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Small, focused, well designed qualitative studies are critically important to our learning

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Dr Rebecca King, Researcher, COMDIS-HSD

Dr Rebecca King, Researcher, COMDIS-HSD


The recent Open Letter to the BMJ editors highlighted a concern held by many qualitative researchers. At COMDIS-HSD, we welcome the open letter to the BMJ editors and agree that there are a number of leading journals that give low priority to qualitative research
COMDIS-HSD considers the contribution of qualitative research to intervention development and evaluation to be critical. Our portfolio of work includes:

  • Exploratory qualitative work to inform the development of context-appropriate interventions;
  • Qualitative methods being integrated into the piloting of interventions and research procedures, in order to assess their feasibility and acceptability; and
  • Qualitative methods used within process evaluations of complex interventions.

We are confident that our learning from qualitative research contributes to more context-appropriate, better quality, more sustainable interventions that can be implemented at scale.
However, we find that, when it comes to publication, we are constrained by a ‘quantitative paradigm’, which assesses the rigour and validity of studies based on criteria that are not always suited to qualitative research. In particular, we note bias against in-depth and focused, but sometimes quite small studies.
Our view is that small, focused, well designed and well implemented studies can be critically important to our learning, and the lessons from them can be applied widely. Such studies should not be rejected as ‘low-priority’, but rather should be considered on their own merit i.e. based on their quality and relevance. We have observed in discussion with journal editors that it can be problematic to get reviewers who fully understand both qualitative research methods and the need for pragmatism.
We advocate the publication of high quality, informative qualitative studies that draw on a wide range of methods, including interviewing, focus group discussions and observations, but also participatory approaches that give voice to participants and enable academics, policymakers and funders to continuously improve health services for those most in need.

5 take-away messages from 'Using Research Evidence: A Practical Guide'

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Authors: NESTA and Alliance for Useful Evidence, 2016

Authors: NESTA and Alliance for Useful Evidence, 2016


Dr Nilam Ashra-McGrath, Research Uptake Manager for COMDIS-HSD shares her 5 ‘take-away’ messages from the recently published Using Research Evidence: A Practical Guide: 
Although this guide, published by the Alliance of Useful Evidence and NESTA, is aimed at those working to change UK policy, much of it is applicable to international development. It offers a good overview of some of the methods that are commonly used to generate research evidence, as well as touching on their pitfalls and assumptions. Among the many sensible messages are 5 good reminders:
1: Not all evidence is equal
Selective use of evidence (known as confirmation bias) via literature reviews rather than systematic reviews can skew everything from research design through to policy discussions. Literature reviews allow us to ‘cherry pick’ the evidence that best fits our argument and justification for research. The guide reminds us that bias – be it based on optimism, hindsight or loss-aversion – can lead us to engage not in ‘evidence-based policy’ but in ‘policy-based evidence’, where our conclusions have already been formed and we are retro-fitting literature and methods to support that conclusion.
Let’s not forget also that esteemed journals are prone to bias, with positive results more likely to be published, while a staggering 65% of negative studies are not even being written up. This has far-reaching consequences, and begs the question of how many policies have been implemented based on positive studies alone. Surely knowing what doesn’t work is just as important?
2: Quality matters
Peer reviewed papers are still seen as the ‘gold standard’ to assess quality, but if journals are prone to publication bias, then this clearly presents a problem; likewise with another gold standard of quality: the systematic review. As the guide points out, a systematic review is “only really as good as the quality of the studies it is based on” (p36). Judging the quality of evidence can therefore be slippery. Researchers have varying views on what quality means (though they won’t always admit this). Is it about methods, integrity, utility, or usefulness? The default position appears to be that research methods determine the quality of evidence, but here we have another ‘hierarchy of evidence’ to consider (see p32-33).
3: Rapid reviews – timing matters
It’s a long road from research to publication, and policymakers have days, if not hours, to make decisions. A robust systematic review can take 6-12 months, and a ‘rapid review’ can take 1-2 months. This means that there are clear advantages to rapid reviews, but the guide makes clear that rapid reviews should follow a systematic process, i.e. have a clear methodology so that the review can be added to when new research becomes available. Databases such as 3ie and Cochrane contain ‘off-the-shelf’ systematic reviews that will help researchers working in time sensitive contexts.
4: Context matters
The guide contains an important reminder that we are predisposed to use methods that we are comfortable with, rather than what suits the context in which the research will take place.
5: Communication matters
By this I mean sharing everything from your research methodology, through to interim and full results, and not just leaving everything until the end of your research to be shared in one academic paper. The Easy, Attractive, Social and Timely (EAST) framework, will help decision makers, and those who supply them with evidence, make more effective and efficient policy.
Aside from the additional instructions to use Google Scholar and stay off Wikipedia, this guide offers many important reminders (all evidence-based, of course). You could skim through the key messages at the end of each section, or you could invest a couple of hours reading this cover to cover. I recommend taking a couple of hours.

