HLTEN514 AApply research Skills within a contemporary

environment

DR Kithsiri Edirisinghe MBBS, MSc, MD ( Medical Administration)

TAA Cert. IV ( Australia)

• OH ! Factor•Observation • Rain / wind / infection in the ward / readmission of cases / increase in Dengue patients / Nurse turnover/ rising cost of healthcare

What is Phenomena ?

• An idea • Perception •Thought•Theory•Model• Re-search model • Conceptual model

What is a Concept ?

•Why ? •When ?•Where ?•Who ?•What else ?

What is Research ?

• Reasoning • Explanation•Argument

What is Theory ?

What is Health Research ?

• Is systematic;

– collection,

– analysis,

– interpretation of data

– to answer a certain question or to solve a problem

related to health

Health Management Research

• “Linking – theory – education – practice to improve administrative practice and standards

“• Health management research helps to :

– Validate healthcare management practices – Analyze effectiveness of healthcare management

interventions – Organize scientific base for healthcare management

practice – Demonstrate the accountability

Why Health research is Important ?

• Health needs of the community---------------Health resources • Health Interventions

• Health resources are scarce to fulfill the health needs of the community• Interventions in health have to be planned properly for it to be effective

• For interventions health information is vital to :– Prioritize the need – Monitor the Coverage, Effectiveness Affordability, Efficiency,

Acceptance, Sustainability – Feed back

Health research plays a major role in this context

Importance of Health Research

• Demand Gap

• Effective interventions

– Coverage

– Accessibility

– Affordability

– Sustainability

– Effectiveness

– Efficiency

• Assessing need & Demand

• Health Planning, Interventions, monitoring of health problems & issues

information • Data

– Facts or phenomena – Raw numbers

• Information – Organizing numbers after scientific analysis– Scientific results through tabulating data

• Intelligence – Interpretation of information by using professional

experience – Expert knowledge

Re – search

• Solid scientific base • Based on previous research – Applied

research • Inventions – Basic research

Research concept / idea / model

1. Based on the phenomena observed – the snap shot – situational analysis

2. Identify issues / problems 3. The identified problem should have a :

– Clear gap in care current and ideal situation– Relevance to healthcare management – Avoidance of duplication – Acceptability - Political / Ethical– Applicability– Urgency

History of health management research

• Activity 01 – group presentation next week

Research Process

1. Selection of a Problem & formulation of objectives of the research

2. Ethical consideration in research 3. Literature review

– Build up on existing scientific research– Referencing and citation

4. Methodology – Conceptual framework and hypothesis – Study design – Data collection – Analysis of data

5. Presentation , Interpretation and dissemination of results

1. Selection of a Problem & formulation of objectives of the research

1. Selection of Problem

The steps :

– Selection of the problem /issue

– Situational Analysis

– Problem identification

– Prioritization of the problem

– Analysis of the problem

– Selection of a problem ( cause / effect )

– Formulation of problem statement • Background of the problem & description of the problem

Hospital clinic

Let s identify issues and move on to organizing the Research!

Selection of the problem

• Situational analysis of the problem – Snap shot of the situation / issue

• Identify the problem/ problems

• Prioritize the problem from the problems– According to the :

• Relevance -Avoidance of duplication -Political acceptability- Applicability• Urgency of data needed- Ethical acceptability

– The prioritized problem should have: – A clear gap, current and ideal situation - No clear reason to this gap -

Analysis of the problem

• Clarify the view points of the stakeholders• Specify the core problem• Analyze the problem – cause and effect diagram• Write down core problem• Brainstorm possible factors contributing to the problem• Identify further contributory factors• Organize the related factors into similar groups

Focus and scope of the Research• Check information collected will be useful, feasible and avoid

duplication

Formulating Problem Statement

• Background– Brief description of socio-economic and cultural characteristics and its importance of

healthcare problem stated (Few illustrative statistics)

