issues such as the nurses’ perceived role in clinicalgiving an overall response rate of 97%. The question-

naire included demographic data, including professional practice, staffing levels, resources, the organisation of thecentre and the requirement for a health needs data base inqualifications and experience, as well as questions about

the nursing staff’s perception of the health needs of clients, evaluating the outcome of nursing care.These findings not only have implications for clinicalthe organisation of the service and professional support.

The next stage of the study involved a structured telephone practice, but also for the methodology used to evaluate thequality of care. The implications of the findings for clinicalinterview with a systematic sample of non-attenders from

each study centre. It was interesting to observe that of those practice have been reported elsewhere (Twinn 1994). Thispaper therefore focuses on the methodological issues21 (64%) families who responded to the interview, of the

18 (86%) who had children living in Hong Kong, all were which emerged from the study within the context of theevaluation of the quality of nursing care.accessing child health care at either a private clinic or

another government centre.

METHODOLOGICAL ISSUES IN THEInterviews EVALUATION OF THE QUALITY OF

NURSING CAREThe final stage of the study involved a semi structuredinterview with a purposive sample of nurses and clients. From undertaking this case study three particular issues

emerged which in my opinion have implications for theThe criteria used for selection of the client sample

755© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759

S. Twinn

methodology used in evaluating the quality of nursing tions about the appropriateness of selecting waiting timesas a measure of the quality of service provision. This iscare. The first of these issues can be described as the cul-

tural context of the evaluation of nursing care. The second particularly so where people with health problems havebeen raised in a tradition of queueing for several hours toissue relates to the use of health data and the third issue

the methods of data collection, in particular the use of ensure being seen by a doctor in the government runGeneral Outpatient Clinics (GOPC).language. Although the first two of these issues have par-

ticular relevance in developing methodologies for the Issues such as this demonstrate the importance of sel-ecting culturally appropriate criteria in measuring theevaluation of care, the third issue raises more general ques-

tions about methodology, in research as well as evaluation, quality of care. In addition the findings demonstrated theinformants reluctance to make demands on the nursingand consequently provides the final focus of the

discussion. staff. A major theme to emerge from the content analysisdemonstrated parents’ concern that nurses had little timeavailable to answer their questions. Parents also stated they

The cultural context of the evaluation of nursingfelt unable to ask questions because of the queues of

careparents waiting to see the nurse.

The cultural context of evaluation studies has implicationsLack of expectations The second factor identified within

not only for research undertaken outside the UK, but alsothe context of perceptions of care is that of lack of expec-

for research undertaken with ethnic minority groupstations in relation to health care. A third of the parent

within the UK, particularly where English is not the firstsample, when asked to describe methods of improving the

language of those individuals. Indeed Nelson et al (1994)service defined it as ‘good enough’ and could not identify

suggest that there is a tendency for researchers ‘to excludeareas for change. Other studies have demonstrated similar

subjects who do not fit neatly into the prevailing culture’.findings with different levels of expectations about service

Leininger (1991) develops this idea further in her debateprovision amongst different cultural groups (Kelley &

about the significance of culture to caring and the impli-Alexander 1991). It is perhaps also significant for the

cations of culture in defining and determining care. Indeeddevelopment of evaluation methodologies that respon-

she argues that the influence of culture on the perceptionsdents expressed surprise at being asked this question, sug-

of care is fundamental to identifying the process of caregesting that generally they did not expect to participate in

and therefore the evaluation process. Although within thisthe planning of health care. It is, however, important to

study the cultural context of the evaluation of care focusesacknowledge that similar findings have emerged in

predominantly on perceptions of care, more general factorsresearch with other cultural groups, where evidence indi-

such as the privacy during the provision of care and par-cates that consumers of health care demonstrate ambiv-

ticipation in research studies were also considered asalence about their participation and involvement in the

implications for the development of the methodology forplanning of care (Waterworth & Luker 1990)

the evaluation of care.Attitude of nursing staff The third factor in determiningperceptions of care related to the attitude of nursing staff.

Perceptions of careOf those 18 (56%) clients who identified need for changein service provision, five identified the need for change inThe perceptions of care identified in the findings from this

study highlight three factors which the author suggests the attitude of nursing staff to clients. Although a smallnumber, this finding was common to three of the four caserequire consideration in the context of the development of

evaluation studies in nursing care. study centres, highlighting the importance of the inter-action between clients and nurses. The importance ofclient–nurse interaction was illustrated particularly whenDemands on the service The first of these factors is

described as demands on the service. Although topics such parents were asked to describe their most satisfactory andleast satisfactory experience in the centre. In each categoryas waiting times and demands on practitioners’ time,

included within this category, are not unique to this par- half of the described experiences related to their inter-action with nursing staff. Their descriptions includedticular cultural context (Gribben 1992, Piper 1989), the

responses of the informants in the study reflect the norms examples of nurses being very caring, as well as descrip-tions of nurses being dismissive and uncaring to parents’of this cultural group.

