Perceived barriers and solutions to operational research The Union, Paris, France MSF, Brussels, Belgium Contacts:

Barrier 1. Time and opportunity for conducting and completing operational research

The needs of Operational research: Protocol development / ethics Searching for funds Collecting and analysing data Writing the papers Dealing with peer review revisions Time Capacity There is no dedicated time available There is limited capacity The first problem

Programme managers do not recognise the relevance of operational research The second problem Programme managers busy Research questions not relevant to programme implementation No coordinator or mechanism to decide research priorities

The third problem Individuals return to RLS with MPH or PhD Why are they not involved in operational research? Appointed to senior-level management posts No budgets for research No opportunities

The Fourth Problem: Technical aspects Research question: No question asked Not asking the right question at programme level Practical skills Conducting and publishing research

Solutions! Integrate Operational research into Annual Plans with targets, activities and budgets Invest in a specific post(s) for Operational Research working in a Programme Management group and under the director  Coordinates and sets research priorities Give good individuals eg 2 days per week to conduct the research (Time) Support young researchers to attend / present at conferences. Better access to scientific literature (open access)

Solutions ! Rethink the training: Union / MSF Model To develop the practical skills for conducting and publishing operational research “ Operational Research Fellowships” – Junior and senior Mentorship [ADH will talk on this]

Barrier 2: Ethics

The Fifth Problem: Ethics Why do I need ethics clearance? Ethics committees are a burden ! Where can I get clearence ? I did not get ethics clearance and the Journal now asks for ethical clearence to publish !!!

Solutions ! Understand Ethics committees Ethical frameworks based on: Duty to alleviate suffering Show respect for human beings To be sensitive to cultural differences Not to exploit the vulnerable  Protect individual rights of research participants  Objective, professional advice by a group qualified in identifying ethical issues in research Regard ethics committees as allies, with helpful ideas to protect your participants and support your study (rather than be a barrier)

Advice ! Check: Which Ethics Committee(s) exist and to whom you must apply. National health authority Institutional (University, NGO), Research group. Their requirements (application form, information sheet, consent form, ….). Their formats must be respected! No ethics = No publication ! When in doubt ask for advice / clearence

Barrier 3: Doing the research- from design to analysis

Data collection and analysis: Collecting too many (or too less) data Plenty of data ! what do I analyse? Design What are the steps needed to run a study ? The sixth Problem: Design & Data

Solutions ! Design and analysis

The study question Is it well defined ? Eg: Why do people default from ART ? What are the main objectives? Eg:To identify reasons for default in programme x What has been done before in this area.? Whats new ? Eg Limited or no published information on ART default from the specific setting or population

The study team and the plan Decide who is the principal investigator - PI Who will be in the study team – hierarchy / authorship Discuss how to do the study, although useful for the PI to have preliminary ideas Decide on the time frame and responsibilities Discuss with your programme manager

Setting and data collection Where will the study be done ? What is your sample size? What is the data you need ? Who is going to collect this data ? How will it be collected (Proforma/ Registers) ? How can the data be verified if this is needed ?

Proforma Relevant information only Avoid collecting information you will not use Pre-test the proforma ? Make enough copies plus some extra

Doing the study Have necessary permissions been obtained (ethics..) and key people informed ? Ensure everyone involved knows about the study, their responsibilities. Are they adequately trained ? Be honest with the data - if information not there then say “No information” Keep completed proforma well organised and safe. Make backups.

Data management Set up an organized data file that follows the format of your proforma Enter data to EPI-INFO, for example Enter data as the study proceeds and verify. Ensure some way of checking data Make back-up copies as you go along

Data analysis Perform data analysis in relation to the objectives EPI-INFO very good at univariate analysis, need better software for multivariate analysis (STATA) Perform your statistical analysis and tests (X 2 test…)

“I have plenty of data – what do I analyze?” 1) “The research question – is there available data to answer it?” 2) “There is available data – what is the best way to use them?” 3) “Can I assure myself that the available data are quality-assured?” 4) “Is my analysis simple, straight forward and reproducible” ? 5) “Is my interpretation of the results logically following the findings” 6) “Have I been able to have a logic flow in the arguments to make the case?” Hans Rieder, The Union

Barrier 5: Writing Skills

The seventh problem: Writing I have no time to write I cannot get started I am stuck on the data and cannot put anything on paper I have too many good ideas I write too much or too little There is no logic to my thoughts I spend all my time re-writing AARGGHH!!

Writing skills for publishing

Journals – are difficult !

Continue to Learn by doing

Look for a friend !

Solution! Learning writing methods for scientific articles – Module 3 of the Operational Research Course (ADH) How to structure an article How search and insert references How to do on-line article submission How to deal with peer review, point-by- point responses to reviewers, and revisions of the article How to avoid the editors wrath !

Barrier 6: Lack of Resources

The eight problem: the resources ? Who will manage research at programme level ? No office infrastructure No implementation support !

Solution ! Appoint and support a focal person for operational research Focal point in TB Control (eg Malawi): Sits on all NTP management committees Understands TB control at district level Competent in research Coordinates national research priorities

Solutions ! Support infrastructure and implementation of research Office space Computer, software, virus protection Internet and Transport [vehicle, fuel, maintenance] Stationary Training Research allowances [performance-related] Small Grants (eg 1500 USD)

Small Grants: Operational Research in Malawi around ART scale up: Operational Research TopicTime PeriodCost USD$ ART in health care workers3 months450 Data quality of ART monitoring3 months450 ART in the army and police force3 months600 What happens to ART patients who transfer from one site to another 6 months1,500 What is the true status of ART patients who are lost to follow-up 6 months1,800

Barrier 7: Dissemination

The ninth problem How will I get my findings known?

Solutions! Research dissemination: Presentations at national forums and international conferences Local dissemination of papers through annual collation of published papers

Scientific Web-Site

Barrier 8: Research to policy and practice

The tenth problem Published research does not get translated into practice ?

Solutions ! Needs strategic thinking… Research question must be relevant to the programme Ministry of Health / partners must be included right at the beginning (co- ownership) Results of research must be rapidly written up for publication and presented to national stakeholders Policy change might require more research

Needs strategic thinking… Needs involvement of key players and Ministry of Health may need assistance in thinking through and implementing the logistics The roll-out of change in practice also needs to be audited as part of operational research

Salaniponi FM et al. Decentralisation of treatment for patients with tuberculosis in Malawi: moving from research to policy and practice. Int J Tuberc Lung Dis 2003; Supplement 7, S38-S47 Chimzizi R et al. Counselling, HIV testing and adjunctive cotrimoxazole for TB patients in Malawi: from research to routine implementation. Int J Tuberc Lung Dis 2004; 8: Harries AD et al. Tuberculosis control in Malawian prisons: from research to policy and practice. Int J Tuberc Lung Dis 2004; 8: