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The DCST’s, research and health service evaluation
Fundamental questions to be addressed
-Should the DCSTs be doing research?
-Why should they be doing research?
-What research should they be doing?
-How do they ensure that research findings are used
Purpose of research for DCST
Evaluation of health programmes
Advocating for change
To Make better and informed decisions on operations of the health care system
Provide evidence for the effectiveness of interventions
Scholarship and academic growth
DCST can do research at almost any stage of the planning cycle
We can do research at almost any stage
Situation analysis• Health needs• Health care utilisation• Perceptions about the health care services
Priority setting / option appraisal• Economic analysis• Cost benefit analysis
Evaluation• Determine impact of interventions
What kind of research should the DCST’s be doing?
• Priority problems (national, provincial, local)
• Action orientated – aimed at developing solutions
• Broad – multi-disciplinary approach
• Timely – results should be available in time for key decision making
• Simple research designs
• Presented in format that useful for decision makers and it should be used
Focus on Action orientated research
Translational research
• Integrating basic research, patient-oriented research, and population-based research so that scientific discoveries made in the laboratory, clinical setting, or population setting result in clinical applications such as interventions to prevent, diagnose, or treat disease.
Need to think explicitly about implication for practice
What is research?
Research is defined as a SYSTEMATIC, SCHOLARLY SCIENTIFIC INVESTIGATION or INQUIRY into an issue, materials and sources in order to establish facts, generate new knowledge and reach new conclusions
Purposes of research
The primary purposes of research are:
Documentation
Discovery
Interpretation
Development of new knowledge
Verification of existing facts
Advancement of knowledge
General research principles
Research
is based on an open system of thought that allows exploration
It involves systematic gathering of data
It involves critical analysis of data
It involves the drawing of conclusions that may be generalised or that specify limits of generalisation
Approaches in research Depending on the purpose of the study, method of
collection, analysis, and interpretation of data, two main approaches are applicable:
Quantitative research
Qualitative research
(None of these is deemed superior to the other)
Others include Operational research, action research, health services research
Quantitative research
Quantitative ResearchResearch that examines phenomena
through the numerical representation of observations and statistical analysis
Quantitative research - measures variables; compares results; tests a hypothesis; generalises its findings to the target population
Quantitative research can either be descriptive or analytical
QUANTITATIVE STUDY DESIGNS
Descriptive Analytical
ExperimentalResearcher compares Outcomes through intervention
ObservationalResearcher comparesoutcomesthrough observation
Examples:
• Case-control (Retrospective) Smoking and lung ca
• Cohorts (Follow-up) Alcohol use and liver cirrhosis
• Cross-sectional Obesity among teenagers
Examples:
• Clinical trials Comparison of effectiveness of 2 anti-convulsants
• Educational intervention assessment using OSCE Compared to “long case”
Examples:
Case-reportCase of 1 scorpion sting
Case seriesTreatment of 30 scorpion stings
Descriptive studies
Descriptive studies use numerical depiction of the characteristics of a single occurrence/ episode OR several similar occurrences.
Descriptive studies include the following designs:
Cross sectional studies
Case report
Case series
Analytical studies
Analytical studies: look for risk factors, associations (between exposure and outcome) and causation.
Analytical studies are either Observational or Experimental
Observational studies
cross-sectional: snapshot of characteristics of a population at a specific point in time. Associations are examined; exposure and effect/outcome are measured at the same time
Case control:
- outcome is known, exposures are looked for retrospectively, associations are examined
Cohort:
- exposure is known, individuals are followed up until outcome of interest
Experimental studiesInvolve interventions directly controlled by the
researcher
Randomised Controlled Trials:
- randomised clinical trials, gold standard of experimental design, every participant has an equal chance of being assigned to either group
Field trials: healthy at-risk participants, eg vaccine trials
Community trials: whole communities participate
Procedures in quantitative research
Study population identification
Sampling with the aim of representation hence random or systematic sampling
Data collection techniques/tools: Questionnaires, data collection sheet/table, surveys
Data analysis: Usually numerical and uses statistical methods
Questionnaires
What is a questionnaire
• List of questions, answered by the respondent
• Indirect measure of the variables you are interested in.
• Questions can be:
-Self administered – respondent fill the questionnaire in themselves
-Interview – interviewer asks the questions
General aspects of a questionnaire
Consult the respondent Able to express opinion freely, opinions valued
Keep it short Ask only pertinent questions
Achieve precise measurement Collect data in its rawest form (income in rand, precise
occupation, age to the year, not age category) highest level of measurement possible
Steps in developing a questionnaire
Step 1.
• List all the variables to be measured
• These are based on the objectives
Steps in developing a questionnaire
Step 2a)
• Decide what type of questions you will ask
Step 2b)
• Formulate the questions you will ask
Phrase your questions
Use simple words
Be concise and clear
Vary wording to produce variation in replies
Avoid complexity – make it simple
Use existing wording if comparative study
Take the edge off sensitive questions
Be precise, highly specific when choosing wordings
Step 3. Sequence of questions
• Start with an introduction – who is doing the study and why – legitimate.
• Often put demographic information at beginning – non-threatening
• Do not put most sensitive questions at the beginning
• Do not put the most important questions last – participant may have given up by then / tired
.
