Health Services Research Methods 3rd Edition by Leiyu Shi – Test Bank
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- What are the major steps in the conceptualization stage of health services research?
In the conceptualization stage, researchers need to understand the general purpose of their investigation, determine the specific research topic, identify relevant theories and literature related to the topic, specify the meaning of the concepts and variables to be studied, and formulate general hypotheses or research questions.
- Draw the distinctions among exploratory, descriptive, and explanatory (or analytic or causal) research. What conditions are most appropriate for each of the three major research purposes?
Exploratory research is usually conducted when relatively little is known about the phenomenon under study; that is, the research topic is itself relatively new and unstudied. The researcher explores the topic in order to become familiar with it and to gain ideas and knowledge about it. Exploratory research may also be undertaken when the researcher is examining a new area of interest. In other words, the topic of interest has been studied by others, but not by the researcher. It may also be used when testing the feasibility of a new methodology. It may have been studied before, but the researcher is now interested in using a new methodology, and the results of the study will guide larger, more complex studies. Exploratory research typically uses qualitative methods, such as case studies, focus groups, or guided interviews. When exploring a topic about which they have little knowledge and there is limited literature on the topic under study, researchers often use these methods to help determine the relevant variables and whom to study.
Descriptive research is conducted to explain a phenomenon. This type of study summarizes the characteristics of particular individuals, groups, organizations, communities, events, or situations as completely, precisely, and accurately as possible, with the ultimate purpose of formulating these descriptions into conceptual categories. The nature of the description differs from exploratory research in that descriptive study is much more structured, carefully conceived, deliberate, systematic, accurate, and precise. It provides detailed numerical descriptions of relatively few dimensions of a well-defined subject. It can be an independent research endeavor or, more commonly, part of a causal research project. Descriptive research frequently employs survey methods and gathers information from a set of subjects or cases carefully selected to enable the researcher to estimate the precision and generalizability of the findings.
Explanatory research, also called analytic or causal research, seeks answers to research hypotheses or problems. It studies the mechanisms and causes behind a phenomenon with experimentation, and may be conducted to explain factors associated with a particular phenomenon, answer cause–effect questions, or make projections into the future. While exploratory research is concerned with questions of “what” and descriptive research with questions of “how,” explanatory research answers questions of “why” or “what will be.” It differs from descriptive research in the scope of the description. Whereas descriptive research seeks information about isolated variables, explanatory research examines the relationships among these variables and is inherently more in-depth.Explanatory research is often associated with experimental research designs that randomly select and assign subjects to experimental and control groups. It relies heavily on multivariate analyses and model-building techniques based on sound theoretical frameworks.
- How do investigators identify research topics?
Research ideas may emerge from the researcher’s own experiences or curiosity, interactions with other researchers, reading the literature, attending workshops or conferences, or any other sources. The choice of a research topic is influenced by a number of factors, including whether the researcher seeks to address a social problem; test or construct a theory; pursue interests according to ability and available resources; or contribute to the field and gain professional recognition.
The major source of research topics are basic social problems in health services, inspired by the big picture of hot topics in the field, what is happening in the neighborhood, and policy issues in the news. HSR may also be conducted to test or construct scientific theories using a disciplinary framework that provides direction in topic selection, research focus, and study design. They draw upon HSR social science theories and, in the process, modify existing theories or develop new ones.
Researchers are also influenced by their own personal interests and experience, and are more likely to be committed to a project in which they have a personal interest. Their ability and available resources also influence their topic selection. Ideally, the focus of research should reflect the background and training of those involved in the research. The amount of available resources also impacts practical considerations. For example, many researchers select their topic based on available data, available time, and the availability of computers and support personnel.
The choice of a research topic can also be influenced by the desire for professional recognition. Researchers may pursue topics regarded as “hot” or prestigious in their disciplines, with the goal of publishing in premier scholarly journals or advancing their careers in terms of tenure or promotion.
Additional sources for research topic may stem from funding announcements, the discussion section of a published study where future research direction is suggested, one’s skill set and access to potential data sources, time and resource constraints, and influences from mentors. Furthermore, a combination of those factors could influence the decision to pursue a research topic.
- Why is literature review considered an integral part of research?
Literature review serves a number of purposes. First of all, it helps narrow the topic by informing researchers about the state of the art and the extent of study on the topic, as well as the current limitations. It can also help identify theories related to the topic of interest, identify relevant and control variables to be included in the analysis, and suggest pertinent research design, procedures, and analysis by indicating how other researchers have addressed the topic. Proper literature review helps position the study in the scientific inquiry of the topic and makes sure the study is an advancement of the current literature rather than a mere duplication or replication.
