Document(s) 8 of 27

Flowchart: Steps in the development of a health systems research proposal

NB: Development of a research process is a cyclical process. The double-headed arrows indicate that the process is never linear.

Module 5: REVIEW OF AVAILABLE LITERATURE AND INFORMATION

Why is it important to review already available information when preparing a research proposal?

• It prevents you from duplicating work that has been done before.
• It helps you to find out what others have learned and reported on the problem you want to study. This may assist you in refining your statement of the problem.
• It helps you to become more familiar with the various research approaches that might be used in your study.
• It should provide you with convincing arguments for why your particular research project is needed.

What are the possible sources of information?

• Individuals, groups, and organisations;
• Published information (books, articles, indexes, abstract journals); and
• Unpublished information (other research proposals in related fields, reports, records, computer data bases)

Where can we find these different sources?

Different sources of information can be consulted and reviewed at various levels of the administrative system within your country and internationally.

ADMINISTRATIVE LEVELS        EXAMPLES OF RESOURCES

You need to develop a strategy to gain access to each source and to obtain information in the most productive manner. Your strategy may vary according to where you work and the topic under study. It may include the following steps:

• Identifying a key person (researcher, decision maker or community member) who is knowledgeable on the topic and ask if he or she can give you a few good references or/and the names of other people whom you could contact for further information;
• Looking up the names of speakers on your topic at conferences that may be useful to contact;
• Contacting librarians in universities, research institutions, the Ministry of Health and newspaper offices and requesting relevant references;
• Examining the bibliographies and reference lists in key papers and books to identify relevant references;
• Looking for references in indexes (e.g. Index Medicus) and abstract journals (see Annex 5.1); which are available in libraries either as hard copies or in computerised form.
• Requesting a computerised literature search (e.g. Medline, see Annex 5.2).

Some agencies will assist with your literature search if requested by telephone or in writing. The request, however, should be very specific. Otherwise you will receive a long list of references, most of which will be not be relevant to your topic. If you are requesting a computerised search it is useful to suggest key words that can be used in locating the relevant references.

References that are identified:

• Should first be skimmed or read.
• Then summaries of the important information in each of the references should be recorded on separate index cards (Annex 5.3) or as computer entries. These should then be classified so that the information can easily be retrieved.
• Finally the literature should be included in your protocol.

Information on an index card should be organised in such a way that you can easily find all data you will need for your report:

For an article the following information should be noted:

Author(s)’ Surname followed by initials. Title of article. Name of Journal. Year, Volume, (number): page numbers of article.

Example:

Louria DB. Emerging- and re-emerging infections: The societal variables. International Journal of Infectious Disease. 1996, 1(2):59-62.

For a book the following information should be noted:

Author(s)’ Surname followed by initials. Title of book. Place: Publisher, year, Edition

Example:

Abramson JH. Survey methods in community medicine. Edinburgh: Churchill Livingstone, 1990, 4^th ed.

For a chapter in a book, the reference can include:

Author(s) of chapter (Surname(s) followed by initials). Chapter title. In: Editor(s) of book, (Surname(s) followed by initials). (eds). Title of book. Place: Publisher, year: page numbers of chapter.

Example:

Todd J and Barongo L. Epidemiological methods. In: Ng’weshemi J, Boerma T, Bennett J and Schapink D (eds). HIV prevention and AIDS care in Africa; A district level approach. Amsterdam: KIT Press, 1997: 51-68.

The formats suggested above have been adopted as standard by over 300 biomedical journals and are referred to as the Vancouver System. In other journals and books it is common to put the year, between brackets, straight after the name of the author(s). This is called the Harvard System. There are more systems in use for referencing to literature. Always carefully look what system is used in the journal you are submitting an article to and follow it systematically.

At present many journals use as few punctuation marks as possible. We therefore have minimised punctuation marks in the examples above. In Harvard style, this looks as follows:

Abramson JH (1990) 4^th ed. Survey methods in community medicine. Edinburgh: Churchill Livingstone.

Further, the index card or computer entry (one for each reference) could contain quotations and information such as:

• Key words;
• A summary of the contents of the book or the article, concentrating on information relevant to your study; and
• A brief analysis of the content, with comments such as:

  — Appropriateness of the methodology; possible weaknesses/comments in literature review

  — Important aspects of the study; and

  — How information from the study can be used in your research. (See Annex 5.3.)

How do you write a review of literature?

There are a number of steps you should take when preparing a review of available literature and information:

• Take your problem analysis diagram as a framework
• Organise your index cards or notes in groups of related statements according to which aspect of the problem they touch upon, e.g., community factors, service factors. Use your problem analysis diagram as a framework for writing (and adapt the diagram in turn as you find more literature).
• Then, decide in which order you want to discuss the various issues. If you discover you have not yet found literature or information on some aspects of your problem that you suspect are important, make a special effort to find this literature. If there is no literature, this supports your justification for conducting the study.