• Description of nature of problem

• Major factors contributed to the problem

• Previous studies performed in the past

• Justification

– Type of information expected to yield from the project and usefulness of the

information

• Definition, important concepts with relation to the problem

– What / when / where / what extent

• Statement of the problem the topic to the research

•IT lab

Activity 01 . Select a problem and go trough the process to and present in next week

2. Ethical consideration

Ethical Consideration

• War crimes after world war II - 1946 • Nuremberg code- 1940

– Guidelines to voluntary consent – Withdrawal of subjects from studies – Protection of subjects from suffering , injury, disability , and death

• Declaration of Helsinki – 1960– Human research after laboratory tests – Review of research protocols by an independent group – Informed consent – Conducted by professionals -qualified scientifically / medically – Benefits must be more than Risks

• Revisions in 1975, - 1996

Ethical ConsiderationNational Health and Medical Research Council

• NHMRC – Australia – “Ethical culture” & “Informed consent” • Strong ethical culture should demonstrate

– honesty and interiority – Respect for human participants , animals and the environment – Good use of public resources in conducting research – Acknowledgement of the others used in research – Responsible communication of the results

• Informed consent – Self determination – Privacy & dignity – Anonymity & confidentiality – To fair treatment – Protection and discomfort from harm

Ethics in research

1. Autonomy

2. Beneficence

3. Non-malificence

4. Privacy

5. Confidentiality

6. Veracity

7. Fidelity

1.Principle of Autonomy

• Humans have the right to non – interference when making decisions about themselves

• Forms the basis of ideas about privacy, confidentiality, veracity and consent

2.Principle of Beneficence

• “I will use treatment for the benefit of the sick, according to my ability and judgment”

Hippocratic Oath

• Conduct is aimed at the good and well being of others

• Principle requires that practitioners provide both appropriate treatment and an assurance that the treatment will not produce more harm than good

3.Principle of Non-malificence

• “Above all do no harm” Hippocratic Oath

• In health care the ethical issues of non-malificence and beneficence are particularly apparent in decisions regarding the institution of dangerous therapy or withdrawal of therapy that is no longer thought to be beneficial.

4.Privacy

• Safeguarding areas where patient does not want to reveal :– History – Examinations – Investigations

5. Confidentiality • Not reveling information collected from the

patient without her / his consent :– Verbally– Examination – Records

• Complicated process• Harm vs. benefit

• Individual • Social

• Use your common sense • Inform superiors

6.Veracity

• Revealing truthful information to the patient:

– As a professional

– Cultural /social /Medical

• Personnel Harm vs. Benefit

• Complicated process

• Experienced person needed

7.Fidelty

• Agreement with the patient

– Verbal

– Non verbal

‘Method of gathering existing information regarding subject’

3. Literature Review

Usefulness of Literature review

1. Avoids duplication and specify the subject

2. Show different aspect of the problem and strengthen the problem analysis

3. Provides facts to make the research efficient and effective

4. Provides guidelines in each step, benefits and constrains that will occur in

performing the study

5. Provides comparative data for the research

• Sources

– Publications , web , research papers, journals

The method of performing Literature review

• Decide on the topics to search and sources

• Organize index card, according to aspect of problem describe• Index card - Key word/ summery of the article/ important to will part – …….., …. Etc.

• Write in the chapter

– How literature has helped the study

– Write reference, properly and a list of reference in alphabetical order

Applying Ethical Considerations in research

• In research emotional or mental harm to study subjects• Even as asking sensitive questions that may violate their

privacy• Observing without their knowledge • Failing to respect certain cultural values, traditions etc.• Remedy :

– Obtaining permission before study begins– not exploring sensitive questions before developing a good

relationship with the informant– Ensuring confidentiality of the data obtained. (name and

address)

4. . Methodology• Developing a conceptual framework • Types of research designs

Main Research categoriesQuantitative Qualitative Research

• In general, qualitative research generates rich, detailed and valid data that contribute to in-depth understanding of the context.

• Quantitative research generates reliable population based and gereralizable data and is well suited to establishing cause-and-effect relationships.

Qualitative / qualitative research

Quantitative research

• Quantitative research refers to counts and measures of things, simply it’s

about numbers, objective hard data.

