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Training senior nurses for health services research:
data-collection and data-analysis in Nigeria.
a course in
A. Bamisaiye
Senior Research Fellow
Institute of Child Health and Primary Care
College of Medicine
University of Lagos, Nigeria
Health services' research is concerned with the study of problems in
health care delivery.
❖
It is essentially practical and uses techniques
derived from social investigation and management research to investigate
the process of providing health services to a population.
It offers real
prospects of improving the coverage and effectiveness of primary health
care, starting from better use of the resources already available (1).
Simple investigations into current practice yield data which used to
improve activities can bring rapid results (2).
In developing countries, the senior nurse is carrying significant
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managerial responsibilities for primary health care.
At present many
primary health care services achieve poor coverage and impact, largely
because of managerial deficiencies and a mode of organisation which is
not responsive to community needs and problems.
The first step to
remedying this situation is to study it, in particular by collecting data
on coverage with respect to important areas of service, to staff performance
(of tasks), proportions of staff time devoted to different types of activity.
the amount of time patients wait in the service, to community needs and
problems and so on.
These are all simple studies of the health services
research type, involving looking analytically at what is actually going
on in a health service, with a view to improving the quality and effectiveness of care provided.
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Unfortunately, the senior nurse has rarely been prepared for this
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research role, although ideally placed to effect real improvements in
health services by means of research and its appropriate application.
However short courses and workshops can help to develop the knowledge
and skills required.
One such course was commissioned by the West African
College of Nursing in July 1985.
Twenty-seven senior nurses from the
five countries of the West African Health Community (Nigeria, Ghana, Liberia,
Gambia and Sierra Leone) gathered in Lagos for a five-day programme.
The
instructional objectives of the course were as follows:
At the end of the course the participant should be able to:1.
Use standard research procedures appropriate for research in nursing
management and staff training.
Specifically, the participant will be able tor1.1
Design a data collection instrument such that reliable and valid
data may be obtained.
1.2
Select a sample according to standard procedures and guidelines.
1.3
Analyse the data collected using standard statistical procedures.
1.4
Present the data in table form according to standard procedures so
that the data is readily comprehended.
2.
Apply the techniques of systematic observation to research in nursing
management and staff training.
Specifically, the participant will be able to:-
2.1
Carry out a simple work-sampling study in a clinic or ward situation.
2.2
Carry out a simple patient flow study in a clinic or OPD situation.
2.3
Utilise a skills checklist to observe individual staff performance.
2.4
Carry out a treatment audit with reference to standard treatment
protocols.
3.
Interpret the results obtained by means of research into nursing
management and staff training, with reference to the context of staff
supplies, administrative patterns and community behaviour.
4.
Give feedback to staff on the results of research into individual
and group performance utilising appropriate communication techniques.
5.
Plan appropriate changes in service, supervision or training based
on the results of the research.
The course emphasised active learning, 58% of the time was spent
on practical exercises in groups.
The practical work was carried out
in the community and in the primary health care clinic run by the Institute
of Child Health and Primary Care in a low-income area of Lagos.
Day 1
Pre-test.
Introduction to health services research ■methods.
Designing a data-collection instrument:
group exercise.
Group presentations.
Day 2
Introduction to sampling methods.
The art of interviewing.
Collecting data by means of interview:
group exercise in the
community.
Analysing data and basic statistics.
Analysis of data collected in community:
group exercise.
Group presentations.
Day 3
Service records as research data.
Sampling and analysing immunisation records:
group exercise
in clinic.
Group presentations.
Using research findings to improve service management.
Introductions to operations analysis.
Day 4
Systematic study of staff performance and service operations.
Task analysis, work-sampling, patient flow:
group exercise
in clinic.
1
Analysis of data collected in clinic.
Group presentations.
Case-studies in groups.
Day 5
research findings.
1.
Giving feed back, to staff on
2.
Using research findings to improve services.
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Post-test and Evaluation.