Bold media plan and strong lifestyle messages take ARK’s NCD work to the nation

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Rumana being interviewed by TV journalist

ARK’s Dr Rumana Huque being interviewed at the national NCD workshop by a TV journalist


A bold media strategy targeting top TV and print journalists has allowed our ARK Foundation partners to reach millions with their message about better prevention and treatment of non-communicable diseases (NCDs) in Bangladesh.
Strong lifestyle messages about unhealthy food habits, low levels of physical activity, smoking and pollution were at the centre of ARK’s recent national workshop on NCDs and helped secure prominent TV coverage for the event across Bangladesh’s three main news channels, as well as wide coverage in the top-rated newspapers and their online versions.
The event, however, went beyond public health headlines and started a national dialogue on the practical service delivery steps that will help Bangladesh reduce the personal, social and economic impact of NCDs. Currently, NCDs, such as cardiovascular disease and diabetes, are responsible for more than 60% of Bangladesh’s annual mortality and account for 60% of the country’s disease burden (measured by financial cost and years of quality life lost).
The event was co-hosted by ARK and the Non-Communicable Disease Control (NCDC) Unit of the Directorate General of Health Services (DGHS). More than 60 participants from all levels of the health service, including delegates from the World Health Organization, came together to share ideas on how to improve prevention, diagnosis and treatment of NCDs in primary care.
According to Dr Rumana Huque, Executive Director of ARK, a key factor in the success of the event was the decision to include managers from every level of the health service.
‘The participants were diverse and that was very important. We had local level healthcare managers who have the practical knowledge of what is happening on the ground to control and treat NCDs. But we also had mid-level programme managers who support them and the senior-level policymakers who take the final decisions.
‘So what came out at the workshop were the challenges that service providers are already facing and the recommendations that we have generated through or work at ARK.
‘Through our research we know that we need more counselling for NCD patients, better training for doctors and health providers, a better supply of medications, improved record keeping and stronger referral links between different parts of the health service.’
Dr Huque, who is part of the core team drafting the Sector Programme – the strategic investment programme for the next five years – added that workshop had been very timely.
‘The workshop helped everyone focus on the priorities; specifically improved NCD services and better lifestyle education. Senior managers and policy makers took note and said that they would be feeding what they had learned into the next Sector Programme.’
Giving the keynote speech at the workshop, Professor Dr Abul Kalam Azad, DGHS Additional Director General (Planning and Development), told delegates that NCDs are responsible for 62% of deaths happening every year in Bangladesh.

Key speakers at ARK’s national NCD workshop. From left: Dr Rumana Huque, Executive Director of ARK, Prof Dr Abul Kalam Azad, DGHS Additional Director General (Planning and Development), Prof Dr Enayet Hussain, NCDC Unit Line Director


He said that Bangladesh had not placed sufficient importance on NCDs, with catastrophic results in terms of premature mortality.
As part the COMDIS-HSD programme, ARK has been working with primary health care facilities in Bangladesh to establish better screening, treatment and referral processes for people with NCDs. Their experience and research findings were fed into group discussions to identify urgent actions that will help Bangladesh achieve its Sustainable Development Goal target of reducing NCD premature mortality by one third by 2030. These include the more timely supply of medicines, a wider range of medicines and dedicated doctors and health educators in ‘NCD corners’ in district hospitals.
Find out more:

What did we achieve in 2015? See our year in pictures

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A happy father and son after seasonal malaria chemoprevention treatment in Ghana

A happy father and son after seasonal malaria chemoprevention treatment in Ghana


HERD won a WHO ‘No Tobacco’ award; we took the stage at world conferences on lung and urban health; we ran our first journal paper writing workshop; and ARK made the news on national TV channels across Bangladesh for their work on non-communicable diseases. It has been a year of major achievement for COMDIS-HSD partners and we’re celebrating and sharing these in our 2015 Review.
Click here to see more of our year in pictures.
 