• Quantitative research is research involving the use of structured questions

where the response options have been predetermined and a large

number of respondents is involved.

• By definition, measurement must be objective, quantitative and

statistically valid.

• The sample size for a survey is calculated by statisticians using formulas.

Quantitative Research

• Systematic and objective process • To gather & analyze information• Information converted to numbers – statistics • Uses numerical picture look at similarities and

differences • Take decision on the relationship of the things measured • This is a very LOGICAL approach • It begins with a hypothesis / argument / educated guess

about the concept and formulate research questions

Classification of Quantitative Research

Classification of Quantitative Research Classification based on :

1. Reasons for conducting the research – Basic ………………find new knowledge – Applied ………….find answers to day to day problems

2. Time span – Cross sectional ……..point of time– Longitudinal …………spread over time

3. Point of collection– Retrospective - ………..Past <-------- Present – Prospective ……………. Present -------- >future

Classification of Quantitative Research Classification based on :

5. Purpose and aim – Descriptive – Exploratory – Explanatory – Predictive

6. Research design – Experimental …….. Interventional– Non experimental …………non interventional/

observation

Description of the Quantitative studies

1. Basic and Applied

This is classified according to the reasons for conducting the research

• Basic – Basic ………………find new knowledge – Vaccine for Malaria / AIDS

• Applied – Applied ………….find answers to day to day

problems – Health needs/ wants

2. Cross sectional & longitudinal

This is categorized as per the time span • Cross sectional

• One point of time• Snap shot • Maximum Months

• Longitudinal• Spread over time• long term• Years

Cross sectional studies • Quantify the distribution of certain variables in a study population at one point

of time ………………(snap shot)• It will include

– Physical characteristics of people, environment; prevent survey of leprosy, evaluation coverage (immunization, ……..)

– Socio-economic characteristics of people; age, education, marital status, no. of children and income.

– Behaviour of people ….. and opinion, that may help to explain the behaviours (….. studies)

– Events that occur in population – death, birth, marital, migration example : census – cross sectional survey covering total population– Disease and distribution – prevalence survey– Health programmes

3.Retrospective & Prospective

Categorized according to a point of collection

– Retrospective - ………..Past <-------- Present– Collect a group of patients with lung cancer and

see the their exposure to smoking – Prospective ……………. Present -------- >future – Collect a group of people who are smoking and

asses the development of lung cancer over period of time

4. Descriptive & Exploratory

This is categorizes as per the purpose • Descriptive

– describe the subjects / situation – Questions asked and answers are need

• Exploratory – Explore the situation – Case studies – Limited scope

Descriptive studies

• They describe relevant situation, people, programme or events

• Majority of the studies performed are descriptive studies

• Systematic collection and presentation of data to give a clear

picture of a particular problem or situation

• Questions are asked to find out answers on the above

mentioned situations

• who, when, where, why , & what to do

Questions asked answers sought• Who? -Personal characteristics• Why?-Reason/association• Where - Distribution• What to do?-Suspect action• When -Time/season or future studies

Descriptive studies

Exploratory studies

• This is a small scale study performed to clarify a problem or situation.

• Mostly performed in management problems to analyze a situation.

• Rapid appraisal method for management.

• Interviews and comparison of a problem is performed.

– Ex. Needs of HIV AID patients of various gender groups and to

prioritize resources allocating (here the various needs are compared, a

rapid appraisal is performed)

6. Experimental & non-experimental studies

This is categorized as per the research design – Experimental …….. Interventional– Non experimental …………non interventional/

observation – Majority are non experimental

Experimental studies

• Randomly select to two groups.

• One is subjected to intervention (or experiment) and the

other without intervention. The outcome of intervention is

obtained by comparing two groups

– (the outcome : effect of the intervention on the problem

or the dependent variable)

• These studies actually prove causation

Experimental studies

• Classical experimental studies have 3 characteristics

1. Manipulation - Researcher does something to one group of

subjects in the study.