Emphasis was placed not only on
the practice of various research
methods'(cluster-sampling, systematic sampling, interviewing,
observation) but also on the process
systematic
of analysing the data obtained.
a whole.
tabulating it and presenting the findings to the group as
of some of the data presented appear
Examples
Table 1 is a composite of
below.
each sampled and analysed
the findings of the four groups of participants who
of Child Health clinic.
a year of immunisation activity at the Institute
As each group presented its findings the discussion highlighted
Lagos.
immunisation coverage of changes
how the data illustrate the effect on
In particular the data
in clinic supplies and mode of service operation.
illustrate the effect on coverage
screening)
of the introduction of a walk in (without
immunisation service in 1981;
of polio vaccine shortages in
1983 and 1984 and of forced reduction in the
level of community outreach
activities in 1984.
Table 2 presents the findings of one group of participants
analysed patient waiting time in the ICH clinic.
data presentation focussed on the
which
Discussion during the
implications of waiting time for service
utilisation and service coverage and possible strategies to reduce waiting
time.
Table 3 presents data on systematic
observation of clinic functioning
overall collected by the group which practised using a simple work-sampling
method.
The discussion focussed on time as a resource and the need to
look systematically at how time is being used in PHC services.
The data
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presented was of observations over a busy two hour period but the group
went on to speculate as to the proportions of time spent on different
activities at less busy times of day and to consider how less busy times
could be used for training, continuing education, management functions
and evaluation.
The objectives on communication of research findings and use of research
findings were met by means of case-studies worked through in groups.
The case-studies illustrated the obstacles to use of research findings
in improving clinic services and frank reference was made to the difficulties
of improving ICH services despite the availability of data such as that
collected by the participants in the earlier exercises.
Formal presentation to the participants as a whole was a feature
of the feed-back at the end of each exercise.
head projector to make their presentations.
Participants used the over
For some of them it was the
first opportunity they had to use this valuable visual aid.
Participants
were encouraged to prepare their tables carefully for presentation and
the discussion always included comments from the group on the layout of
the tables as well as on the content.
The emphasis on formal presentation
and careful preparation of tables was felt important in helping the
participants acquire confidence in presenting research findings in public.
Certainly nurses must be prepared for a critical reception of their efforts
to develop a health services research role for themselves and a polished
and professional presentation of research data will help establish
credibility.
Assessment and evaluation
The assessment by means of pre and post test showed an increment
of mean score from 28% to 48%, however the range of post-test scores was
from 22% to 81%.
The content on statistics posed the most difficulty
for the participants and undoubtedly lowered the scores.
Another course
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would need to give more time to basic statistics.
Health services research
need not be excessively quantative but it does require some
treatment of data.
statistical
The course was extremely well received by the participants.
Over 80% evaluated it highly on every parameter.
The senior nurse as a health service researcher
The WACN participants ended the course full of enthusiasm for health
services research.
The Institute of Child Health, Lagos, is offering
support to those who wish to develop a research programme and two Lagosbased participants are working on this at present.
However, it would
be unrealistic to expect the bulk of the participants in this short course
to embark immediately on health services research.
There are a number
of obstacles to be overcome, not least of which is a lack of recognition
by the hierarchy in which they work of research as an appropriate activity
for the senior nurse manager.
Short courses such as the one described
here are useful in preparing nurse managers for the research role.
For
the role to be fully operational there must also be, in many cases. a
re-definition of job responsibilities and positive encouragement in the
form of grants, awards and other kinds of recognition for the nurse who
succeeds in carrying out health services research.
Equipping those in
the forward ranks of primary care with the knowledge, skills and confidence
to carry out simple studies into service functioning, with the aim of
immediate service improvement, offers real prospects for strengthening
the delivery of primary care.
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Table 1
Immunisation status by year of birth,
ICH clinic, Lagos, 1985
Immunisation
Year of birth
%
1981
1982
1983
1984
BCG
70
82
76
73
DPT 3
60
71
67
51
Polio 3
54
65
30
16
Measles
71
58
46
44
All immunisations
21
43
21
14
None
5
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3
V
(a)
Data derived from a systematic 10% sample of immunisation
records filed at the ICH clinic.
(b)
Data collected and analysed by four groups of participants
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attending the WACN course in research methods for senior
nurses.
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Table 2
Patient waiting time at the
ICH clinic, Lagos, 1985
Service station
Mean waiting time
Mean service time
Main waiting area
177.5
1
Nurse interviewing
area
21
11
Exit table
.7
1
Cash table
.8
1
Injection/
immunisation area
1
1
Drug table
3
3
204
18
Total
(a)
(minutes)
Data derived from observation of six randomly selected
patients attending the ICH clinic.
