Qualitative methods for health research , Qualitative methods for health research , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

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Qualitative methods for health research

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How to Research

Background
Comprehensive geriatric assessment (CGA) is a multi-dimensional, multi-disciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older people with frailty so that a co-ordinated and integrated plan for treatment and follow-up can be developed. This is an update of a previously published Cochrane review.

Objectives
We sought to critically appraise and summarise current evidence on the effectiveness and resource use of CGA for older adults admitted to hospital, and to use these data to estimate its cost-effectiveness.

Search methods
We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 5 October 2016; we also checked reference lists and contacted study authors.

Selection criteria
We included randomised trials that compared inpatient CGA (delivered on geriatric wards or by mobile teams) versus usual care on a general medical ward or on a ward for older people, usually admitted to hospital for acute care or for inpatient rehabilitation after an acute admission.

Data collection and analysis
We followed standard methodological procedures expected by Cochrane and Effective Practice and Organisation of Care (EPOC). We used the GRADE approach to assess the certainty of evidence for the most important outcomes. For this update, we requested individual patient data (IPD) from trialists, and we conducted a survey of trialists to obtain details of delivery of CGA. We calculated risk ratios (RRs), mean differences (MDs), or standardised mean differences (SMDs), and combined data using fixed-effect meta-analysis. We estimated cost-effectiveness by comparing inpatient CGA versus hospital admission without CGA in terms of cost per quality-adjusted life year (QALY) gained, cost per life year (LY) gained, and cost per life year living at home (LYLAH) gained.

Main results
We included 29 trials recruiting 13,766 participants across nine, mostly high-income countries. CGA increases the likelihood that patients will be alive and in their own homes at 3 to 12 months' follow-up (risk ratio (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10; 16 trials, 6799 participants; high-certainty evidence), results in little or no difference in mortality at 3 to 12 months' follow-up (RR 1.00, 95% CI 0.93 to 1.07; 21 trials, 10,023 participants; high-certainty evidence), decreases the likelihood that patients will be admitted to a nursing home at 3 to 12 months follow-up (RR 0.80, 95% CI 0.72 to 0.89; 14 trials, 6285 participants; high-certainty evidence) and results in little or no difference in dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials, 6551 participants; high-certainty evidence). CGA may make little or no difference to cognitive function (SMD ranged from -0.22 to 0.35 (5 trials, 3534 participants; low-certainty evidence)). Mean length of stay ranged from 1.63 days to 40.7 days in the intervention group, and ranged from 1.8 days to 42.8 days in the comparison group. Healthcare costs per participant in the CGA group were on average GBP 234 (95% CI GBP -144 to GBP 605) higher than in the usual care group (17 trials, 5303 participants; low-certainty evidence). CGA may lead to a slight increase in QALYs of 0.012 (95% CI -0.024 to 0.048) at GBP 19,802 per QALY gained (3 trials; low-certainty evidence), a slight increase in LYs of 0.037 (95% CI 0.001 to 0.073), at GBP 6305 per LY gained (4 trials; low-certainty evidence), and a slight increase in LYLAH of 0.019 (95% CI -0.019 to 0.155) at GBP 12,568 per LYLAH gained (2 trials; low-certainty evidence). The probability that CGA would be cost-effective at a GBP 20,000 ceiling ratio for QALY, LY, and LYLAH was 0.50, 0.89, and 0.47, respectively (17 trials, 5303 participants; low-certainty evidence).

Authors' conclusions
Older patients are more likely to be alive and in their own homes at follow-up if they received CGA on admission to hospital. We are uncertain whether data show a difference in effect between wards and teams, as this analysis was underpowered. CGA may lead to a small increase in costs, and evidence for cost-effectiveness is of low-certainty due to imprecision and inconsistency among studies. Further research that reports cost estimates that are setting-specific across different sectors of care are required.

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Comprehensive geriatric assessment for older adults admitted to hospital

This is the last in a series of three articles 

Series editors: Catherine Pope and Nicholas Mays

The barriers to the uptake of the findings of traditional quantitative biomedical research in clinical practice are increasingly being recognised. 1 2 Action research is particularly suited to identifying problems in clinical practice and helping develop potential solutions in order to improve practice.3 For this reason, action research is increasingly being used in health related settings. Although not synonymous with qualitative research, action research typically draws on qualitative methods such as interviews and observation.

#### Summary points

Action research is increasingly being used in healthcare settings

It is a style of research rather than a specific method

Three elements are important: the participatory character of action research; its democratic impulse; and its simultaneous contribution to social science and social change

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(Credit: LIANE PAYNE)

Action research is not easily defined. It is a style of research rather than a specific method. First used in 1946 by Kurt Lewin, a social scientist concerned with intergroup relations and minority problems in the United States, the term is now identified with research in which the researchers work explicitly with and for people rather than undertake research on them.4 Its strength lies in its focus on generating solutions to practical problems and its ability to empower practitioners—getting them to engage with research and subsequent “development” or implementation activities. Practitioners can choose to research their own practice, or an outside researcher can be engaged to help them identify problems, seek and implement practical solutions, and systematically monitor and reflect on the process and outcomes of change.