2. Control -The researcher introduce one or more control groups to

compare with the experimental group

3. Randomization -The researcher randomly assign subjects to control

and experimental groups (given equal chance for selection to either

group)

Quantitative Research process

1. Conceiving 2. Designing 3. Conducting 4. Analyzing 5. Using

1. Conceiving the study • Research problem identification phase• Research development phase

– What to study ?– What is the problem – What frame work ?– What are the variables ?

2. Designing the study

• Select a type of design– Study design

• Identify the sample – Sample selection

• Decide how to collect data – Data collation method

3. Conducting the study

• Ethical clearance • Requite subjects• Collect data • Analyzing the study

4. Analyzing the study

• Describe the sample • Answer the research question • Interpret results

4. Using the study

• Recommend further study• Dissemination of results and how to do

1. Conceiving the study

Selection of Problem

The steps :

– Selection of the issue ?? Phenomena

– Situational Analysis – Snap shot

– Clear problem identification

– Prioritization of the problem

– Analysis of the problem – ( find -cause / effect ) – optional

– Brain storming

– Formulation of problem statement • Background of the problem & description of the problem

Phenomena on Hospital clinic

Let s identify issues and move on to organizing the Research!

– Selection of the issue• Stagnation at the medical clinics • Frequent complains & conflicts

– Situational Analysis • stagnation , inconvenience , disorganized

process • poor seating facilities , unsatisfied patients , no

proper treatment and high risk to patients • poor administration , poor number of staff

– Clear problem identification • “Overcrowding of the Medical Clinics at

Teaching hospital Ragama, 2011.”

Analyze the problem - Cause & effect analysis

Causes - reasons for the problem

– Infrastructure – ventilation , light , seating , small waiting and clinic

area

– Human resources – low number , lazy staff , untrained staff

– Methods – no method , ineffective method , old method

– Patients – lack of compliance and patience

Effects – results of the problem

inconvenience, poor quality , image of the hospital , risk for the

patients

Problem – overcrowding of the medical clinics

Cause & effect diagram problem tree

Study Frame work

Selection of Variables

• Variable

– “Characteristic of a person, object or a phenomena that takes different forms or that

varies.”

– Variable two main types

• Numerical variables - takes Number form

– Weight , height ( 23 kg . and 100 cm)

• Categorical variables - category form

– Color , Race ( black , white and Sinhalese , Tamils , Muslims )

• Uses of variables

– To construct questions

– To improve the validation of data and form tables

– To indicate variables in statistical form & treatment

Classification of Variables

• According to the type, epidemiological, statistical variety

• Type

– Biological , physical, socio- economic ,events & service delivery

• Epidemiological

– Dependent

– Independent

– Confounding

– Background

Main Causative factor Smoking

Other factors Alcohol , occupation

Effect Lung Cancer

Problem – Dependent Main factors – Independent

Confounding –effect both Background factors Age, sex , race

Background – no direct effect

• Dependent

– Describe the problem of the study

• Waiting time

• Independent

– Describe the direct causative factors

• Availability of staff

• Efficiency of the staff

• Confounding

– These affects both dependent and independent variables

– They either weaken or strengthen them • poor infrastructure

• Background• Old age

• Language barrier

• Formulation of Variables

– Find contributory factors

– Rephrase

• Making variable neutral

• Long waiting time – “waiting time “

– Operationailize

• making variables measurable through indicators

– 1 hour - good

– > 1 hour to 2 hours- reasonable

– > 2 hours - poor

– Define

• To ensure consistency and remove confusion and bias

– “The time patient enters to the OPD clinic, up to seen by the consultant doctor”

– Scales measurement • Mnts. , Hours ,

VariablesThe factors that have identified in problem analysis may be negative. By

rephrasing it has to be made as neutral variable where it can take both negative and positive forms ;

• Long waiting time (-) - Waiting time• Absent of D (-) -Availability FD• Lack of supervision - Frequency of supervisory visit