(b)
Data collected and analysed by
one group of participants
attending the WACN course in research methods for senior
nurses.
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Table 3
Proportions of staff time devoted to different
areas of activity, ICH clinic, Lagos, 1985
Activity
Proportion of time
Direct service
55
Supportive service
14
Staff interaction
7
Training
4
%
Supervision
Waiting
8
Transit
3
Non-productive
9
100
Total
(a)
Data collected on a sample of staff by means of observations
every 2 minutes over a two hour period in the ICH clinic.
(b)
Data collected and analysed by one group of participants
attending the WACN course on research methods for senior
nurses.
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References
1.
Taylor, C.E.
World Health Forum 4 : 4
(1983)
2.
Ekunwe, E.O.
World Health Forum 5 : 4
(1984)
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VAITIHG TIME AND ITS IMPACT OH SHTVICE ACCEPTABILITY
AJR) COViBAGE AT AN MCH CLINIC IN LAGOS, NIGERIA,.
A. Bamisaiye, Ph.B.,
Senior Research Fellow,
0. Ransome—Kuti, F.R.C.P.,
Professor of Paediatrics and Primary Care,
A. A. Fainurewa,
Research Assistant.
Institute c ' Child Health and Primary Care,
ollege of Medicine
1 diversity of Lagos
Add; *ss for correspondence:
A. BaMsaiye
Institute of Child Health
P.M.B. 1001
Surulere
Lagos
NIGERIA
|a Ireo
SmiAKYx
The Institute of Child Health and Primary Care, College of Medicine,
Lagos provides an integrated maternal and child health service to a defined
target community within a low income area of Lagos.
The service is fully
available to the population and no geographic or cost barriers to access
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exist.
However service contact figures indicate that the acceptability
of the service to the community is less than desirable.
It is suggested that long waiting time is a factor which reduces
the acceptability of the service and hence utilisation.
The data is
presented, on waiting time collected by means of a patient flow study over
one week of service operation.
Mean waiting time for mothers attending
for routine visit was 162 minutes and mean time spent receiving service
was 13 minutes.
Time spent in the clinic varied in relation to the
number of patients attending o: a particular day, type of service received
and number of children accorapai 'ing the mother.
Although the waiting time
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probably compares favourably wl h conventionally organised child health
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clinics it is unacceptably high for members of the community and acts as
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a constraint to achieving optimum service coverage of the target community,
particularly with preventive care.
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Existing service organisation features
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which contribute to length of waiting time are discussed and strategies
to reduce waiting time are proposed.
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INTRODUCTIONx
The low ratio of health personnel and facilities to population
in the developing countries is frequently emphasised.
Less emphasised is
the fact that when health services do exist they are far from being fully
or properly utilised by the people.
(1)
The Institute of Child Health (iCIl), College of Medicine, Legos
offers an inte/rrated preventive, promotive and curative health service
five days a week to mothers and pre-school children in a target area of
30,000 persons.
A home-based referral for service system is a key feature
with a team of community workers visiting eligible families every four
months.
Resource availability is high, the service is staffed, equipped
Accessibility,both geographic and
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The densely settled target community surrounds
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and supplied at near optimum level.
economic, is also high.
the clinic such that even the farthest street is no more than 7-10 minute
walk away4
A nominal charge is made for registration and attendance and
drugs are provided at subsidised cost.
barriers to service use are minimal.
Hence geographic and direct cost
However the acceptability of the
service to the community is obviously far from complete, as indicated by
data on community/service contact (2).
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The service has attained its coverage objective of an 80% registration
of the eligible population but has been less successful in meeting coverage
objectives set at the same level in the areas of immunisation and regular
attendance*
A systematic sample of the immunisation records of children
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bom in 1980 indicated that only li2% had completed three doses of DPT
and polio immunisation by 12 months of age.
Attendance figures for the
period I976 - 8 indicated that only 23% of 0 - 1 year old, 39% of
2-3 years old and
of h - 5 years olds had complied with the pre
scribed schedule of clinic attendance in relation to age.
Moreover, the
ratio of well to sick visits at the clinic during 198O - 1981 was at the
level of one well visit to five sick .visits.