Indeed despite clients differing in their perception of concerns.It is interesting that, although parents justified their criti-acceptable waiting times, the majority considered waiting

for as much as 90 min to see the nurse as acceptable; a cisms of the nurses’ behaviour once more within the con-text of demands on the service, the importance of nurse–very different finding from the studies cited above.

Although this response may in part reflect the value placed client interaction in determining patient satisfaction withservices is reflected in other research studies (Megivernby parents on the health of their child, it also raises ques-



et al. 1992). Indeed although evidence such as this suggests amongst the client sample who were generally willing andenthusiastic to offer their opinions of the service.the significance of the nurse–client interaction in

determining quality of care, the apparent reluctance of par-ents in this study to express criticism of this important

The use of health datacomponent of care, highlights the implications of thisphenomenon in both the collection and interpretation of The second major methodological issue in the evaluation

of the quality of care to emerge from the study was that ofdata within different cultural contexts.the use of health data. Within this category two particular

Privacy More general issues to emerge within the culturalissues require addressing. The first of these relates to the

context of the evaluation of care included factors such asmethod of recording data and the second to accessing

the degree of privacy provided during consultations withsources of data. The manual search of the records demon-

the nurse. Because of the demands on the service, nursestrated a wide range of quality in recording health data.

informants described the lack of privacy they were able toAlthough this finding is not unique to this study (Aaronson

provide during their consultations with parents as a major& Burman 1994), the practice of health data being entered

factor influencing the quality of the provision of care.by a range of different professionals using a mixture of

Indeed the lack of privacy emerged as a repeated resourceEnglish and Chinese, raises questions about interpret-

issue throughout the data analysis. However, clients wereation and translation as well as accuracy of the data.

much less concerned about this issue stating that they wereIndeed both these issues highlight the difficulty of

only discussing ‘baby matters’ and privacy was notinterpreting the data obtained from the health records as

important to them in this context.a measure in the evaluation process.

Although it is possible to argue that parents accessingthe service are used to small crowded living accommo-

Sources of data The source of data raises further questionsdation with little privacy in their life, it is important to

for consideration, since although data are collected manu-note that one women stated that if privacy was available

ally on a number of health indicators, currently there isparents may be prepared to discuss more sensitive health

no method of readily accessing this information. Inissues. This is a particularly important observation within

addition some data are collected on a territory wide basis,a culture where the uptake of cervical cytology is low and

and therefore not available for nurses to use to determinebreast cancer is a major cause of death amongst women

health needs of the population of the catchment area of(Pei et al. 1991, FPAHK 1993, DoH 1994). This finding not

the centre. In addition at present there is no systematiconly highlights the implications of the cultural context in

data base from which to identify morbidity and mortalitythe development of evaluation tools, but also the different

rates, highlighting once again the difficulty of targettingperceptions of nurses and clients in the evaluation of

health needs and measuring the effectiveness of thecare.

outcome of nursing interventions.In addition it is perhaps important to add that bothResearch participants The final issue for consideration

within the context of cultural issues, once again is more researchers and practitioners have experienced difficultyin accessing data held by the Department of Health.general and relates to the participation of informants in

research. As in any research informed consent was Although this situation in part results from the lack of acomputersied data base, the situation was complicated atobtained from all the participants as part of the ethical

procedures of the study. However, informal feedback the time of the study by difficulties generally in accessingpotentially sensitive information in the Territory. Despiteobtained at the briefing sessions of the nursing staff, sug-

gested that despite concern about the participating in the some of these issues being resolved by the implementationof a system of computerized records currently being devel-study, in reality they considered they had little choice but

to participate in the study, since the research was being oped, the philosophy of open access to health data remainsa more complex issue. However, the recent introductionundertaken with the collaboration of the nursing division

of the Department of Health. They also initially expressed of legislation on access to information may help to addressthis issue.their distrust and concern as to why their centre had been

selected for the study.Although the earlier discussion suggests that concerns

Methods of data collection: the use of language.such as this may be equally relevant to all cultural groupswhere evaluation research is undertaken, the continuing The final methodological issue to be considered in this

paper relates to the implications of the use of language inpresence of a hierarchical nursing structure in Hong Kongraises questions about the voluntary nature of participants the methods of data collection. Although this issue has

much wider implications than merely studies in the evalu-in the study; a phenomenon which may indeed have impli-cations for the interpretation of data. It is interesting, how- ation of care, three particularly relevant areas were ident-

ified from the findings of this study. The first of theseever, this reluctance to participate was not observed


