Operations Research in Health and Family Planning byProf V. K. Tiwari, NIHFW, N Delhi<br />XIII Annual Conference of Indian Association of Preventive & Social Medicine, UP-UK Chapter, HIHT Dehradun<br />25-9-2010<br />
Background of OR<br />OR Used in second world war to precisely hit enemy targets by Americans<br />Thereafter, focus shifted to Management problems in business and industries<br />During sixties, WHO and Population Council started OR applications in Health and Family Planning.<br />
What is operations research?<br />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.<br />
Goals of operations research <br /> Provide program managers/policy makers with information to make decisions to improve program operations (to solve problems) eg:<br /><ul><li>Increase efficiency, effectiveness and quality of service delivered by providers
Increase availability, accessibility and acceptability of services desired by users</li></li></ul><li>Focus and Objectives of OR<br /> Focuses on:<br /><ul><li>Day-to-day activities or ‘operations’ of Health, FP and HIV/AIDS programs etc
Search for solutions</li></ul> Objectives: <br /><ul><li>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</li></li></ul><li>Five basic steps of OR<br /><ul><li>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.
Replication and up-scaling.</li></li></ul><li>Step I<br />Problem identification and diagnosis <br />
Problem definition<br /><ul><li>Problem should be defined in terms of its</li></ul> - Occurrence, intensity, distribution, and other measures (such as impact) for which data are already available.<br /> -It emphasises on performance problem ie gap between desired and existing parameters<br /><ul><li>Defining a problem includes</li></ul> -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<br />
Problem justification<br />The key aspects in justifying the research problem are:<br /><ul><li>Knowing whether the problem is current and timely (topical) and perceived by programme managers
Does it relate to broad social, economic and health issues (unemployment, status of women, HIV, FP etc)?
Is solution replicable?</li></li></ul><li>Step II<br />Strategy selection<br />
Selecting a strategy<br />Identify potential (alternate) strategies that could be used to solve the program problem<br /><ul><li>Indicate why the selected strategies are most appropriate
Justify the selection of strategy by:</li></ul>-Past success<br /> - Simplicity of implementing the strategy<br /> - Potential for sustaining the strategy<br /> - Cost effectiveness of strategy<br /> - Technical feasibility of strategy etc<br />
Criteria for selecting strategy-example <br /><ul><li>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:</li></ul>-accelerate the scaling-up,<br /> - leverage existing research capacities and structures? <br />Is the strategy sustainable?<br />
Defining study objectives and hypothesis<br /><ul><li>Ultimate objective -</li></ul> - Describes expected contributions arising from the study (overall expected outcome) <br /> - Contribute to the justification of why the research on the problem was required (relate purpose of study to larger health outcomes)<br /> 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”<br />
Defining study objectives<br /><ul><li>Immediate objective (state what will happen) </li></ul>- Relate directly to the research problem situation <br /> - Indicate the variable that will be examined and measured <br /> - Should be stated in behavioral terms<br /> - Specify-Who will do; How much of what; To whom; When; Where, and What purpose?<br />For example – <br /> 1. “By 2008, the national program in India will develop a youth- friendly program to provide comprehensive VCT to youth aged 16- <br /> 18 years. <br /> 2. Assess program in terms of utilization of services by youth, cost- effectiveness of services and reduction in sexual risk behaviours.<br />
Defining study hypotheses<br /><ul><li>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 indicate major independent and dependent variables of interest</li></li></ul><li>Examples of hypotheses<br /><ul><li>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</li></li></ul><li>Independent and Dependent Variables<br /><ul><li>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</li></ul>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.<br /> <br /> Most HIV/AIDS behavioral research studies are based on a model that includes intervening variables<br />
To summarize –<br />All OR studies should include:<br /><ul><li>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)</li></li></ul><li>Possible OR topics<br />Reducing stigma & discrimination at workplace for HIV patients <br /><ul><li>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
Thinking points?</li></ul>- Provide 3-4 points to define and justify the problem <br /> - Identify strategy<br /> - State objectives (at least) and frame hypotheses <br />
Step III<br /> Experimentation and Evaluation<br />
Intervention Description<br /><ul><li>Who will be responsible for implementing the intervention</li></ul> - indicate organization(s) responsible and categories of people eg teachers, doctors, peers etc.<br /><ul><li>Where will the intervention activities take place </li></ul> - be as specific eg in 30 clinics, 20 slums etc. <br /><ul><li>What activities will be initiated</li></ul>- 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 <br />
Testing Intervention-OR<br /><ul><li>Intervention study designs range from</li></ul>- True-experimental <br /> - Quasi-experimental <br /> - Non-experimental <br />
Common notation<br />RA- Random assignment<br />Experimental group receives intervention<br />Control group –does not receive intervention<br />X – program intervention; denotes experimental<br />Q – observation measurement passage of time<br />Experimental Group<br />Control Group<br />RA<br />X<br />O<br />Notation of Study Designs<br />
Quasi-Experimental<br /><ul><li>Quasi-experimental – no randomization between intervention and control group</li></ul>Experimental group 01 X 02<br /> <br /> Control group 03 04<br />
Non-experimental designs<br /> Time <br /> <br />Posttest only X 01<br /> <br />Pretest-Postest 01 X 02<br />
Study methods<br /><ul><li>Data Collection Technique
Quantitative – numerical based </li></ul> - Survey/structured questionnaire <br /><ul><li>Qualitative – descriptive </li></ul> - In-depth interviews<br /> - Key-informant interviews<br /> - Focus group discussions <br /><ul><li>Data collection framework – to plan for data collection identify study outcomes, indicators to measure the outcomes, respondent and data collection methods</li></li></ul><li>Study outcome<br />Indicators/area of inquiry<br />Respondents <br />Data collection methods<br />Quality of post natal CARE given when women return to health care facility<br /> <br />Percentage of essential practices administered correctly <br /> <br />Percent of essential messages given<br />Postpartum HIV –positive women - clients<br /> <br />Health care providers<br />Observations of providers<br /> <br /> <br /> <br />Key informant interviews with providers<br /> <br />Survey <br />