Most studies of service utilisation have examined the issue of
acceptability by focussing on the characteristics of the service user,
for example maternal education, beliefs, prejudices etc. (3)
However
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there is a real need to look also at the service itself and to what extent
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aspects of service organisation may unwittingly create barriers to full
service acceptability by the community.
Long waiting time has been frequently mentioned as one service
organisation factor which may limit service acceptability and utilisation
(h - 7).
However, there is rather little empirical data on the actual
time spent in health service situations by users in developing countries.
The few studies identified report total time spent in out-patient services
between three to four hours, with waiting time usually comprising the
greater part of-this (8-11).
There tends to be an implicit assumption on the part of service
providers that mothers in the developing world have this time to spare.
However, it has been pointed-out that for both rural and urban women in
developing countries surplus time may be extremely limited, particularly
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when they ere shouldering major economic responsibilities within the
family (12 - 1£).
In such a situation, when women have many demands on
their time, long waits at the clinic may prove deterrent to service use.
Considerable efforts have been made in the ICII clinic to
streamline the delivery of care, for example carefully planned patient
flow; use of home-based records and pre-packaged drugs; expanded roles
for staff such that nurses diagnose and treat 9^ of patients attending.
Despite these efforts to reduce waiting time as a deterrent to service
use, informal community feed-back indicated that waiting time at the ICH
clinic was still too long.
It was decided to collect data to ascertain
exactly how long mothers were spending in the clinic and whether this
h.
indicated a need to revise aspects of service organisation.
The following reports the resulting investigation into waiting and
service time, in relation to attendance i t the clinic overall and also
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for different kinds of clinic visit.
METHOD t
A study of patient waiting time war, carried out in February, I98O,
over one week of service operation.
r
A modified systematic sample of 2$%
of mothers was selected for obsei ’ation from among those waiting for
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service at various points throu hout the clinic at the start of each clinic
day.
In all, 562 mothers were observed.
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Selected mothers were given a
distinctive card and asked to present this card at each service station
they visited*
On presentation, the time of arrival at the service station 3
the time service was received and the time of departure from the station
and any relevant remarks were noted.
I.
Members of the ICH field research unit were especially trained to
pl
ip.
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record the observations and were oriented to the method by means of
a one—day pilot study.
Observation began at 8 a.m. each day, the
official opening of the clinic and continued until the last patient
had left.
Seventy-five percent of mothers were already present by 8 a.m.
each day, and a further 20% came in within one hour.
Informal
observation suggests that many mothers come in considerably before
8 a.in. since the clinic operates on a ’’first come, first serve” basis.
Broadly speaking, service was defined as direct service in the
form of a one-to ono encounter between mother/child and service
personnel.
Consequently, the duration of the Health Talk, (mean 11
minutes), which consists of a member of staff addressing all mothers
present, was not counted in the service time spent by any one mother.
The Food Demonstration session posed a particular problem in this regard,
since those mothers attending spent most of their time watching and
listening to the demonstration and nutrition education.
regarded as receiving preventive and promotive service tliroughout the
often lengthy classes.
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They could be
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However, service time was counted as that time
when a mother/child was actually participating in the preparation or
III
consumption of the food.
RESULTSt
The data were analysed by hand.
Overall mean waiting time was
I36 minutes (2 hours and 16 minutes) but the range was considerable,
from 3 minutes to 278 minutes.
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Overall mean service time was 13 minutes
but again the range was considerable, from 2 to 10£ minutes.
Since the large
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very helpful, waiting and service time by type of visit to the clinic
appear in Table 1•
In the week of observation,
of the mothers attending
came for a routine visit and spent roughly 2j hours waiting (162 minutes)
for 13 minutes of service.
The shortest waiting time (80 minutes) was
spent by the next largest group of mothers (31%) who came solely for
an
injection.
Those mothers attending food demonstration class (8%) waited the
longest (over 3J hours) whereas mothers attending for the first time (7%)
received the most service (37 minutes).
The existence of bottle-necks, or service stations where waiting time
is significantly greater, appears in Table 2.
The two points at which
patients collect in any number for long periods are in the area of the
Weighing Table, which also functions as the general waiting area for the
clinic, and of the Exit Table, where those patients waiting for injection
or immunization congregate.
