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Health System Research:
Designs and Methods
Tulsi Ram Bhandari
Ph D Scholar
Outlines of presentation
 Introduction
 Development
 Objective
 Areas
 Designs, methods & techniques
 Ethical issues...
What is research?
 Scientific and systematic search for
information on particular subject/issue.
 Embedded in epistemolo...
What is health system research?
 Part of research/health research,
 Results closely linked to health system,
 Initially...
Development of HSR
In 1967, Division of Research in
Epidemiology and Communication
Science (RECS) was established for
res...
Development cont…
In 1978, Global Advisory Committee on
Medical Research and Sub-committee
on Health Services Research we...
 In 1980, WHO recognized and
established Health System Research
with following mandates-
 Promotion, coordination and in...
 In 2000, Health Policy and System Research was
launched to improve the performance of health
systems.
 First time in 20...
Health system ?
It is defined as-
“All the organizations, people
and actions whose primary
intent is to promote, restore ...
Definition of HSR
 “the multidisciplinary field of scientific
investigation that studies how social factors,
financing sy...
Concern of HSR
Prime concern of HSR is to provide
information for decision-making that
can improve the functioning of the
...
Concern Areas of HSR5
(2)
(4)
(1) (3)
Objective of HSR
…to provide health managers at all
levels, as well as community
members, with the relevant
information t...
Importance of HSR
 It is needed to-
 Strengthen the health care.
 Work with real field problems
 Use variety of resear...
Steps/process of HSR
Define research
problem
Literature
review
Review concepts
& theories
Review previous
findings
Generat...
Research Design
It is considered as a "blueprint" for
research, dealing with at least four
problems:
which questions to ...
Designs: HSR
Non-Intervention
studies
Intervention
studies
Exploratory
studies
Descriptive
studies
Comparative/
Analytical...
Exploratory Studies
 It is a small-scale study of relatively
short duration, which is carried out
when little is known ab...
Descriptive studies
 It involves describing the characteristics
of a particular situation, event or case,
such as- physic...
Comparative or analytical
studies
 It attempts to establish causes or risk
factors for certain problems by comparing
two ...
Cross-sectional comparative
studies
 It is a type of survey focus on describing
as well as comparing groups.
 Researcher...
Case – control studies
 Investigator compares one group
among whom the problem that he
wishes to investigate is present, ...
Case-control design
Population
Cases
Controls
Risk factor
Present
Risk factor
absent
Comparison
Risk factor
Present
Risk f...
Cohort studies
 In a study, a group of individuals that is
exposed to a risk factor (exposed group)
is compared to a grou...
Cohort studies design
Population
Exposed to
risk factors
Not exposed
to risk factors
Problem
Present
Problem not
present
C...
Experimental Studies
 In this study, individuals are randomly
allocated to at least two groups.
 One group is subject to...
Experimental studies Design
Population
Sampling
Sample
Randomization
Experimental group Control group
Data collection Data...
Quasi-experimental studies
 It is missing either randomisation or the use
of a separate control group.
 However, it alwa...
Study group before
Comparison
Study group afterIntervention
Pretest-posttest experimental studies
 It is quite easy to se...
Design Vs Method
 Design ≠ method of data collection
 Design ≠ quantitative / qualitative
Design?
Systematic plan/proced...
Methods in HSR
Methods Tools
Quantitative
Survey/ census: Structured Interview/
self administered questionnaire
Structured...
Methods in HSR cont…
Methods ToolsQualitative
Case studies
Guideline/structured
format/conceptual framework
Focus Group Di...
Quantitative
 Explanation,
prediction
 Test theories
 Known variables
 Large sample
 Standardized
instruments
 Often...
Relationship b/w Qualitative and
quantitative methods in Research
Qualitative
studies
Quantitative
studies
Themes
Understa...
Data Collection Techniques
 Using available information,
 Observing,
 Interviewing,
 Administering written questionnai...
Using available information
 Routinely collected data,
 Secondary data: HMIS, NDHS, Census etc
 Unpublished record repo...
Observing
 Observation of human behaviours,
 Observation of objects
 Types of observation-
 Participatory vs non-parti...