- Draw the distinction between the nominal and operational definitions of a concept being studied. What are their respective roles in research?
A nominal definition serves as the working definition for the project and captures the major dimensions as agreed upon by the scientific community and reflected in the literature. When there is disagreement or lack of consensus as to the dimensions a particular concept should include, the nominal definition serves to rule out other possible dimensions of the concept. It is not specific as to how a concept is to be observed, though, and different researchers may observe a concept differently based on the nominal definition.
An operational definition specifies a unique method of observation. It indicates what specific variables are to be observed, how they are to be observed, and how these observations are to be interpreted. The operational definition lays out all the operations or steps to be undertaken to measure a concept. It also follows the nominal definition and makes each of the specified dimensions more concrete and observable.
- What are the major characteristics of a research hypothesis? Identify common ways of specifying research hypotheses.
Research hypotheses describe the variables and units to be studied and specify the relationships among variables. They must be conceptually clear, must be statements of fact susceptible to empirical investigation (statements that can be proven right or wrong through research), must be specific and narrowly defined to allow actual testing, must be practical, must be suited to investigation by available techniques and research methods, and are probabilistic in nature (they may not be confirmed with certainty).
Research hypotheses may be specified in the form of conditional statements (e.g., if–then statements), continuous statements (e.g., the more X, the more Y), difference statements that indicate that one variable differs in terms of the categories of another variable, or mathematical statements that have the form Y = f(X), which means “Y is a function of X.”
- What are the common indicators of health status?
The common indicators of health status include physical, mental, general, and social health measures. The physical health measures include symptoms; mortality-based measures such as crude death rate, condition-specific death rates, infant mortality, maternal mortality, and life expectancy; measures of morbidity such as the incidence or prevalence of specific diseases; measures of disability related to illness and injury such as one’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs); and indicators regarding the use of health services, such as number of doctor visits per person per year, percentage of persons who have not seen a doctor within the past year, interval between doctor visits, short-stay hospital admission and discharge rate, and short-stay hospital average length of stay.
The mental health measures include symptoms such as psychophysiologic symptoms and psychological symptoms, as well as one’s self-assessed psychological state. General health perceptions refer to self-ratings of one’s health status. The social health measures include symptoms such as health-related limitations in the performance of usual social role activities, and social well-being, which includes social contacts (frequency of social activities a person undertakes within a specified time period) and social resources (adequacy of interpersonal relationships and the extent to which social contacts can be relied upon for support).
- Identify the determinants of health and explain how they affect health status.
The four major determinants of health are environment, lifestyle, heredity, and medical care, and must be considered simultaneously when addressing the health status of a population. Environment encompasses events external to an individual, over which he or she has little or no control. It provides the context of health services delivery, including both physical and social dimensions. These environmental factors can adversely affect health far more than any inadequacy of the health care system. Lifestyle involves decisions by individuals for their health over which they have some degree of control. Specifically, they have the greatest control over leisure activity, moderate control over consumption, and the least control over employment and occupational factors. Heredity is concerned with the basic biologic and organic makeup of individuals, which can lead to genetic disorders, congenital malformations, and mental retardation; conditions related to maturation and aging, such as arthritis, diabetes, and cancer; and disorders of the skeletal, muscular, cardiovascular, endocrine, and digestive systems. Medical care services have relatively little impact on health status compared to health behaviors, genetics, and the social, cultural, and physical environments in which people live.
- Draw the distinctions between the following pairs of terms: incidence and prevalence, mobility limitation and functional limitation, ADL and IADL, and social contract and social resources.
Incidence refers to the number of new cases of a disease in a defined population within a specific time, while prevalence refers to the number of instances of a given disease in a given population at a designated time.
Mobility limitation refers to an inhibited ability to move around, such as being confined to one’s bed or house, or requiring help to get around inside or outside of one’s house. Functional limitation refers to an inhibited ability to perform activities of daily living (ADLs) such as bathing, dressing, toileting, transferring into and out of a bed or chair, continence, and eating.
Social contact refers to the frequency of social activities a person undertakes within a specified time period, such as visits with family members, friends, and relatives, and participation in social events such as membership activities, professional conferences, and workshops. Social resources refers to the adequacy of interpersonal relationships and the extent to which social contacts can be relied upon for support.
- What are the behavioral risk factors that may contribute to disease or poor health status?