Lift off for our writing workshop: partners aim for paper in 6 days

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rocket-pencilCOMDIS-HSD partners have come together for an intensive writing workshop aimed at transforming some of our latest research into high-quality draft papers ready for submission and review.

The 6-day workshop, which is taking place in Amsterdam, will guide partners through each stage of writing their research paper.

This will range from developing the introduction, methods, results and discussion sections, through to handling tables, figures, references, online electronic submission, peer review and revision.

In this hands-on week of writing, participants will be individually mentored by experienced researchers from the International Union Against Tuberculosis and Lung Disease (The Union) and Medecins Sans Frontieres (MSF). The Union and MSF work with the World Health Organization to offer this and other courses under the collective title of SORT-IT (structured operational research training initiative).

According to Professor Anthony Harries, lead facilitator of the workshop and Senior Advisor and Director of the Department of Research at The Union, the module is about developing confidence as well as practical skills:

‘Many researchers do a lot of work in the field developing a study protocol, collecting and analysing data, but get blocked when it comes to writing up the results.

‘This week should remove some of the myths surrounding scientific writing. Writing is like any skill, it can be learned and it is much more satisfying and productive when you know how.’

Partners will be working with research data from some of their latest COMDIS-HSD studies, including research that focuses on understanding current antibiotic use among children in China, the media’s response to urban health issues in Nepal and delivering enhanced cardiovascular disease care through rural health facilities in Pakistan.

We will be tweeting throughout the week with progress and top tips. Follow us on @COMDISResearch and use the hashtag #COMDISwrites to get involved.

See all our published research papers here.

Sleeves up for Swazi partners on Global Handwashing Day

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Student nurse Lindokuhle Mhlongo demonstrates good handwashing technique to a patient

Student nurse Lindokuhle Mhlongo demonstrates good handwashing technique to a patient


COMDIS-HSD partners, Good Shepherd Hospital in Swaziland, rolled up their sleeves on Global Handwashing Day to spread the word about good hand hygiene. A team of 10 student nurses, together with staff from the hospital’s Infection Prevention and Control (IPC) team, demonstrated good handwashing practice to patients as they waited in the outpatients’ area.
Patients were also shown a video and given a leaflet explaining the importance of handwashing and encouraging them to use soap, wash often and wash long enough. Handwashing is the most effective and simplest thing you can do to prevent infections, including hospital acquired infections.
Patients were able to ask their own questions, such as whether running water is necessary as opposed to just using a bucket and dipping their hands in.
The event, which was fun as well as informative, coincides with wider work to establish a new IPC committee to provide stronger guidance on IPC adherence and improvements throughout the hospital. These will include developing the hospital’s infrastructure to ensure better access to hand hygiene facilities and ongoing improvements to sanitary facilities and ventilation.
COMDIS-HSD is also helping the hospital secure the necessary resources to ensure hand gel is available on every ward.
Read more about our IPC work here.

World No Tobacco award for Nepal partners HERD

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HERD executive director Dr Sushil Baral (left) accepts the award from Dr Frank Paulin, acitng WHO representative, Nepal

HERD executive director Dr Sushil Baral (left) accepts the No Tobacco award from Dr Frank Paulin, acting WHO representative, Nepal