The effect of day of the week c
waiting time 4id not appear to the
extent expected from impressionistic < bservation of p^aks in attendance at
start and end of the week.
II
Mean waiting time was indeed longest on Monday
(11;9 minutes) but only fell t <Low 130 minutes on Thursday when it declined
to’ III4 minutes, scarcely mo? a than a 30 minutes variation from the longest
waiting time.
As is to be expected, waiting and service time increased in direct
relation to the number of service stations visited (Table 3).
In other
words, the more "components" in the package of integrated preventive,
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curative and promotive care the mother received, the longer the
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the time she spent in the clinic.
Mothers ax‘e expected to bring all their pre-school children
with them on each routine visit.
Few do so, Table I4 shows that 811%
mothers attending were accompanied by one child only.
Since the time
spent in the clinic rose steeply for each additional child accompanying
the mother, (Table I4) this is hardly surprising, particularly if only
one of a mother’s children appears to ”'need
,
” attention.
DISCUSSION;
The total time spent by mothers in receiving service at ICH
probably compares favourably with conventionally organised child health
clinics, for example those where a single doctor sees all children atten
ding.
However, the waiting time for those mothers who attend the ICH clinic
for a routine visit, an average of 2 hours and h? minutes (Table 1) falls
short of attaining our stated service objective of 1^ hours waiting time.
Moreover, waiting time of this duration is almost certainly deterrent to
clinic use by mothers sufficient to achieve optimum coverage of the
population with preventive and promotive care.
It has been demonstrated
that patients will wait willingly for curative care for a serious complaint.
(16)
The predominance of sick visits to the ICH clinic endorses this
finding.
Despite intensive health education efforts in the community, most
mothers still seem to assign a lower value to preventive and promotive care.
Consequently, they are not likely to give priority to clinic attendance
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for this type of service when allocating their scarce resources of time.
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The opportunity cost of attending health services for mothers in the
developing world, who may often be shouldering major economic responsibility
within the fajnily, becomes significant.
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Coauminity perception of waiting time within the clinic
greater than that revealed by this study.
is even
A small sample of mothers gave
a mean estimate of the time they would normally spend in the clinic as
31* hours.
Interestingly, staff perception of tine spent in the clinic
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was considerably less than actual waiting time,
hours.
A simil<;r discrepancy between staff
that is a mean of
and patient perception of time
costs has also been reported from Indonesia (1?).
One service orgeinisation change, intended to speed the delivery
of care, iws already been inctituted.
Mothers bringing children for
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routine immunisation now proceed directly for this service, without prior
•screening for a contra - indicating condition, as in the past (18).
has had the effect of drastically reducing waiting time for
This
this group
of mothers and attendance for immunisation lias doubled since this system
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was introduced.
However, it is desirable to attempt to reduce waiting time in general,
in order-to-increase the overall ^requenijt of visits to the clinic.
If
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mothers pae sure of being attended to quickly and easily a pattern of
regular and frequent visits to the clinic can be established.
This offers
a real possibility of reducing serious morbidity and resultant mortality.
Frequent contact with families enables careful monitoring over time of
children with nutritional and related problems, support to mothers using
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oral rehydration methods, daily review of measles cases etc.
Consequently, two further proposals are made to speed up the
delivery of health care at the ICH clinic.
First, to encourage prompt
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resumption on duty by staff and prompt start of service.
nay result in waiting time for patients which exceeds the tine that the
personnel were late in arriving, due to a snowball effect.
(10)
Secondly, the introduction of a two-shift clinic as a step
towards permitting a more variable arrival time by patients.
There is
no real possibility of decisively reducing average waiting tine in
clinics when all patients are required to arrive at the same time and to
be assembled together before service starts.
(9, 10).
In such a
situation, women may arrive within 20 minutes of each other, yet depart
within several hours of each other depending on whether they were at the
front or back of the waiting area.
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The only real argument for.a common
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arrival time is that it permits the daily Health Talk to be given to a
large captive audience.
The unspoken arguments are that clinics have
always been organised this way and that it is more convenient for staff.
Education of both the staff and the community will be required On the
advantages of attending clinic at different times, to ensure a more
even flow of patients throughout the working day.