Organise questions
Have consistent formatting so respondents can get used to answering
Group questions by objectives
Anticipate computer data entry Pre-code questions before data collection
Clearly indicate branching Clear respondents away from irrelevant questions
Make it easy to fill out; will increase response rate
Step 4. Plan the layout and the design
Have a distinctive look E.g., coloured paper, graphics for questions is
appealing Well laid out questionnaire more likely to be
filled in
Don’t squeeze too much onto one page Crowding questions on a page can make the
questionnaire appear too long
Pre-testing
Pre-test the questionnaire Start by filling out the survey yourself, then ask
individuals to do so Ask for feedback on the questionnaire Is it too long? Any problem with wording?
Pilot study Send questionnaire to a small sample of
respondents Use data to determine which items will be used
for indexes, modify unclear questions, create pre-coded, single-choice questions based on responses to open-ended questions
Disadvantages of questionnaires
• Provides only limited insight into problem– Limited response allowed by questions– Maybe not the right questions are asked
• Varying response – Misunderstanding/misinterpretation
• Need to get it right first time– Hard to chase after missing data
End product of Quantitative research
Reports usually with numerical and statistical indices of comparison e.g. prevalence, incidence, Relative Risk, Odds Ratio, sensitivity, specificity, P-value, confidence intervals
Comparison, association, causation
Tested hypothesis
Generalizable information
Qualitative Research
Qualitative Research
This is any a type of research that produces findings not arrived at by means of numbers and statistical procedures or other means of quantification
Qualitative research focuses on the way human beings live and interact in their natural setting.
Has an interpretive character, aimed at discovering the meaning events have for the individuals who experience them
When to use qualitative methods
Exploration: they can reveal the nature of certain situations, setting, processes, relationships, systems or people
Interpretation: enable the researcher to;
a) gain new insights about a particular phenomenon
b) discover problems that exist within the phenomenon
c) Elicit feelings, thoughts, ideas, perceptions
Verification: allow the researcher to test the validity of certain assumptions, claims, theories or generalisations within real-world contexts
Qualitative designs
Case study
Ethnography
Phenomenological study
Narrative study
Participatory Action Research
Case study
Case study:
- a particular individual, program or event is studied in depth for a defined period of time
- suitable for learning more about a little known or poorly understood situation
- useful for generating or providing preliminary hypothesis
Ethnography
Ethnography:
- looks in depth at an entire group that shares a common culture
- the group is in its natural setting for a lengthy period of time
- intention is to identify cultural norms, beliefs, social structures and cultural patterns
Phenomenology
Attempts to understand peoples’ perceptions, ideas, perspectives and understanding of a particular situation or phenomenon
Phenomenological studies are appropriate in providing insight into human experiences e.g. what is it like to have a terminal illness?
Narrative research
This design uses stories of experiences by an individual or group of individuals in establishing an understanding of an event or way of life.
Stories are a powerful way of presenting qualitative information and data is collected over long period of time from one or more participants
Participatory Action Research
A research method that involves researcher(s) and participants collaborating to create change/improve a particular situation
In this design the researcher gains deep insights by being a participant, living together and observing the other study participants during the life event under study
It allows the researcher an unobstructed view of the participants lives/experiences
Useful in studying intense social circumstance e.g. prison life, refugees, times of war
Procedures in Qualitative studies
The researcher acts as a “human instrument” of data collection
Sampling usually aims at richness of the information hence Purposive sampling
Data is in the form of speech, language, stories, expressions, observations etc
Analysis include: Content, language, discourse, ethnographic (culture patterns)
Data collection techniques1. Interviews
Individual standardized interview
Semi-structured interview
Unstructured interview
2. Focus group interviews
3. Observation
External observer
Internal observer
Participant observer
End product of qualitative research
Informative Reports that are descriptive, incorporating expressive language and the “presence of voice of participants in the text”
Ideas, perceptions, experiences, feelings
Hypothesis generation
Other priority research approaches for Department of Health
Action research
”Essentially action research is concerned with
generating knowledge about a social system,
while, at the same time, attempting to change it”
(Meyer, 2001:173).
• Quality of care
• Strengthening the system – drugs, pharmacy, laboratories
Health service evaluation
• Health service evaluation is always used for decision making
• The research questions are derived from goals
• Always takes place in real world setting
• Results pertain ONLY to programme / service being evaluated.
• NOT generalisable
Health services research• Health services research is the scientific investigation of the
use, costs, delivery and effects of health care treatments or services for individuals and populations.
• It is not about collecting information for information’s sake or transforming facts from one place to another.
• Health services research involves systematically seeking knowledge which will lead to improvements in the delivery of health care.
Use of Research findings
• Sometimes No use
• Have it as an interesting fact
• Use it to make decisions
• Use it to persuade / influence others
• Use it to change behaviour
• Use it to evaluate services, improve patient care, improve management etc
Barriers to utilisation of research findings
• Time taken to do research
• Way it is presented – complicated and use of specialised terminology
• Specific recommendations absent
• Recommendations impractical
• Results not communicated at all
• Decision often based on more than research findings – cost, politics, equity etc.
Facilitating implementation of research findings
• Involve stakeholders throughout the research process
• Give them regular feedback
• Develop a systematic dissemination and communication strategy for reaching potential users including publishing
• Identify and present research to all stakeholders and obtain feedback on findings and recommendations
• Actively lobby and mobilise action for and support the use of results
How to ensure research is used
Communication between researcher and consumer of research.
Decision makers should be involved in development of research so that it is relevant and meets their needs
Identify all potential users of research at the beginning – if they are only involved at the end the results will never be used
Manage conflict of expectations – policy makers want results quickly and research takes time
Conclusion
If a man will begin with certainties, he will end in doubts; but if he will be content to begin with doubts, he will end in certainties.
Francis Bacon (1561-1626),_Advancement of Learning_