Health Research and Social Development Forum (HERD) has been presented with a World No Tobacco Award 2015 by the World Health Organization (WHO).
The award recognises HERD’s work to develop and implement a behaviour change intervention for tobacco cessation – a project that has already resulted in a 37% quit rate among smokers.
Supported by COMDIS-HSD, HERD has focused specifically on the provision of individual counselling, education and follow-up sessions for lung health patients visiting primary health care centres.
Receiving the award on behalf of his team, HERD executive director, Dr Sushil Baral, said: “We have been working very closely with the Ministry of Health and Population in the sector of tobacco control since our establishment in 2004. We started with the inter-linkage of tobacco users being vulnerable to tuberculosis.
“Our approach has been generating the evidence, informing the policy and changing the practice. We are proud that our effort, through the feasibility study intervention in the primary health care settings, has been acknowledged by the ministry and WHO.”
HERD project co-ordinator for tobacco control, Sudeepa Khanal, added: “It is a great moment for us as all the effort we have put in to tobacco control initiatives has finally paid off.”
Shraddha Manandhar, research officer, who observed and monitored the intervention in one of the primary health centres in Kathmandu, explained: “We had to conduct several meetings and follow-up sessions to finally come up with a successful result – a 37% quit rate among smokers who received the intervention support. The wait has been worthwhile.”
Every year, WHO gives the World No Tobacco Day awards to individuals and institutions selected for their long-term commitment and outstanding contribution to research, advocacy, health promotion, capacity building and other activities that promote and enforce tobacco control.
Read more about how the team developed the intervention in the HERD LinkedIn blog.

COMDIS-HSD partners active players at 12th International Conference on Urban Health

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Source: joiseyshowaa, Flickr. CC-BY-SA

Source: joiseyshowaa, Flickr. CC-BY-SA


COMDIS-HSD partners joined urban health experts from across the world at the 12th International Conference on Urban Health (ICUH) held in Dhaka, Bangladesh in May.
Playing an active role across the 4-day event, our Nepal partners, HERD and Bangladesh partners, ARK Foundation, gave detailed presentations on their ongoing research in the urban health field.
HERD presented some key issues from its Urban Health Project aimed at supporting the government to develop an urban health policy and strategy in Nepal. These included the need for clear evidence about the extent of urban poverty and the needs of the urban poor.
Following an in-depth exploration of the urban policy development process in Nepal by HERD senior research officer, Sudeepa Khanal, her colleague and HERD programme manager, Hom Nath Subedi, contributed to a detailed Q&A session answering questions from the floor about their experiences so far in developing the strategy.
ARK research associate, Farid Ahmed, gave a presentation on the rationale behind their current study on Public-Private Partnerships (PPPs) to improve access to family planning services in Bangladesh. Specifically, the presentation focused on using the PPP model to increase access among the urban poor to Long-Acting Reversible Contraceptive (LARC)..
ARK also presented on the limitations of existing household surveys in identifying the health needs of the poorest urban dwellers. In the presentation ARK volunteer Ru-Yi Lin illustrated how samples used in existing surveys are skewed towards the wealthiest urban residents.
Solutions to these challenges, such as new sampling and mapping techniques, were presented by Dana Thomson (Harvard Medical School), and HERD’s Uden Maharjan presented on the use of these techniques in Kathmandu in the initial phases of HERD’s urban household survey.
The conference, the first ICUH to be hosted in Asia, acknowledged that cities are drivers of national development. Delegates used their joint concluding statement to agree that the health of people in cities should be a central concern in sustainable development, pointing specifically to the need for capacity building, applied research and stronger governance for urban health.
Currently more than half the world’s population lives in cities and by 2050 it is estimated that 70% of the world’s population will be urban dwellers. While this presents challenges for all countries, delegates emphasised that the pace and scale of urbanisation is now most rapid in low and middle-income countries.
Read more about our partners’ reflections on ICUH 2015.

COMDIS-HSD reflections on ResUpMeetUp symposium and training

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resup-croppedCOMDIS-HSD was well represented at the recent ResUpMeetUp symposium and training, with attendees from Nepal (HERD), China (Global Health Research and Development) and Uganda (Malaria Consortium). Sudeep Uprety (HERD) presented a paper on strengthening the media’s response to urban health issues in Nepal. Badru Gidudu Walimbwa (Malaria Consortium) also presented a paper on assessing and addressing barriers to IPTp uptake in Uganda. Both presentations were very well received. Read the reflections on this workshop from our 3 attendees here.