It must be admitted
that staff resistance to the idea has so far prevented the re-organisation
of the ICII clinic along these lines, although discussion continues.
However, the importance of reducing patient waiting time, as a means of
improving acceptability, utilisation and service coverage, warrant the
trial of this and other methods to make services more convenient^and
hence more acceptable, for users.
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Table 1
Time spent in an MCH Clinic by type of
service received, Lagosi 1980.
Type of service
No, of Patients
%
X Waiting
Time (min.)
X Service
Time (Min.)
Routine visit
301
(5h)
162
13
Inject.ion*
176
(31)
80
2
Food Demonstration Class**
h3
(8)
217
20
Registration
39
(7)
202
37
559
(100)
The type of visit made by 3 mothers was not identified
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* Mothers bringing children to comp: ?te en injection series,
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or for a Heaf Test reading.
*•* Mothers of malnourished or weight faltering children attend
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FDC before being seen for a complaint or routine visit.
*** New patients.
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Table 2
Waiting end service time at different Stations
within an MCH Clinic, Lagos! 1930
X Waiting'
Time
(in min.)
Station
Weighing Table*
Food Demonstration Class
Registration
Exit Table **
Interviewing Cubicles
Immunisation
Injection
X Service
Time
(in min.)
of Patients
attending
(n«5^2)
102
1
30*
60
■48
l|0
7
8
7
96
21
12
lloaf Testing
10
10
Hb Testing:
Drugs ***
Dressing
8
3
1
11
1
8
1
1
1
1
1
S
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79
22
5’8
12
11
36
2
#
Waiting for weighing and then to be called into the interviewing
cubicle area. Virtually all patients for interview wait in the
Weighing Table area, however, only those children due for
weighing are actually weighed.
**
Exit Table:
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This station conducts the traffic, or flow of
patients around the clinic directing patients to where they ri
to go to next. It also regulates waiting time for the Injectj m/
Immunisation area.
***
Commonly used drugs are pre-packed for dispensing at interviewing
cubicles. Other drugs are collected from the Drug station.
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Tabic 3
Time spent in an MCI! Clinic by number of
stations visited, La{jos: 1980.
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% patients
Attending
(B-562)
X Waiting
Time
(min.)
X Service
Time
(min.)
2
86
2
32
3
139
7
12
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162
12
22
5
180
22
17
6
217
25
10
7
218
31
6
No. of Stetions
I’.
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•7^-1 so
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Table l|
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spent in an MCH Clinic by number of children
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accompanying the mother, LagosI 1980.
Number of chiIdren
% mothers
Mean time spent
acconipExyine; mother
(n-562)
in clinicJ (min.)
1
8h
12^
2
114
192
3
2
23$
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REFERENCES
1.
Mahler, H. (1?8O)
Speech at a special Convocation of the
University of Lagos.
2.
Tanahashi, T. (1978)
Health Service coverage and its evaluation.
Bull, V. H. Crg 56 (2) 295 - 303
3.
Mckinlay, J.B. (1972)
Some approaches and problems in the study of
the use of services — on overview J. Health
and Human Behav. 13, H5 - 52.
h.
Bannerji, D. (1973)
Health behaviour cf rural populations Been.
and Pol, weekly, Dec. 2261 - 8
5- Benyoussef, A and
Wessen, A.F (197b)
Utilisation of health services in developing
countries! Tunisia Soc. Sci. and Med. 8,
287 - 30h
6.
Bennett, F. J* (1966)
The use of services by newcomers to the towns of
East Africa: J. Trop. Paediatrics. 12, 66-7
7» Cunningham, N* (1969)
An evaluation of an auxiliary — based child
health service.' in rural Nigeria J,. Soc.
Health Nigeria 3, 21
Aehitey, G. A. Wurapa,
F. K. and Belcher, B. W. (1972) Danfa rural
health centre: Its patic. ts and services
1970 - 1 Ghana Med. J. 1 » 3, 266 - 273*
9. Vogel, !• 0. et al(l976)
Operational study of the O at Government
Hospital, Kiambu, Kenya I Africa^Medjj^J.
53, 3, 168 - 86.
10.
Keller, A* et al (1975)
The impact of the organisation of Family
Planning Clinics on waiting time £tud. in
Family Planning 5, 5, 13h - kO
11.