Most definitions of action research incorporate three important elements: its participatory character; its democratic impulse; and its simultaneous contribution to social science and social change.5

Participation is fundamental to action research: it is …

 [1]: pending:yes

https://www.bmj.com/content/bmj/320/7228/178.1.full.pdf

Qualitative research in health care: Using qualitative methods in health related action research

Implications of transdisciplinarity for sustainability research

Action research in context, process and practice action research case studies working from a project perspective.

Action Research for Health and Social Care: A Guide to Practice

This paper identifies the need for a debate about the appropriateness of action research for nursing as it seeks to achieve the status of a research-based profession. It also identifies a related need to inform such a debate by bringing together three sets of writings that are not normally united in the nursing research literature-those of action research, organizational culture and professionalization. In nursing, as in education, action research is being deployed as part of a professionalizing strategy, since amongst other things it seems to offer a means of developing reflective practitioners and of producing knowledge for practice. The increasing popularity of action research amongst nurse researchers suggests that it is seen to reflect the attributes to which nursing aspires as a profession, including a concern to realize humanistic values. Action research was embraced by the teaching profession before nursing, and nurse researchers are increasingly drawing on the ideas of influential educationalists in defining action research as an emancipatory strategy and a form of collaborative enquiry rooted in reflective practice. This paper argues that in the managerialist context of the British National Health Service action research may be reduced from a participatory methodology into a method for getting people to collaborate with managerial goals and internalize the values of the corporate culture. The danger is that in the name of reflective practice nursing work may become increasingly individualized. The challenge for action research in nursing is how to respond to this dilemma, and this may require looking critically at the managerial values underpinning the NHS reforms and at the organizational context in which action research strategies are deployed.

Action research as a professionalizing strategy: issues and dilemmas

Objectives: to evaluate the effect of a care home rehabilitation service on institutionalisation, health outcomes and service use.

Design: randomised controlled trial, stratified by Barthel ADL index, social service sector and whether living alone. The intervention was a rehabilitation service based in Social Services old people's homes in Nottingham, UK. The control group received usual health and social care.

Participants: 165 elderly and disabled hospitalised patients who wished to go home but were at high risk of institutionalisation (81 intervention, 84 control).

Main outcome measures: institutionalisation rates, Barthel ADL index, Nottingham Extended ADL score, General Health Questionnaire (12 item version) at 3 and 12 months, Health and Social Service resource use.

Results: the number of participants institutionalised was similar at 3 months (relative risk 1.04, 95% confidence intervals 0.65–1.65) and 12 months (relative risk 1.23, 95% confidence intervals 0.75–2.02). Barthel ADL Index, Nottingham Extended ADL score and General Health Questionnaire scores were similar at 3 and 12 months. The intervention group spent significantly fewer days in hospital over 3 and 12 months (mean reduction 12.1 and 27.6 days respectively, P < 0.01), but spent a mean of 36 days in a care home rehabilitation service facility.

Conclusions: this service did not reduce institutionalisation, but diverted patients from the hospital to social services sector without major effects on activity levels or well-being.

/pdf/a-randomised-controlled-trial-of-a-care-home-rehabilitation-3ncgly5y1x.pdf

A randomised controlled trial of a care home rehabilitation service to reduce long-term institutionalisation for elderly people

Commenting on earlier work in the Journal of Advanced Nursing on action research, this paper takes up the theme of definition and approach and presents an original action research typology Three key criteria of action research -‘reeducation’,‘problem focus’, and‘improvement and involvement’— are related to four broad types of action research‘experimental’,‘organizational’,‘professionalizing’and‘empowering’The typology is of general relevance not only to action researchers but to any project concerned to resolve problems and bring about improvements in practice, including evaluation research Following discussion of the typology, it is used to analyse three different action research projects, including one conducted by the authors in collaboration with a project team It is shown that each of these projects, which are all concerned in some way to improve standards of nursing care in hospitals, contains elements of different types which may at times be in conflict The ability to recognize this and to be explicit about the different types may assist action researchers in selecting an appropriate approach and in anticipating problems which may arise during the course of a project's life

Making sense of action research through the use of a typology

This study reports research on the experiences of stroke survivors and their informal carers who are receiving stroke services in the community. As part of a qualitative evaluation of a Pilot Community Stroke Service in Nottingham, England, interviews were conducted with stroke survivors, their families and friends, alongside interviews with the managers and professionals providing the service. The findings from the interview data were compared across cases and with findings from analyses of documentary data such as clients’ individual plans, and participant observational data, such as those of team meetings. Data analysis revealed that of the 57 survivors, 13 had suffered setbacks that were a direct consequence of their interactions with health and social care services and were system induced. This paper introduces and discusses the concept of the system induced setback by exploring the experiences of these 13 survivors. Implications for understanding the interplay of service provision and disease process are highlighted.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/1467-9566.00243

Elizabeth Hart

Papers

Action Research for Health and Social Care: A Guide to Practice

Action research as a professionalizing strategy: issues and dilemmas

A randomised controlled trial of a care home rehabilitation service to reduce long-term institutionalisation for elderly people

Making sense of action research through the use of a typology

System induced setbacks in stroke recovery