Interviewing
 High degree of flexibility: In-depth interview
 Semi-structural interview
 Low degree of flexibility: str...
Administering
 Ways of administering-
 Sending by mail/email and receiving by
same ways,
 Hand-to-hand delivering and l...
Projective technique (PT)
 Ask the participant to response the
hypothetical or incomplete question.
 E.g.
 Suppose your...
Mapping and Scaling
 Mapping is a valuable technique for
visually displaying relationships and
resources.
 Process mappi...
Systematic/extensive review
 Online available literature review
 Published documents review
 Grey literature review
 U...
Case studies
 Examine to a great extent in order to
find out and correct possible errors.
 Common used case studies tech...
System Review
 systems review is a technique, used to elicit
the situation (Past and present) of an
organization.
 Commo...
Program Evaluation
 Common techniques –
 Content analysis: textual analysis
 both qualitative and quantitative studies
...
Program Evaluation cont…
 Financing analysis
 Government financing in health
 Corporate financing
 Private financing i...
Demand and supply analysis
Supply side intervention Demand side intervention
Institutional Innovation
Financial incentives...
Social Network Analysis (SNA)
 It is defined as a distinctive set of methods used
for mapping, measuring and analysing th...
Meta-Analysis
 A systematic method of evaluating
statistical data based on results of
several independent studies of the
...
Ethical issues in HSR
 Ethical approval and informed consent,
 Respect of participants,
 Autonomy of individual partici...
Limitations of HSR
 Difficult in randomization and equal
participation of subject,
 High turnover: retirement, transfer,...
Conflict of Interest in HSR
 Among research team/s and members.
 Financial issues and quality of research.
 Disseminati...
Conclusion
 HSR is a new discipline of research/ health
research.
 Health services research, health policy and
system re...
At last…
 First Global Symposium on Health
Systems Research (HSR), Was
organized in Montreux, Switzerland, 16–
19 Novembe...
Thank you!
Development of HSR
In 1967, Division of Research in
Epidemiology and Communication
Science (RECS) was established for
res...
Development cont…
In 1978, Global Advisory Committee on
Medical Research and Sub-committee
on Health Services Research we...
 In 1980, as per the recommendation of
Health Services Research Sub-
committee, WHO had recognized
Health Service Researc...
 In 1980, Health System Research was
considered as an organization with
following mandates-
 Promotion, coordination and...
 In 1990, Technical Discussions of Forty-
Third World Health Assembly finalized the
following four major themes/issues in...
 In 2000, Health Policy and Systems Research was
officially launched with the following objectives :
 Stimulate the gene...
 First time in 2002, under the umbrella of
Health System Research there was
initiated a new sub area Public Health
System...
Supply and demand barriers to
utilization of health care
...
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Health system research designs and methods

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Transcript of "Health system research designs and methods"

  1. 1. Health System Research: Designs and Methods Tulsi Ram Bhandari Ph D Scholar
  2. 2. Outlines of presentation  Introduction  Development  Objective  Areas  Designs, methods & techniques  Ethical issues  Limitations  Conflict of interest  conclusion
  3. 3. What is research?  Scientific and systematic search for information on particular subject/issue.  Embedded in epistemological position and theoretical framework.  Collects essential evidence with the help of different research methods.
  4. 4. What is health system research?  Part of research/health research,  Results closely linked to health system,  Initially, it was known as health service research,
  5. 5. Development of HSR In 1967, Division of Research in Epidemiology and Communication Science (RECS) was established for research works, under WHO. In 1972, RECS was restructured into Division of Strengthening Health Services (SHS) and Health Services Research responsibilities were transferred to Division of SHS.
  6. 6. Development cont… In 1978, Global Advisory Committee on Medical Research and Sub-committee on Health Services Research were formed- to achieve “Health For All by the year 2000” and Implement the “Primary Health Care” approach successfully.