Behavioral risk factors that may contribute to disease or poor health status are broken down into three categories: leisure activity risks, consumption risks, and occupational risks. Leisure activity risks include sexual promiscuity and unprotected sex and lack of exercise. Consumption risks include overeating, cholesterol intake, alcohol consumption, alcohol addiction, cigarette smoking, substance dependency, and excessive glucose (sugar) intake. Occupational or employment risks include dangerous occupations, unsafe workplaces, and stressful jobs.
- What are the unique characteristics of medical care services as compared with other market products or services?
Medical care services differ from other commodities in a number of important ways. First, the demand for medical care services stems from the demand for a more fundamental commodity, namely, health itself. Therefore, the demand for medical care is a derived demand. Second is the agency relationship, in which a principal hires an agent to perform a service and delegates the decision-making authority to the agent. Unlike typical agency relationships in which the agent acts purely in the interest of the principal, physicians’ decisions typically reflect not only their patients’ preferences, but also their own self-interests, including pressure from colleagues and institutions, medical ethics, and a desire to make use of resources. As a result, health care utilization may well depend on the organizational environment.
The third difference concerns the price paid for health care. In most medical services, the money paid out-of-pocket at the point of usage is often significantly lower than the total eventual payment, largely due to insurance coverage. It is generally believed that the combination of comprehensive insurance for patients and fee-for-service payment for providers is what has driven the health care system to be the way it is at the present—a voracious black hole for economic resources. Thus, the use of medical care services is related to how the services are financed.
Finally, medical care services are influenced by the environment in which services are provided, namely the social, economic, demographic, technological, political, and cultural contexts surrounding the provision of health services.
- What are the types of research reviews and their respective purposes?
There are four major types of research reviews: the integrative research review, theoretical review, methodological review, and policy-oriented review. The integrative research review aims to accomplish such objectives as presenting the state of knowledge on the topic under review, highlighting issues left unresolved or unstudied, and directing future research so that it is built on cumulative inquiry. Theoretical review provides a detailed summary of existing relevant theories and findings based on which theories were developed or tested, assesses which theories are more powerful and consistent with known findings, and refines theories by reformulating or integrating concepts from existing theories. Methodological review is used to identify the strengths and weaknesses of the existing designs for a particular topic and explain to what extent differences in findings are the results of differences in design. Policy-oriented review summarizes current knowledge on a topic so as to draw out the policy implications of study findings.
- Identify commonly used computerized abstracting and indexing services used in health services research.
The most common online abstracting service is MEDLARS (Medical Literature Analysis and Retrieval System), which provides users access to a host of specialized databases in the fields of biomedicine, health administration, cancer, population studies, medical ethics, and more. MEDLINE is the most well-known of the MEDLARS databases, and is the world’s leading bibliographic database of medical information. PubMed provides access to the Hospital Literature Index, which provided the primary guide to literature on hospital and other health care facility administration between 1945 and 2000. Public Health, Social Medicine and Epidemiologyis available via Elsevier and contains such topics as biostatistics and biometrics, health care, epidemiology, screening and prevention, populations at risk, food and nutrition, lifestyles, and evaluation of intervention.
National Technical Information Service (NTIS) Health Collection covers such areas as community and population characteristics, data and information systems, economics and sociology, environmental and occupational factors, health care delivery organization and administration, measurement methodology, needs and demands, technology, delivery plans, projects and studies, education and personnel training, and health-related costs, resources, and services. The Social Sciences Citation Index covers 50 different social science disciplines and carries more than 1,500 journals. Project MUSE is an online database for humanities and social science. Psychological Abstracts is frequently used in the behavioral sciences and is included in the online database PsycINFO. Dissertation Abstracts International focuses exclusively on abstracts of dissertations regardless of discipline. ProQuest Dissertations and Theses Online is an available database that provides full-text access to dissertations and theses. Google Scholar is a widely used and free web search engine that indexes scholarly literature.
- What are the strengths and weaknesses of research review as a scientific inquiry?
The principal strength of research review is its contribution to the tracking and advance of scientific knowledge. Research review based on a systematic rather than an idiosyncratic approach is important to maintaining the credibility of conclusions, particularly at a time when research review plays an increasing role in the definition of knowledge. It also has the advantage of being efficient in that it is less expensive, requires less staff, and has a less demanding time requirement. It also provides a more predictable schedule that is less subject to outside factors.
The main disadvantage of research review is the constraints on the materials available for review. Inconsistencies, missing information, and many other quality variations among published reports invariably create problems for the investigator. Assumptions must be made and compromises sought to make use of current studies. Research review on some topics may not be feasible if a limited number of studies have been conducted on these topics.
- What are the general categories of information likely to be focused on in research review?