Zein, A. (1978)
Operational etu y of the out-patient Depart
ment at the public Health Hospital at Gondar,
Ethiopia Ethiopian Med. J. 16, k5 ~ 52
12.
Sorimshaw, N. S. (197k)
Myths and realities in international health
planning, Am. J. Pub. Health 6k, 192-8
13.
Popkin, B. M. and Solon,
S. F. (1976) Income, time, the working
mother and child nutriture J. Tropical
Paediatrics 22, 156-66
8.
I
$3
U.
Boserup, E. (l?70)
Womans role in Economic
Development New Yorki St. Martin’s
Press
15.
Lonehurst, R. (1981)
Cropping pattern, nurition and
child care in a Nigerian village
Development Digest
86-93
16.
Munywoki, S., Shimoni,
N. and Hyndman, G. (1975)
Satisfaction among out-patients
visiting I4 Health Units in Kiambu
district, Kenya. E. African Med.
Journal £2, 6, 30(f”- 18
17.
Morley, D. and Woodland,
M. (1979) See How They Grow Londont
MacMillian.
18.
World Health Organisation
(1982)
Review of contraindications for
Vaccines included in the Expanded
Programme on Immunisation. Genevas
Draft Working Paper.
11
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INSTITUTE OF CHILD HEALTH AND PRIMARY CARE
FOR
WEST AFRICAN COLLEGE OF CURSING
COURSE IN APPLIED RESEARCH FOR SENIOR NURSES
OF THE WEST AFRICAN REGION 8th - 12th JULYf 1985
Introduction to design of a data - collection instrument
1.
When we collect information from people we do so by means of
asking questions. This situation of question and answer is
termed an interview.
An interview has 3 elements
(1) interviewer, who asks the questions,
(2) respondent, who answers the questions
(3) intrument, the form on which the questions are
written.
The instrument may be of 2 types
(1) a guestionnarre which is self-administered by
the respondent. If you are given a list of
questions about yourself to answer at home and
bring back the following day, this is a questionr.airre. It is only suitable for use with literate
and highly educated populations and consequently
is not used often in community health surveys in
developing countries.
(2) a schedule which is administered by the
interviewer. This is most commonly used in
developing countries, the questions are written
out and read to the respondent by the interviewer
who then marks the respondent's replies on the
schedule * He sure you alwasys use the correct
term for the kind of interview instrument you use.
The questions asked can be of 2 main typess(1) Structured
(2) Unstructured.
Structured questions are those in which the answers have
alredy been arranged or grouped into categories of response.
2.
2.1
Structured questions in which only ONE answer is possible.
Eg. State your sex:
Male
Female
30 - 39
40 - 49
50 - +
This kind of question is suitable for objective data such as
age, educational level, occupation, income etc. where there is only
one possible answer.
-
State your age
/2..
••
/2..
2.2
Structured questions of the check list type where SEVERAL
answers are possible:
Ea - Please tick those research methods listed below that you
are familiar with:S amp1ing
Designing a survey form
Interviewing: ___________________
Analysis of data
______
Tabulation of data
_____________
Basic statistics
___________
Tick all those foods that you would particularly
recommend a mother should give her malnourished child
Custard
Bread
Egg
Beans
Ice cream
Yam
Fish
Tea
2.3
Structured questions of the rating scale type where the
respondent is asked to rate according to a given standard,
state in order of preference etc.
Eg Please rate your familiarity with the research methods
listed. Tick the appropriate column.
Not Familiar
1
Sampling
designing a survey
form
Interviewing
analysis of data
Tabulation of
data
Basic statistics
some
Reasonably
Experience*
Familiar
2
3
Very
Ea
/3..
Please rank the fo^ds below in order of your prc'^. ..
preferred food and 5 against
Put 1 against the least
most preferred food:
Bread
Yam
Pice
Beans
Maize
3.
I
i
!