  7. 7.  In 1980, WHO recognized and established Health System Research with following mandates-  Promotion, coordination and information exchange in the practice of HSR,  Strengthening of national capabilities for HSR training and development  Support to substantive research in priority areas. Development cont…
  8. 8.  In 2000, Health Policy and System Research was launched to improve the performance of health systems.  First time in 2002, under the umbrella of Health System Research there was initiated a new sub area Public Health System Research by the public health system research interest group (PHSR-IG). Development cont…
  9. 9. Health system ? It is defined as- “All the organizations, people and actions whose primary intent is to promote, restore or maintain health.” (WHO-2000)
  10. 10. Definition of HSR  “the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviours affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations.” 6
  11. 11. Concern of HSR Prime concern of HSR is to provide information for decision-making that can improve the functioning of the health system.
  12. 12. Concern Areas of HSR5 (2) (4) (1) (3)
  13. 13. Objective of HSR …to provide health managers at all levels, as well as community members, with the relevant information they need to make decisions on health-related issues and problems they are facing.
  14. 14. Importance of HSR  It is needed to-  Strengthen the health care.  Work with real field problems  Use variety of research disciplines  Apply practical scientific knowledge for improving health care and health status.
  15. 15. Steps/process of HSR Define research problem Literature review Review concepts & theories Review previous findings Generate research question/s (?) Researchdesign &executiveplan Execute research project Analyze & interpret results Submit report Disseminate results Seminar/ workshop Publication
  16. 16. Research Design It is considered as a "blueprint" for research, dealing with at least four problems: which questions to study, which data are relevant, how to collect data, and how to analyze and interpret the data.
  17. 17. Designs: HSR Non-Intervention studies Intervention studies Exploratory studies Descriptive studies Comparative/ Analytical studies Experimental studies Quasi-experimental studies Pre-post experimental studies
  18. 18. Exploratory Studies  It is a small-scale study of relatively short duration, which is carried out when little is known about a situation or a problem.  It may include description as well as comparison.  Approach the problem from different angles at same time (Triangulation). E.g. piloting studies, small scale comparative studies
  19. 19. Descriptive studies  It involves describing the characteristics of a particular situation, event or case, such as- physical, socio-economic and cultural, behavioural, etc.  It can be carried out on a small or larger scale- 1. Small scale: case studies 2. Large scale: surveys/census (Note: one time data collection)
  20. 20. Comparative or analytical studies  It attempts to establish causes or risk factors for certain problems by comparing two or more groups, some of which have or develop the problem and some of which have not.  It can be carried out as follows- 1. Cross-sectional comparative studies 2. Case – control studies 3. Cohort studies
  21. 21. Cross-sectional comparative studies  It is a type of survey focus on describing as well as comparing groups.  Researchers wish to determine the role of independent variable to dependent variable. (Note: relationship between variables)
  22. 22. Case – control studies  Investigator compares one group among whom the problem that he wishes to investigate is present, and another group called a control or comparison group, where the problem is absent, in order to find out what factors have contributed to the problem.
  23. 23. Case-control design Population Cases Controls Risk factor Present Risk factor absent Comparison Risk factor Present Risk factor absent PresentPast (Retrospective study, looking backward)
  24. 24. Cohort studies  In a study, a group of individuals that is exposed to a risk factor (exposed group) is compared to a group of individuals not exposed to the risk factor (non-exposed group).  The researcher follows both groups over time and compares the occurrence of the problem.
  25. 25. Cohort studies design Population Exposed to risk factors Not exposed to risk factors Problem Present Problem not present Comparison Problem Present Problem not present FuturePresent (Prospective study, looking forward)
  26. 26. Experimental Studies  In this study, individuals are randomly allocated to at least two groups.  One group is subject to an intervention, or experiment, while the other group(s) is not.  The outcome of the intervention is obtained by comparing the two groups.
  27. 27. Experimental studies Design Population Sampling Sample Randomization Experimental group Control group Data collection Data collection Manipulation/intervention No manipulation/placebo Data collection Data collection Comparison
  28. 28. Quasi-experimental studies  It is missing either randomisation or the use of a separate control group.  However, it always includes the manipulation/ intervention. Study design Control group before Study group Comparison Control group after Study group afterIntervention
  29. 29. Study group before Comparison Study group afterIntervention Pretest-posttest experimental studies  It is quite easy to set up because uses only one group.  The situation is analysed by comparing before and after the intervention. Study design
  30. 30. Design Vs Method  Design ≠ method of data collection  Design ≠ quantitative / qualitative Design? Systematic plan/procedure under which a study is carried out. Method ? Systematic process of achieving certain ends with accuracy and efficiency, in an ordered sequence of fixed steps.
