Operations Research in Health and Family Planning byProf V. K. Tiwari, NIHFW, N Delhi XIII Annual Conference of Indian Association of Preventive & Social Medicine, UP-UK Chapter, HIHT Dehradun 25-9-2010
Background of OR OR Used in second world war to precisely hit enemy targets by Americans Thereafter, focus shifted to Management problems in business and industries During sixties, WHO and Population Council started OR applications in Health and Family Planning.
What is operations research? OR is the application of scientific methods, techniques and tools to problems involving the operations of a system so as to provide those in control of operations with optimum solutions to the problem.
Goals of operations research Provide program managers/policy makers with information to make decisions to improve program operations (to solve problems) eg:
Increase efficiency, effectiveness and quality of service delivered by providers
Increase availability, accessibility and acceptability of services desired by users
Focus and Objectives of OR Focuses on:
Day-to-day activities or ‘operations’ of Health, FP and HIV/AIDS programs etc
Search for solutions
To yield answers to perceived program problems
To seek practical solutions to problem situations
To provide information to improve/scale up existing services and plan future ones
Five basic steps of OR
Problem identification and diagnosis-situation analysis and other qualitative methods including triangulation.
Strategy selection-cost effective, feasible, non interfering too much.
Strategy experimentation and evaluation-field research/computer simulation or analysis.
Information dissemination and utilization.
Replication and up-scaling.
Step I Problem identification and diagnosis
Problem should be defined in terms of its
- Occurrence, intensity, distribution, and other measures (such as impact) for which data are already available. -It emphasises on performance problem ie gap between desired and existing parameters
Defining a problem includes
-Review of relevant literature, examine current service statistics, seeking educated opinion from programme managers, obtain probable reasons for the problem from social, economic, and health perspectives/theory
Problem justification The key aspects in justifying the research problem are:
Knowing whether the problem is current and timely (topical) and perceived by programme managers
How widespread is the problem?
Does it affect key population?
Is problem related to ongoing program activities?
Solutions not known
Does it relate to broad social, economic and health issues (unemployment, status of women, HIV, FP etc)?
Is solution replicable?
Step II Strategy selection
Selecting a strategy Identify potential (alternate) strategies that could be used to solve the program problem
Indicate why the selected strategies are most appropriate
Justify the selection of strategy by:
-Past success - Simplicity of implementing the strategy - Potential for sustaining the strategy - Cost effectiveness of strategy - Technical feasibility of strategy etc
Criteria for selecting strategy-example
Does the selected strategy have the potential to enhance HIV prevention from parents to children?
Is there a perceived need for the strategy among stakeholders?
Does the strategy build upon previous work and thus:
-accelerate the scaling-up, - leverage existing research capacities and structures? Is the strategy sustainable?
Defining study objectives and hypothesis
Ultimate objective -
- Describes expected contributions arising from the study (overall expected outcome) - Contribute to the justification of why the research on the problem was required (relate purpose of study to larger health outcomes) For example – “Ultimate objective of the intervention study is to contribute towards improving the quality of life for PLHA and the effectiveness of prevention, care and support activities offered by CBOs to PLHA”
Defining study objectives
Immediate objective (state what will happen)
- Relate directly to the research problem situation - Indicate the variable that will be examined and measured - Should be stated in behavioral terms - Specify-Who will do; How much of what; To whom; When; Where, and What purpose? For example – 1. “By 2008, the national program in India will develop a youth- friendly program to provide comprehensive VCT to youth aged 16- 18 years. 2. Assess program in terms of utilization of services by youth, cost- effectiveness of services and reduction in sexual risk behaviours.
Defining study hypotheses
Statement about an expected relationship between two or more variables that permit empirical testing
It specifies the expected relationship among variables
Most appropriate when conducting field intervention studies
They serve to direct and guide our research
They indicate major independent and dependent variables of interest
Examples of hypotheses
PLHA who receive comprehensive counseling on ART that includes discussion of side effects and their management before ARV treatment begins are more likely to adhere effectively after a year than PLHA who have not received counseling on ARV before they begin therapy
Community-based HIV/AIDS organizations that actively involve PLHA in planning and implementation of programs will be more likely to achieve their objectives that similar organizations that do not involve PLHA in planning and implementation of programs
Dual protection programs that focus on counseling women together with their male partners will be more successful than dual protection programs that focus only on counseling women
Independent and Dependent Variables
Independent variable causes, determines or influences the dependent variables (direct relationship)
Dependent variables is the central concern of the research proposal’s problem statement
Independent variable acts on the dependent variable through intervening variables which increase or decrease the effect the independent variable has on dependent variable
Eg – To increase condom use (dependent variable) a program initiates a large BCC program (independent variable). Campaign alone can not increase condom use. The intervening variables that might influence the dependent variable would be people’s knowledge, attitudes, sexual risk behaviors and risk perception.
Most HIV/AIDS behavioral research studies are based on a model that includes intervening variables
To summarize – All OR studies should include:
Ultimate objective (state the anticipated contributions of the study)
Immediate objective (state what will be done immediately)
Hypotheses (state the expected relationship between two or more variables)
Research Question (Why, how etc)
Possible OR topics Reducing stigma & discrimination at workplace for HIV patients
Manage risky sexual behaviour among secondary school students
Quality of care for people living with HIV and AIDS
Reducing transmission of HIV from Parents to children
Best ways to introduce ECPs
Optimum cost of injectible contraceptives
Best ways to involve PPs in FP/RNTCP etc
- Provide 3-4 points to define and justify the problem - Identify strategy - State objectives (at least) and frame hypotheses
Step III Experimentation and Evaluation
Who will be responsible for implementing the intervention
- indicate organization(s) responsible and categories of people eg teachers, doctors, peers etc.
Where will the intervention activities take place
- be as specific eg in 30 clinics, 20 slums etc.
What activities will be initiated
- describe sequence of events eg may start with training of health providers (describe nature and duration of training); next a series of meetings in the health facilities (describe frequency and purpose of meetings
Common notation RA- Random assignment Experimental group receives intervention Control group –does not receive intervention X – program intervention; denotes experimental Q – observation measurement passage of time Experimental Group Control Group RA X O Notation of Study Designs
Time 01 X1 02 03 04 Experimental Group 1 RA Control Group True Experimental Design I
Time 01 X1 02 03 X2 04 05 06 Experimental Group 1 Experimental Group 2 Control Group RA True Experimental Design II
Time 01 X1 02 03 X2 04 05 X1+X2 06 Experimental Group 1 RA Experimental Group 2 Control Group True Experimental Design III
Quasi-experimental – no randomization between intervention and control group
Experimental group 01 X 02
Control group 03 04
Non-experimental designs Time
Posttest only X 01
Pretest-Postest 01 X 02
Data Collection Technique
Quantitative – numerical based
- Survey/structured questionnaire
Qualitative – descriptive
- In-depth interviews - Key-informant interviews - Focus group discussions
Data collection framework – to plan for data collection identify study outcomes, indicators to measure the outcomes, respondent and data collection methods
Study outcome Indicators/area of inquiry Respondents Data collection methods Quality of post natal CARE given when women return to health care facility
Percentage of essential practices administered correctly
Percent of essential messages given Postpartum HIV –positive women - clients