S. Twinn

relates to the use of professional language, particularly in study demonstrated the complexity of the processesinvolved in translation.the development of the interview guide. The use of the

term ‘weighing’ in the parent interview guide provides a A lack of understanding by the English researcher aboutone of the responses in an interview with one of the nurseuseful illustration from the study. From the author’s pro-

fessional background in health visiting practice in the UK, informants led to three different bilingual nurses translat-ing that particular section of the interview. As shown inthe term weighing is generally interpreted as having the

baby weighed and may or may not include receiving the brief extract of one interviewer–informant interaction(Figure 1) all three translators provide a different interpret-professional advice.

However, in practice in Hong Kong, the term is used to ation of the Cantonese data. Although this finding mayhave more relevance for the implications of the translationdescribe the process of bringing the baby to the centre for

advice, not merely to the physical activity of weighing. process in the analysis of qualitative data (Twinn 1995),in the author’s opinion this finding raises questions aboutAlthough the researchers had considerable discussion

about professional practice prior to and during the devel- the validity and reliability of findings generated fromevaluation studies which have involved the use ofopment of the interview schedule, this particular issue had

not arisen. In the author’s opinion the use of professional translation in the collection and analysis of data.language not only has implications for the development ofthe tools for evaluation, but also the interpretation of the

CONCLUSIONSdata.

Obviously the findings of this case study cannot be gen-eralized to other cultural groups. However, the issuesMethods of data collection The development of the inter-

view guide also highlighted the complexity of developing raised in this paper, not only highlight some of the com-plexities of evaluating care in public health nursing, butmethods of data collection for use in evaluation studies in

a different cultural setting, particularly where translation also more importantly the significance of addressing cul-turally specific issues when developing the methodologyof the tool is required. In this study the researchers used

both the literature review and local expert opinion to for the evaluation of care.identify topics for inclusion within the semi-structuredinterview guide used with both the parents and nurses.

Translator IThe guides were then developed in English and translatedinto Cantonese. One particular problem encountered was In27 Have you seen the bruising on children’s body that alarmthat for some words and concepts such as privacy and you for more attention or some marks of physicalhealth needs there was no obvious Cantonese equivalent punishment?and the Cantonese speaking researcher had to use R28 No, I haven’t seen that. But I’ve seen some burning marks

of the candle. But it is quite common for the boat people toappropriate phrases to convey the meaning to informants.use these, burning on newborn’s body for they always cry.In this study only one interviewer was used which

allowed for consistency of interpretation of concepts suchTranslator IIas privacy. Although authors such as Nelson et al (1994)

argue that, due to the nature of interviewing, this approachIn27 Have you seen any bruises that caused concern?is appropriate when using qualitative methods of data col-R28 No I haven’t … but I have seen some burn marks from

lection, inevitably the interviewer elaborated on the pointsresulting from Joss sticks. the new born babies of fisherman

for discussion in different ways during the interviews with got pairs of burn marks on their trunk if they cry a lot.clients and nurses. This process raises questions abouthow translation and the use of language influence the data Translator IIIcollection, particularly in relation to the validity andreliability of concepts within the interview schedule. In27 Have you ever seen some bruise marks or ‘bamboo stick’

marks that will warrant you to do something about it?R28 No I have never seen one. but I did see babies burned withImplications of translation Indeed these questions raise

joss stick. the new born babies like to cry and when theythe final issue for consideration within the context of thecry, the boat people like to use joss sticks to burn theiruse of language in association with the methods of datababies on their nipples. They usually make the marks withcollection which is that of the implications of translationthe joss sticks and make several holes.

for the interpretation of data. As described earlier, theinterviews were carried out in Cantonese and then trans- (These transcripts represent a verbatim translation of the Chineselated and transcribed in English. Although there is little data which is why it may seem grammatically incorrect)reference in the literature to the influence of translationon issues of validity and reliability in qualitative data Figure 1 Three different translations of the same interviewers

question (IN27) and the response (R28)analysis, an incident in the analysis of the data in this



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Methodology issue in the evaluation of the quality