Defining what the problem is Framing a research question FETP India

Defining what the problem is

Framing a research question

FETP India

Competency to be gained from this lecture

Formulate a precise research question that usefully addresses public health

needs

Key areas

• Levels in fundamental or applied research

• Working with programmes to understand their data needs

Asking yourself the right question

• Two ways to deal with a poor or irrelevant research question: Try to answer it

• The answer may be of no use of anyone• There may be no answer…

Try to reframe it

• If your research question is wrong: No good hard work will save your work

• If your research question is right: You have an opportunity to do a good job

Applied epidemiology

Field epidemiology

Field epidemiologists feed programme managers with

information for action

Plan

AssessEvaluate

Implement Applied epidemiology

Fundamental and applied epidemiological projects

Type of projects Objective of the investigations

Relevance to field epidemiology

Fundamental research

Theoretical rationale -

Applied research Efficacy +

Prevention research Effectiveness ++

Assessment, monitoring and evaluation

Implementation +++

Progressing towards applied research questions: Immunization

example• Fundamental research

Studies assessing candidate vaccine antigens

• Applied investigation Clinical trials

• Prevention research Social marketing, cost effectiveness

• Assessment, monitoring and evaluation Post implementation evaluation,

coverage survey Applied epidemiology

Working with public health managers to identify data needs

• Identify public health problems • Estimate public health importance • Analyze problems• Review what is being already done• Identify the information needed to

improve

Addressing the data needs of programmes



improve


Identification of a public health problem

• Any disease, injury, risk factor, environment threat or social condition that can cause death / disability

• Points that need to be characterized What

• Nature / etiology of the condition How much

• Magnitude Who

• Population at risk Where

• Geographic locations When

• Time of occurrence / seasonal variations

Health problem statement: Example

• Diphtheria rates in Hyderabad, AP, India, increased from 11 to 21 per 100,000 between 2003 and 2006, particularly affecting children 5 to 15 years of age

• Specifies: What Where How much When Who




improve


Criteria used to assess the public health importance of a problem

• Burden of disease Use local, national and international

estimates• Death• Disease• Disability• Economic losses

• Recent emergence • Availability of effective interventions• Cost effectiveness of interventions




improve


Analysing a public health problem:Spreading out issues to identify

options• Identify the problem

E.g., High diphtheria rates

• Identify causes Immediate determinants

• E.g., Low immunization coverage Direct and indirect contributing factors

• E.g., Minorities

• Identify consequences E.g., Mortality from diphtheria

• Identify possible solutions E.g., Increase coverage of boosters


1 1Health

problem

Determinants

Direct contributing

factors

Indirect contributing

factors

Consequences: -1 -2 -3

2

3

2

<Specify>

<Specify>

<Specify>

Determinants and contribution factors diagram for a public health problem

Possible intervention 1



Diphtheria

ExposureHealth

problem

Determinants

Direct contributing

factors

Consequences: -Deaths -Disease

- Disability

Immunization

Supplemental vaccination

activities

Treatment

Susceptibility

Minorities

Crowding

Ventilation

An analysis of the problem of diphtheria in Hyderabad, AP, India

Housing



improve


Reviewing planned, ongoing or completed interventions

• Locate the level of the various interventions: Determinants Contributing factors

• Review effectiveness• Estimate cost effectiveness• Analyze implementation status

Input Process Outcome


Interventions for diphtheria in Hyderabad, AP, India

• Treatment of cases Antibiotics and support, no antitoxin

• Immunization Intervention

• 3 doses of primary vaccination• 2 boosters during the 2nd and 4th year

Implementation• Reported coverage: 100%• No validation• Possibility of pockets with low coverage




improve


Identifying the information needed to allow better prevention and

control• Is the problem a consequence of a failure to

implement a well validated strategy? Need of assessment, monitoring and evaluation

• Is the problem a consequence of difficulty to apply a recommended strategy? Need of prevention research

• Is the problem a consequence of a limitation or of a lack of validated strategy (i.e., the recommendations are implemented but they don’t work)? Applied investigation


Making sure you are not re-inventing the wheel

• Identify what is known (easy) Guidelines Recommendations Reviews Literature search

• Identify what is not known (difficult) Meeting reports Research agenda Expert opinion


What is known and unknown about Diphtheria in Hyderabad, AP, India

• Established facts Primary immunization protects small children Boosters are needed for longer term

protection Reported coverage is high

• Areas of uncertainty: Vaccine failure?

• Is the vaccine as effective as it is supposed to be ? Failure to vaccine?

• Could there be pockets of lower coverage that could allow the disease to spread?


Anticipating what will be done with the information that will be delivered

by an applied research project

• Anticipate the various possible results of the study Imagine scenarios of various possible

answers to the research question

• Identify the kind of public health action that could be realistically taken for each case scenario


Expected benefit of a diphtheria study in Hyderabad, AP, India

• If the vaccine efficacy is low: Programme evaluation could identify where

the problem is (e.g., Cold chain? Manufacturer?)

• If there are pockets of lower coverage: Supplemental immunization activities could

increase population immunity


Evolving public health concepts are like onions being peeled

• Sound answers to good research question allow prevention BUT bring new questions

• These questions should be framed with the same careful methods

• Addressing consecutive publichealth questions is: Useful Gratifying


The life cycle of epidemiological investigations: The never ending

storyIdentifying data needs

Spelling out the research question

Formulating the study objectives

Planning the analysis

Preparing data collection instruments

Analysing data

Drawing conclusions

Formulating recommendations

Involving the programme

Collecting data

Here we go again

Possible future next step for the diphtheria study in Hyderabad, AP,

India• Conclusions

Booster is key for protection among children > 5 years

Booster coverage drops among selected minorities

• Possible next question What is the best strategy to use to increase

the coverage of booster among minorities?


Take home messages

• Have a customer-focused attitude with public health managers to cater to their needs for strategic information

• Imagine yourself with your results in hands and try to imagine how they would contribute to better health Determine how the results of the study will

bring strategic information that will unlock new prevention / control opportunities

Additional resources on research question

• Template of a slide set framing a research question

• Example of research question slide set (HIV in West Bengal)

• Case study on research question formulation (Scrub Typhus in Darjeeling, Volume 1)

Documents

Defining what the problem is Framing a research question FETP India