I. PROBLEM IDENTIFICATION
If the causes of a problem are obvious,
we are dealing with a management problem which may be solved without further
research. If, for example, in a sanitation project essential building materials
such as cement have been unavailable for a large part of the project period,
one should try to ensure the supply of cement rather than embark on research to
explore the reasons why the project did not reach its targets.
In the previous
module, a number of research questions were presented that may be posed at the
various levels of the health system.
These questions
can be placed in three broad categories, depending on the type of information
sought:
1. Description of health
problems required for planning interventions
Planners need to know the magnitude and distribution of health needs in a population as well as of health resources, in order to formulate adequate policies and plan interventions.
Planners need to know the magnitude and distribution of health needs in a population as well as of health resources, in order to formulate adequate policies and plan interventions.
2.
Information required to evaluate ongoing interventions with respect to:
·
coverage of health needs
·
coverage of target group(s)
·
acceptability and quality
·
costs
·
effects/impact,
to assess progress and the need for adjustment on a routine basis.
3.
Information required to define problem situations in interventions
in any of the fields mentioned under 2, and to analyse possible causes in order
to find solutions. These causes may include lack of
or inequitable distribution of resources, vague or policies, and any
environmental factors affecting needs, interventions and resources (See Figure
2.1).
Although
research in support of planning and evaluation (categories 1 and 2 mentioned
above) is an important focus for HSR, the modules will concentrate on the third
category, because health managers are frequently confronted with problems of
this type. It is assumed, however, that research skills acquired in the present
course will be of use in the broader field of planning and evaluation as well.
Whether a
problem situation requires research depends on three conditions:[1]
1.
There should be a perceived difference or discrepancy
between what exists and the ideal or planned situation;
2.
The reason(s) for this difference should be unclear (so that it makes sense to develop research questions); and
3.
There should be more than one possible answer to a
question or more than one solution to the problem.
For example:
Problem situation:
In District X (pop. 145,000) sanitary conditions are poor (5% of
households have latrines) and diseases connected with poor sanitation, such as
hepatitis, gastro-enteritis and worms, are very common. The Ministry of Health
has therefore initiated a sanitation project which aims at increasing the
percentage of households with latrines by 15% each year. The project provides
materials, and the population should provide labour. Two years later, less than
half of the target has been reached.
Discrepancy:
35% of the households should
have latrines, but only 15% do have
them.
Research question:
What factors can explain this difference?
Possible answers:
1.
Service-related factors, such as
forgetting to adequately inform and involve the population, bottlenecks in the
supply of materials, differences in training and effectiveness of sanitary
staff, lack of co-operation between sectors.
2.
Population-related factors, such as
situations where community members lack understanding of the relationship
between disease and sanitation or have other problems, for example due to
poverty, which they consider more important.
3.
Physical factors/ecosystems, such as
hard soil, or land subjected to frequent flooding.
II. CRITERIA FOR PRIORITIZING PROBLEMS FOR RESEARCH
Because HSR is
intended to provide information for decision-making to improve health care, the
selection and analysis of the problem for research should involve those who are
responsible for the health status of the community. This would include managers
in the health- and health-related services, health care workers and community
leaders, as well as researchers.
Each problem
that is proposed for research has to be judged according to certain guidelines
or criteria. There may be several ideas to choose from. Before deciding on a
research topic, each proposed topic must be compared with all other options.
The guidelines or criteria discussed on the following page can help in this
process:
Criteria for selecting a research topic:
1.
Relevance
2.
Avoidance of duplication
3.
Urgency of data needed
(timeliness)
4.
Political acceptability of
study
5.
Feasibility of study
6.
Applicability of results
7.
Ethical acceptability
1. Relevance
The topic you choose should be a priority problem. Questions to be
asked include:
·
How large or widespread is the
problem?
·
Who is affected?
·
How severe is the problem?
Try to think of serious health problems that affect a great number
of people or of the most serious problems that are faced by managers in the
area of your work.
Also, consider the question of who perceives the problem as
important. Health managers, health staff
and community members may each look at the same problem from different perspectives.
