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 ORFocuses on:

Day-to-day activities or ‘operations’ of Health, FP and HIV/AIDS programs etc

Search for solutions

Objectives:

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 definition 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 justificationThe 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

Thinking points?- Provide 3-4 points to define and justify the problem -      Identify strategy- State objectives (at least) and frame hypotheses

Step III

Experimentation and Evaluation

Intervention Description 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

Testing Intervention-OR

Intervention study designs range from- True-experimental

- Quasi-experimental

- Non-experimental

Notation of Study Designs

RA

Experimental Group

Control Group

XO

Common notation

RA- Random assignmentExperimental group receives intervention

Control group –does not receive intervention

X – program intervention; denotes experimental

Q – observation measurement passage of time

True Experimental Design I

RA

Experimental Group 1

Control Group

Time

01 X1 02

03 04

True Experimental Design II

Time

01 X1 02

03 X2 04

05 06

Experimental Group 1

Control Group

Experimental Group 2

RA

True Experimental Design III

Experimental Group 1

Control Group

Experimental Group 2

RA

Time

01 X1 02

03 X2 04

05 X1+X2 06

Quasi-Experimental

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

Study methods 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 Health care providers

Observations of providers   Key informant interviews with providers Survey

THANK YOU