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_