Community members, for example, may give a higher priority to economic concerns
than to certain public health problems.
To ensure full participation of all parties concerned, it is advisable
to define the problem in such a way that all have an interest in solving it.
Even within villages, opinions may
differ on how important a problem is. It is therefore obligatory to discuss the
problem with community leaders, as well as peripheral villagers, males as well
as females, rich and poor, exploring their perceptions of the problem.
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Note:
If you do not
consider a topic relevant, it is not worthwhile to continue rating it. In that case you should drop it from your list.
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2. Avoidance of duplication
Before you decide to carry out a study, it is important that you
find out whether the suggested topic has been investigated before, either
within the proposed study area or in another area with similar conditions. If
the topic has been researched, the results should be reviewed to explore
whether major questions that deserve further investigation remain unanswered.
If not, another topic should be chosen.
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Note:
Also, consider
carefully whether you can find answers to the problem in already available,
unpublished information or just by using your common sense. If so, you should
drop the topic from your list.
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3. Urgency of data needed (timeliness)
How urgently are the results needed for making a decision or
developing interventions at various levels (from community to policy)? Consider
which research should be done first and which can be done later.
4. Political acceptability
In general it is advisable to research a topic which has the
interest and support of the local/national authorities. This will increase the
chance that the results of the study will be implemented. Under certain
circumstances, however, you may feel that a study is required to show that the
government's policy needs adjustment. If so, you should make an extra effort to
involve the policy-makers concerned at an early stage, in order to limit the
chances for confrontation later.
5. Feasibility
Look at the project you are proposing and consider the complexity of
the problem and the resources you will require to carry out your study. Thought
should be given first to manpower, time, equipment and money that are locally
available.
In situations where the local resources necessary to carry out the
project are not sufficient, you might consider resources available at the
national level; for example, in research units, research councils or local
universities. Finally, explore the possibility of obtaining technical and
financial assistance from external sources.
6. Applicability of possible results/recommendations
Is it likely that the recommendations from the study will be
applied? This will depend not only on the management capability within the team
and the blessing of the authorities but also on the availability of resources
for implementing the recommendations. Likewise, the opinion of the potential
clients and of responsible staff will influence the implementation of
recommendations.
7. Ethical acceptability
We should always consider the possibility that we may inflict harm
on others while carrying out research. Therefore, review the study you are
proposing and consider important ethical issues such as:
·
How acceptable is the research
to those who will be studied? (Cultural sensitivity must be given careful
consideration). Is the problem shared by target group and health
staff/researchers?
·
Can informed consent be
obtained from the research subjects?
·
Will the condition of the
subjects be taken into account? For example, if individuals are identified
during the study who require treatment, will this treatment be given? What if
such treatment interferes with your study results?
·
Will the results be shared with
those who are being studied? Will the results be helpful in improving the lives
or health of those studied?
These criteria can be measured by the
following rating scales:
SCALES FOR RATING RESEARCH TOPICS
Relevance
1.
= Not relevant
2.
= Relevant
3.
= Very relevant
Avoidance of duplication
1.
= Sufficient information already available
2.
= Some information available but major issues not covered
3.
= No sound information available on which to base problem-solving
Urgency
1.
= Information not urgently needed
2.
= Information could be used right away but a delay of some months
would be acceptable
3.
= Data very urgently needed for decision-making
Political Acceptability
1.
= Topic not acceptable to high level policymakers
2.
= Topic more or less acceptable
3.
= Topic fully acceptable
Feasibility
1.
= Study not feasible, considering available resources
2.
= Study feasible, considering available resources
3.
= Study very feasible, considering available resources
Applicability
1.
= No chance of recommendations being implemented
2.
= Some chance of recommendations being implemented
3.
= Good chance of recommendations being implemented
Ethical acceptability
1.
= Major ethical problems
2.
= Minor ethical problems
3.
= No ethical problems
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In order to assist a group in selecting and rating different
research topics, we will use the nominal group technique (NGT)
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