• Poor knowledge of signs, causes and -Knowledge of sign, cause and Consequences TB consequence

b. Operationalizing Variable

• Making variable measurable• Some variables can be measured easily but some cannot be categorized easily. Measurable • categorization of variable presents as ‘Indicators’

• ‘Poor knowledge of pregnant mother mother’ - Factor

• Rephrase the Variable- Level of knowledge of pregnant mother • Operationalize Indicator • Correct answer to < 3Q – poor 4-6 -reasonable • > 7 – good

• Weight/age >80% std - Well nourished I

• 0-80% std - moderate malnutrition • > 60% std - severely malnutrition

c. Defining Variables & Indicators

• To ensure everyone understand the exactly what has been measured and to ensure consistency in the measurement, definition of variable and indicators are need.

• Ex. Waiting time – ‘when patient enters the front door of OPD until it is seen and a doctor or register or \ obtain a card’

• Experts comments : previous study variable and logical variable should be considered here.

The process of quantitative study

2. Designing the study • Select a type of design

– Study design

• Identify the sample – Sample selection

• Decide how to collect data – Data collation method

The process of quantitative study

3. Conducting the study • Ethical clearance • Requite subjects• Collect data • Analyzing the study

The process of quantitative study

4. Analyzing the study• Describe the sample • designing the study • Answer the research question • Interpret results

Quantitative Research

• Ideal for studies which:– Can be countered – Not many numerous factors – Very structured/ organized – Objective / purpose – Results tend to be clearly defend– Easily interpreted

Qualitative & Quantitative Research

Qualitative research

• Qualitative Research is collecting, analyzing, and interpreting data by

observing what people do and say.

• Qualitative research refers to the meanings, concepts, definitions,

characteristics, metaphors, symbols, and descriptions of things.

• More subjective than quantitative research

• Uses different methods of collecting information,

– Mainly individual, in-depth interviews and focus groups.

– The nature of this type of research is exploratory and open-ended. Small numbers of

people are interviewed in-depth and/or a relatively small number of focus groups are

conducted.

• Quantitative• Objective• Research questions: How many?

Strength of association?• "Hard" science• Literature review must be done

early in study• Test theory• One reality: focus is concise and

narrow• Facts are value-free and unbiased• Reduction, control, precision• Measurable• Mechanistic: parts equal the

whole• Report statistical analysis.

• Qualitative• Subjective• Research questions: What? Why?• "Soft" science• Literature review may be done as

study progresses or afterwards• Develops theory• Multiple realities: focus is

complex and broad• Facts are value-laden and biased• Discovery, description,

understanding, shared interpretation

• Interpretive• Organismic: whole is greater than

the parts

• Quantitative• Basic element of analysis is numbers• Researcher is separate• Subjects• Context free• Hypothesis• Reasoning is logistic and deductive• Establishes relationships, causation• Uses instruments• Strives for generalization• Generalizations leading to prediction,

explanation, and understanding• Highly controlled setting:

experimental setting (outcome oriented)

• Sample size: n• "Counts the beans"

• Qualitative• Report rich narrative, individual;

interpretation. Basic element of analysis is words/ideas.

• Researcher is part of process• Participants• Context dependent• Research questions• Reasoning is dialectic and inductive• Describes meaning, discovery• Uses communications and

observation• Strives for uniqueness• Patterns and theories developed for

understanding• Flexible approach: natural setting

(process oriented)• Sample size is not a concern; seeks

"informal rich" sample• Provides information as to "which

beans are worth counting"

Selection

• The decision of whether to choose a quantitative or a qualitative design is

a philosophical question.

• Which methods to choose will depend on the:

– Nature of the project,

– The type of information needed the context of the study

– The availability of recourses (time, money, and human).

Combination of both • It is a combination of two types of research. It is also called pluralistic

research.

Advantages of combining both types of research include:• Research development (one approach is used to inform the other, such as

using qualitative research to develop an instrument to be used in quantitative research)

• Increased validity (confirmation of results by means of different data sources)

• Compleme ntarity (adding information, i.e. words to numbers and vice versa)

• Creating new lines of thinking by the emergence of fresh perspectives and contradictions.