1. Defining what the problem is Framing a research question FETP India

2. Competency to be gained from this lecture Formulate a precise research question that usefully addresses public health needs

3. Key areas Levels in fundamental or applied research Working with programmes to understand their data needs

4. 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

5. Field epidemiology Field epidemiologists feed programme managers with information for action Plan AssessEvaluate Implement Applied epidemiology

6. Fundamental and applied epidemiological projects Type of projectsObjective of the investigations Relevance to field epidemiology Fundamental researchTheoretical rationale- Applied researchEfficacy+ Prevention researchEffectiveness++ Assessment, monitoring and evaluation Implementation+++

7. 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

8. 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

9. 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

10. 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

11. 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 Addressing the data needs of programmes

12. 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

13. 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 Addressing the data needs of programmes

14. 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

15. 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 Addressing the data needs of programmes

16. 1 1 Health problem Determinants Direct contributing factors Indirect contributing factors Consequences: - 1 - 2 - 3 2 3 2 Determinants and contribution factors diagram for a public health problem Possible intervention 1 Possible intervention 2 Possible intervention 3

17. Diphtheria Exposure Health 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

18. 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

19. 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 Addressing the data needs of programmes

20. 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 Addressing the data needs of programmes

21. 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

22. 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 Addressing the data needs of programmes

23. 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 Addressing the data needs of programmes

24. 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? Addressing the data needs of programmes

25. 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 Addressing the data needs of programmes

26. 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 Addressing the data needs of programmes

27. 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 public health questions is:  Useful  Gratifying Addressing the data needs of programmes

28. The life cycle of epidemiological investigations: The never ending story Identifying 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

29. 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? Addressing the data needs of programmes

30. 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

31. 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)