Where do you put which information?

Clearly, you will use some literature when describing the local context (country, region) or your problem. Note that all facts you mention need a source, except some general and well-known statements.

Also, for the description of the selected problem, you will use all available raw, grey or published literature you can obtain, well quoted (see below). You may use literature from other countries or regions to illustrate your point. If these sources are many you could have a separate section on international literature (see Annex 5.4). More complex studies using theoretical models should have a separate section or chapter discussing these models, which could come after the ‘Statement of the Problem’ section.

Referencing

You always need to reference all the literature that you refer to in your review. When you use the Vancouver system, you will use consecutive numbers in the text to indicate your references. At the end of your paper or chapter (of a book) you will then list your references in that order, using the format described above. In your research proposal the references will come before the annexes (see Modules 1 or 18).

Alternatively, you can use the Harvard system and refer to the references more fully in the text, putting the surname of the author, year of publication and number(s) of page(s) referred to between brackets, e.g., (Shiva 1998:15-17). If this system of citation is used, the references at the end of the proposal should be listed in alphabetical order (see Annex 5.5).

The Harvard author/date system of referencing seems easier, as you can change the order of paragraphs without consequences for your referral system. However at present, computers have programmes that change the numbers of your references automatically if you reshuffle the text while using the Vancouver system.

Possible bias

It is useful to be aware of various types of bias. This will help you to be critical of the existing literature. If you have reservations about certain references or if you find conflicting opinions in the literature, discuss these openly and critically. Such a critical attitude may also help you avoid biases in your own study. Common types of bias in literature include:

• Playing down controversies and differences in one’s own study results;
• Restricting references to those that support the point of view of the author; and
• Drawing far-reaching conclusions from preliminary or shaky research results or making sweeping generalisations from just one case or small study.

Ethical considerations

The types of bias mentioned above would put the scientific integrity of the responsible researcher in question. Moreover, careless presentation and interpretation of data may put readers who want to use the study’s findings on the wrong track. This may have serious consequences, in terms of time and money spent on HSR and it may even lead to wrong decisions affecting people’s health. A similarly serious act, for which a researcher can be taken to court, is the presentation of research results or scientific publications from other writers without quoting the author. Therefore, appropriate referencing procedures should always be followed in research proposals as well as in research reports.

Introduction to group work

For this group work session you will choose a group chairperson. In the sessions that follow you will always have a group chairperson as well as a recorder.

The functions of a chairperson are to:

• Make sure that all parts of the group work assignment are understood and completed by the group as a whole
• Take care that all group members have a chance to contribute. (A chairperson should not dominate the discussions or always present the results of the group work in plenary sessions.)
• Make sure that tasks are distributed between group members, if they are many, but that the group as a whole has a chance to discuss the different contributions before they are presented in plenary
• Take care that 10 minutes before a plenary session is due to begin, flip charts or overhead sheets are prepared for presentation
• Keep flip charts and other group products together carefully for further use, or delegate this task to a group member
• Organise and co-ordinate the typing of various sections of the research report and carefully store the drafts or delegate this task to a group member

The major function of the recorder is, to take care that the flip charts or overhead sheets to be presented in plenary:

• Meet the requirements of the group work assignment
• Contain the main elements of the discussion
• Are clearly written and readable at a distance

Recorders may change each session, but the leadership role should remain with one group member, for efficiency’s sake. This is especially important during the last week, when the final draft of the research proposal is being prepared.

REFERENCES

Gibaldi J (1995) MLA Handbook for Writers of Research Papers. New York: Modern Language Association of America.

Jen Tsi Yang et al. (1996) An outline of Scientific Writing: For Researchers with English As a Foreign Language. Singapore: World Scientific Publishing. www.amazon.com/exec/obidos (through internet, Sept. 2000).

Lindsay D (1996) Guide to Scientific Writing. Australia: Addison & Wesley. (paperback)

Annex 5.1: Samples from an abstract journal

Annex 5.2: Example of output from a computerised literature search on women and AIDS, through Medline

Annex 5.3: Example of a reference summarised on an index card

Annex 5.4: Example of literature review with references: Vancouver referral system

Part of the literature review in support of the study ‘Factors contributing to defaulting from out-patient treatment among tuberculosis patients who registered in Masvingo Province, Zimbabwe’.*

It is interesting that studies quantifying problems in case-finding and case-holding in TB are far more numerous than studies identifying contributing factors, and further, that knowledge, attitudes and practices of patients often receive more attention than those of staff. In areas as different as India and Honduras the same factors appeared responsible for reluctance of patients to come forward for treatment: lack of knowledge of early symptoms, fear of stigma attached to the disease, or a combination thereof.²⁰ Yet, a study in Japan showed that he average ‘doctor’s delay’ (time between first visit to a doctor and actual diagnosis) always surpassed the ‘patient’s delay’ (time between reported onset of symptoms and first visit to a doctor). For patients who reported early with complaints, within two months after onset of symptoms, the delays in diagnosis were relatively most extensive.²¹ Aluoch²² found the same for Kenya.

Also with respect to patients compliance with treatment we have to consider the multiple contribution of patients, community as well as services. In particular in turbulent times, for example when the TB services are abruptly integrated in the general health system, as happened in Botswana in the end of the 1970s, defaulter rates as high as 75% have been reported.²³

Other studies in South Africa,²⁴ India,²⁵ Papua New Guinea²⁶ and Malaysia²⁷ as well as the Botswana study23 concentrate more on patient and community factors, sometimes in interaction with service factors. Poverty, mobility (migrant labour), poor accessibility of TB services, lack of support from relatives, peers or employers, socio-cultural factors (conflicting perceptions of causes and treatment preferences; fear of stigma) and illness factors (low severity of disease at diagnosis, duration of symptoms) emerge as good predictors of poor patient compliance. Very interesting is, however, the shared emphasis on the poor information patients receive on their disease. Roy found in his study in Malaysia²⁷ that even among patients who were hospitalised for two or three months before starting out-patient treatment, 70% did not know they were suffering from an infectious disease and 80% did not know how long they had to stay in hospital or how long the estimated total duration of their treatment would be. He states that most of the medical and paramedical staff have neither the training nor the interest to give health education, a task for which they have not been primarily employed.

In the field of health education, encouraging experiments have been carried out in some of the countries mentioned above. Papua New Guinea, where patients defaulted en mass both during in- and out-patients treatment, health education was turned into a participatory exercise. Patients not only were explained the basic facts of TB in understandable terms but also listened through the stethoscope to the crackles in their chests and were shown X-rays of affected lungs compared to healthy lungs. As in Malaysia, more experienced patients were involved in health education, besides the health staff; they became the peer educators of newly diagnosed victims of TB and their relatives. The percentage of non-complying out-patients dropped from 50 to 20 within half a year.²⁶

The literature underlines the urgency of the planned research in Masvingo Province where the AIDS and TB epidemics seem to fuel each other. It also emphasises the necessity to study the problem of low patient compliance with treatment from different sides: that of the services, the patient and the community.

* In: Joint Project on Health Systems Research (1996) HSR: It can make a difference. Vol. 3: Under-utilisation of tuberculosis services in Southern Africa. Harare: WHO/AFRO.

References and notes

20. Westaway MS. Knowledge and attitudes about tuberculosis of black hospitalised TB patients. Tubercle, 1990, 71: 55-59.

21. Aoki M, Mori T, Shimao T. Studies on factors influencing patient’s, doctor’s and total delay of tuberculosis case-detection in Japan. Bulletin of the International Union Against Tuberculosis, 1990, 60(3-4):128-130.

22. Aluoch JA. A survey to assess passive case-finding in pulmonary tuberculosis in Kenya. East African Medical Journal, 1983, 60(6):360-365.

23. Varkevisser CM. TB Control in Botswana; Problem identification. Amsterdam: Royal Tropical Institute, 1977:42-53; 24-41.

24. Bell J, Jach D. Tuberculosis patient compliance in the Western Cape, 1984. South African Medical Journal, 1988, 73:31-33.

25. Barnhoorn F, Adriaanse H. Insearch of factors responsible for non-compliance among tuberculosis patients in Wardha District, India. Social Science and Medicine, 1992, 34(3): 291-306.

26. Garner P, Hill G. Brainwashing in Tuberculosis management. Papua New Guinea Medical Journal, 1985, 28:291-293.

27. Roy RN. Systematic health education of tuberculosis patients and of the population. Bulletin of the International Union Against Tuberculosis, 1990, 60(3-4):33-34.

Annex 5.5:Same part of literature review as 5.4, now using the Harvard referral system

It is interesting that studies quantifying problems in case-finding and case-holding in TB are far more numerous than studies identifying contributing factors, and further, that knowledge, attitudes and practices of patients often receive more attention than those of staff. In areas as different as India and Honduras the same factors appeared responsible for reluctance of patients to come forward for treatment: lack of knowledge of early symptoms, fear of stigma attached to the disease, or a combination thereof (Westaway 1990). Yet, a study in Japan showed that he average ‘doctor’s delay’ (time between first visit to a doctor and actual diagnosis) always surpassed the ‘patient’s delay’ (time between reported onset of symptoms and first visit to a doctor). For patients who reported early with complaints, within two months after onset of symptoms, the delays in diagnosis were relatively most extensive (Aoki et al 1990). Aluoch (1983) found the same for Kenya.

Also with respect to patients compliance with treatment we have to consider the multiple contribution of patients, community as well as services. In particular in turbulent times, for example when the TB services are abruptly integrated in the general health system, as happened in Botswana in the end of the 1970s, defaulter rates as high as 75% have been reported (Varkevisser 1977).

Other studies in South Africa, (Bell and Jach 1984) India (Barnhorn and Adriaanse 1992), Papua New Guinea (Garner and Hill 1985) and Malaysia (Roy 1985) as well as the Botswana study (Varkevisser 1977) concentrate more on patient and community factors, sometimes in interaction with service factors. Poverty, mobility (migrant labour), poor accessibility of TB services, lack of support from relatives, peers or employers, socio-cultural factors (conflicting perceptions of causes and treatment preferences; fear of stigma) and illness factors (low severity of disease at diagnosis, duration of symptoms) emerge as good predictors of poor patient compliance. (etc., etc.)

REFERENCES

Aluoch JA (1983) A survey to assess passive case-finding in pulmonary tuberculosis in Kenya. East African Medical Journal 60(6):360-365.

Aoki M, Mori T, Shimao T (1990) Studies on factors influencing patient’s, doctor’s and total delay of tuberculosis case-detection in Japan. Bulletin of the International Union Against Tuberculosis 60(3-4): 128-130.

Barnhoorn F, Adriaanse H (1992) In search of factors responsible for non-compliance among tuberculosis patients in Wardha District, India. Social Science and Medicine 34(3):291-306.

Bell J, Jach D (1988) Tuberculosis patient compliance in the Western Cape, 1984. South African Medical Journal 73:31-33.

Garner P, Hill G (1985) Brainwashing in Tuberculosis management. Papua New Guinea Medical Journal 28: 291-293.

Roy RN (1990) Systematic health education of tuberculosis patients and of the population. Bulletin of the International Union Against Tuberculosis 60(3-4):33-34.

Varkevisser CM (1977) TB Control in Botswana; Problem identification. Amsterdam: Royal Tropical Institute:42-53, 24-41.

Westaway MS (1990) Knowledge and attitudes about tuberculosis of black hospitalised TB patients. Tubercle 71:55-59.

Trainer’s Notes

Module 5: REVIEW OF AVAILABLE LITERATURE AND INFORMATION

Materials

• Examples of:

  —Abstract journals

  — Index Card

  — Computer printouts

  —Literature reviews and reference lists

  (You can use copies of Annexes 5.1-5.5, and supply your own examples.)

• Some blank index cards or blank sheets of paper for each participant

Be sure that a course library is ready for use. Prior to the workshop, facilitators should look through their own resources to find any relevant articles they may have for each research topic.

Introduction and discussion

Discuss why and how to do a review of the literature. Have participants suggest answers to the questions, but provide additional information when necessary.

• Refer to the annexes for examples of tools that can be used to find information relevant to a specific research topic and an example of a literature review
• It may be useful to have the assistance of a librarian in this session.
• Provide information on national library facilities that may be available during or after the course.
• Stress the importance of developing libraries at all management levels in organisations and ministries concerned with solving health problems.
• Present the points concerning preparation and use of index cards or computer entries, or at least small summaries on separate sheets of paper.
• Insist that the participants should be ‘writing’, not merely ‘citing’ when using the sources in different parts of their proposal, and provide different options for ‘putting what where.’
• Discuss possible biases in documents and literature review. Stress the researcher’s responsibility for presenting his findings honestly so that he does not put readers who want to implement the findings on the wrong track.
• Ask for comments or questions concerning the review of the literature and problems participants are likely to face. Determine how you can help the participants to overcome these problems.

Group work

• Ask the group to begin reviewing relevant literature and information departing from their problem analysis diagram. If possible, try to obtain relevant papers and reports from various sources for use even during the course.
• As a first step, each participant should review at least two articles, reports, or books, using index cards or blank sheets of paper to make summaries.
• Then the information should be put together in the ‘Background’ and ‘Statement of the Problem’ sections, and a decision will have to be made where to put international literature. Make sure that references are made in a consistent way, by using the Vancouver or the Harvard system (or another system of their choice).
• Emphasise that the review of literature should be thorough and critical. Only references that relate directly to the proposed research should be discussed. Irrelevant literature should not be mentioned.

Document(s) 8 of 27