Research review is likely to focus on four general categories: background, design, measurement, and outcome. In the background category, source indicates the media or information channel from which a study is retrieved. In the design category, it is possible that the general categorization as presented will not be sufficient. Researchers may then include additional design characteristics. In the measurement category, investigators may document the use of particular scales, available instruments, and specific features of the analytic models. In the outcome category, if more quantitative analysis is envisioned, more precise statistical information related to study results may be recorded.
- What is the general purpose of meta-analysis, and what are its commonly used procedures?
Meta-analysis refers to statistical analyses that combine and interpret the results of independent studies of a given scientific issue for the purpose of integrating the findings. The approach treats each study in the review as a case within a sample of studies and applies statistical analysis to each case.
The first thing researchers do is summarize the information abstracted from the studies reviewed based on the coding sheets. Next, the investigator may conduct a more refined subgroup analysis by grouping the studies into comparable categories based on a number of criteria. The results of the subgroup analysis can be compared with the analysis done on the total studies. Such a comparison enables researchers to evaluate whether sources and quality of research are significantly related to differences in results. If they are, investigators can present the meta-analytic results separately for different sources of information and different levels of quality of research. If the findings are mixed, the researcher may conduct a simple vote counting using a sign test to assess whether observed differences are significant.
The most popular and most important meta-analysis procedure is called effect size analysis. Effect size is the size or strength of the impact of one factor on another. In meta-analysis, the effect size is determined by the difference between the control and treatment change scores. Effect size may be estimated by the coefficient of determination.
The first step is to identify the effect size to be investigated, and the second step is the actual computation of an effect size for each study reviewed. In situations where data have already been processed, the effect size can be computed based on the given information.The substantive interpretation of the size of the effect may be made by reference to other information. The most useful interpretation occurs when an effect size is compared with other effect sizes using similar variables.
The standard error measures how accurately the effect size has been measured. The smaller the standard error, the more accurate is the measurement. Once the researcher has calculated effect sizes for all studies, he or she then averages these effects to obtain the mean.
The homogeneity test is used to test for the homogeneity of effect sizes, that is, whether obtained effect sizes were random samples estimating a single effect size or coming from different populations. The result of this test is compared with a chi-square for df = k – 1, where k is the number of studies. If the value is larger than the critical value in the chi-square table, the result becomes significant and suggests the effect sizes did not come from a single population value.
- Do the following exercise as a way to learn the process of research review. The purpose of this exercise is to conduct an integrative research review on a health services research topic of interest to you. Your review should follow the five-step process delineated in this chapter. It is possible that the class may be divided into groups, with each member responsible for one step of the process.
- First, conduct a preliminary review to identify the topic to be reviewed.
- Second, prepare a coding sheet based on the preliminary review, pilot-test the coding sheet using additional studies, and then revise the coding sheet.
- Third, ascertain the key terms used in your search. You may want to consult Index Medicus or other index publications for verification. Identify a computer-based abstracting service available in your library (e.g., MEDLINE) and conduct the search using the MeSH terms that coordinate best with your key terms. You may want to limit your initial search to a few years. Perform a parallel manual search and compare the differences between the two approaches.
- Fourth, record relevant study information on the coding sheets. If feasible, have different coders code the same studies and compare the results. If there are too many differences between the coders, you may want to revise the coding sheet or design a code book that accompanies the coding sheet. Then recode the articles.
- Fifth, based on the information abstracted on the coding sheets, prepare a summary table of the major variables of interest. If applicable, conduct an effect size analysis using the formulas and example from Table 4.2 as a reference. Make qualitative assessments of the studies being reviewed, focusing particularly on the uniqueness of study settings, interventions, and sample characteristics.
- Finally, prepare a formal report of your review using the following sections: Introduction, Methods, Results, and Discussion. Consult the relevant sections for contents to be included in the review.
Answers will vary, but should follow the five-step process delineated in this chapter. Responses should include:
- Evidence that a preliminary review was conducted to identify the topic to be reviewed
- A coding sheet based on the preliminary review, along with evidence that it was pilot-tested with additional studies and revised as necessary
- A list of relevant key terms and evidence that a search was performed on a computer-based abstracting service such as MEDLINE using the selected terms; evidence that a parallel manual search was performed; and a comparison of the differences between the two approaches
- Relevant study information on the coding sheet, ideally with different coders having coded the same studies and compared their results
- A summary table of the major variables of interest, evidence that an effect size analysis was performed (if applicable), and qualitative assessments of the studies reviewed, with a focus on the uniqueness of study settings, interventions, and sample characteristics
- A formal report of the review using the following sections: Introduction, Methods, Results, and Discussion
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