  31. 31. Methods in HSR Methods Tools Quantitative Survey/ census: Structured Interview/ self administered questionnaire Structured interview schedule/ questionnaire Record review / Service statistics Checklist Observation Checklist System analysis/review Combined tools Secondary data use/analysis Statistical software Content analysis Combined tools Meta-analysis, systematic review Statistical software Social Network Analysis(SNA) Combined tools Mapping(Process & Service) With GIS map/ sketch map
  32. 32. Methods in HSR cont… Methods ToolsQualitative Case studies Guideline/structured format/conceptual framework Focus Group Discussion Guideline In-depth Interview guideline Participatory observation Checklist/daily diary Cognitive mapping With GIS map/sketch map Mixedmethods (Triangulation) E.g. FGD+ In-depth interview+ structured interview Guidelines + Interview schedule Projective techniques Combined with other methods (FGD, questionnaire, interview)
  33. 33. Quantitative  Explanation, prediction  Test theories  Known variables  Large sample  Standardized instruments  Often deductive Qualitative  Explanation, description  Build theories  Unknown variables  Small sample  Observations, interviews  Often inductive Qualitative vs Quantitative Methods
  34. 34. Relationship b/w Qualitative and quantitative methods in Research Qualitative studies Quantitative studies Themes Understanding problems & identifying associations with and between contributing factors Operational definition of variables Measuring problems & testing hypotheses about contributing factors
  35. 35. Data Collection Techniques  Using available information,  Observing,  Interviewing,  Administering written questionnaire,  Focus group discussion,  Projective technique,  Mapping scaling, and  others
  36. 36. Using available information  Routinely collected data,  Secondary data: HMIS, NDHS, Census etc  Unpublished record report,  Publications  Grey literature( rarely available published documents),  Newspapers,  Case histories, etc
  37. 37. Observing  Observation of human behaviours,  Observation of objects  Types of observation-  Participatory vs non-participatory  Open vs conceal  Observation tool: checklist  Structural  Semi-structural
  38. 38. Interviewing  High degree of flexibility: In-depth interview  Semi-structural interview  Low degree of flexibility: structural interview  Exit interview, supplementary interview, etc  Interview tools  Guideline  Structured schedule
  39. 39. Administering  Ways of administering-  Sending by mail/email and receiving by same ways,  Hand-to-hand delivering and later collection,  Gathering respondent and requesting to response and return immediately.
  40. 40. Projective technique (PT)  Ask the participant to response the hypothetical or incomplete question.  E.g.  Suppose your child suffered from ARI, what would you do?  If your wife was to propose that you use condoms, you would ...  PT can be combined with other methods: FGD, questionnaire, interview etc
  41. 41. Mapping and Scaling  Mapping is a valuable technique for visually displaying relationships and resources.  Process mapping  Service mapping  Scaling is a technique that allows researchers through their respondents to categorise certain Variables.
  42. 42. Systematic/extensive review  Online available literature review  Published documents review  Grey literature review  Unpublished document/desk review  Review focused on analytical question, etc
  43. 43. Case studies  Examine to a great extent in order to find out and correct possible errors.  Common used case studies techniques  Use systemic rapid assessment toolkit  Use conceptual framework  Use unstructured questionnaire  Participatory observation, etc.
  44. 44. System Review  systems review is a technique, used to elicit the situation (Past and present) of an organization.  Common techniques of SR-  Structural review  Narrative analysis of selective documents  Time and motion analysis  Cost analysis  Trend analysis  Demand and supply analysis  Gaps and surplus analysis  Disease burden analysis  Lot Quality Assurance Sampling(LQAS)
  45. 45. Program Evaluation  Common techniques –  Content analysis: textual analysis  both qualitative and quantitative studies  Analysis: objective, scopes, outputs/outcome  Cost analysis 1. Cost-utility 2. Cost-benefit 3. Cost- effectiveness 4. Cost –minimization  Budget analysis  Sources of revenue  Areas of expenditure
  46. 46. Program Evaluation cont…  Financing analysis  Government financing in health  Corporate financing  Private financing in health  Per-capita health expenditure  Catastrophic healthcare/expenditure  Role of user fees, etc Health expenditure= government financing + private expenditure
  47. 47. Demand and supply analysis Supply side intervention Demand side intervention Institutional Innovation Financial incentives Skill development Improved infrastructure Providers Health Services Consumers /users Empowerment Awareness …
  48. 48. Social Network Analysis (SNA)  It is defined as a distinctive set of methods used for mapping, measuring and analysing the social relationships between people, groups and organizations.  It consists of 3 stages:  describing the set of actors and members of the network;  characterizing the relationships between actors; and  analysing the structure of the systems and generating information…
  49. 49. Meta-Analysis  A systematic method of evaluating statistical data based on results of several independent studies of the same problem.  Produces a stronger conclusion than can be provided by any individual study.  Useful for quantitative as well as qualitative studies
  50. 50. Ethical issues in HSR  Ethical approval and informed consent,  Respect of participants,  Autonomy of individual participants,  Benefits and risks,  Dissemination and publication of results,  Unique human nature and implementation of protocol  Conflict of interest, …
  51. 51. Limitations of HSR  Difficult in randomization and equal participation of subject,  High turnover: retirement, transfer, change, etc  Difficult to match with relevance policy and community’s expectation,  Cost and benefits: control and distribution  Implementation of results with scare resources  Donor interest and influence  Access/permission , publication and dissemination of results
  52. 52. Conflict of Interest in HSR  Among research team/s and members.  Financial issues and quality of research.  Disseminating and publishing of the results.  Maintaining the distance and relationship with participants.  Conflict with government’s regulations, policies, programs, interests…
  53. 53. Conclusion  HSR is a new discipline of research/ health research.  Health services research, health policy and system research and public health system research are very close terms with health system research.  Health system research is being influenced by global politics and investments rather than its own philosophy.
  54. 54. At last…  First Global Symposium on Health Systems Research (HSR), Was organized in Montreux, Switzerland, 16– 19 November 2010  Second Global Symposium is going to be organized from 31st Oct. to 3rd Nov. 2012, Beijing, People's Republic of China.
  55. 55. Thank you!
  56. 56. Development of HSR In 1967, Division of Research in Epidemiology and Communication Science (RECS) was established for research works, under WHO. In 1972, RECS was restructured into Division of Strengthening Health Services (SHS) and Health Services Research responsibilities transferred to SHS.
  57. 57. Development cont… In 1978, Global Advisory Committee on Medical Research and Sub-committee on Health Services Research were formed- to achieve “Health for All by the year 2000” and Implement the “Primary Health Care” approach successfully.
  58. 58.  In 1980, as per the recommendation of Health Services Research Sub- committee, WHO had recognized Health Service Research as a priority area and established Health System Research. Development cont…
  59. 59.  In 1980, Health System Research was considered as an organization with following mandates-  Promotion, coordination and information exchange in the practice of HSR,  Strengthening of national capabilities for HSR training and development  Support to substantive research in priority areas. Development cont…
  60. 60.  In 1990, Technical Discussions of Forty- Third World Health Assembly finalized the following four major themes/issues in health research- Health systems research, Nutrition research, Research capability strengthening, and Science, research and health care. Development cont…
  61. 61.  In 2000, Health Policy and Systems Research was officially launched with the following objectives :  Stimulate the generation and synthesis of knowledge, encompassing evidence, tools and methods  Facilitate the development of capacity for the generation, dissemination and use of knowledge among researchers, policy makers and other stakeholders  Promote the dissemination and use of knowledge to improve the performance of health systems. Development cont…
  62. 62.  First time in 2002, under the umbrella of Health System Research there was initiated a new sub area Public Health System Research by the public health system research interest group (PHSR- IG). Development cont…
  63. 63. Supply and demand barriers to utilization of health care ...
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