I
Unstructured questions are usually those in which the responder :
is asked for a statement of his belief, or opinion or reason ana
a blank space is left on the schedule for his actual answer to
written in eg:
What do you hope to gain from this research course:
Facts may also be collected by means of instructured quest,
if you are not sure of the kind of response:
Ea
Current job responsibilities (please describe)
After you have collected data from a number of respondents in
the form of unstructured questions, then you can go through thw~T» ... decide that the responses fall into a pattern of most commonly ~ ^4.
responses. You can then group each individual response into a
category of response. It would be tedious and unhelpful for t..c
reader to read through, for example, 30 separate responses by nc-.-sr s
to the question "why did you not keep your last clinic appointment’’
But these responses can probably be grouped into a category set '
follows:Response
mother travelled
mother forgot
mother too busy
child not ill
Frequency
////
Illi
Illi
III
H
If you ask an unstructure question always try to develop a
set for reporting the answers in grouped form:
/4..
«•>«
.
tv.
/4..
Points to remember in designing survey schedules
Be relevant| clear and unambiguous
4.1
All your question should relate to your main topic*
"How ofte.n do you bring your children to the clinic ?"
not a good question because we do not know what time^
period it refers to whether one month or one year, and
also the children are likely to be brough at different
time, depending on their ages and health needs. It would
be better to say "During the last 4 months how often
did you attend clinic with each of your children ?"
and the information for each child would be listed
separately.
4.2
Dp_not ask more than one thing in the same question
Would you like to have cheaper drugs and afternoon
clinics ?" is NOT a good question because two entire1*’
different topics are being covered in one question.
It is better to ask two separate questions e.g.
-
-
4.3
"What do you feel about the cost of drugs at the
clinic ?"
"What do you feel about the suggestion of having
afternoon clinics ?"
Do not influence the respondent in the way you word
the questions:
Influencing the respondent is termed bias, that is he
answers the question in a way which does not really
reflect what he thinks because of how you ask the
question. "Good mothers breast-feed their babies for
the first year of life, how long did you breast-feed
your baby ?" is not a good question because no mother
wants to give an answer that suggests she is not a
good mother. It is better to ask simply "How many
months did you breast-feed your last baby ?"
In this way you avoid the risk of bias resulting from
women’s concern to appear good mothers in your eyes.
Bias is very hard to avoid but is best prevented by
asking ourselves constantly "am I likely to influence
the respondents reply in any particular direction by
the way I have worded this question ?"
?
i
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5.
Good interview schedules are hard to design. It is esscnti-.l
to try out your schedule with a pre-test before you actually
embark on your research Study. A pre-test will involve trying
out 10-20 interview s in a real life situation. It will
quickly show you which questions "work " and which do not.
I '
AB/85.
I
i-.
!i
I
I
I
INSTITUTE OF CHILD HEALTH AND PRIMARY CARE
FOR
WEST AFRICAN COLLEGE OF NURSING
COURSE IN APPLIED RESEARCH FOR SENIOR NURSES
OF THE WEST AFRICAN REGION 8TH - 12TH JULY, 1985.
Introduction to sampling;
In research it is not always possible or desirable to stucy
case in the population.
The process of selecting some cases for study is called SAMPLIi.'JProvided the sample is properly selected, any findings from stuc ..?.■
the sample may be generalised, or applied, to the entire populr*afrom which the sample was selected.
If the sample is properly selected we say that it is REPRESENTAT" 'E
of the population from which it is selected.
2.
>7
>3
io
Probability sampling
This uses random selection methods such that every case
the population has an equal chance of being selected.
2.1
•-5
Simple random sampling
For random sampling you require a SAMPLE FRAME which is a
!>(>
.37
49
4l
03
57
8i
list of every case in the population with which you are conce-xi..
for example you may wish to interview a sample of 100 student
nurses. The list of names of all the students in the School of
Nursing is the sample frame. Each student is given a number ar-,
using a TABLE.of RANDOM NUMBERS 100 names are selected.
You may also use an even simples method of random sample
selection which is particularly suitable for selecting a fair..;
small number of cases from for .'example, among members of starr
or clinic patients.
70
23
S2
79
77
>3
*5
•; ?
45
32
Each person is given a number and then the
numbers are written on small peices of paper, jumbled together
and the desired number of cases picked out of the box. This
method is sometimes called the ”Lucky dip” method.
10
• »o
S1
2.2
Systematic sampling
‘ I
^•7
This is used with a very large number of cases such as file
83
68
32
cards in a clinic record cabinet which may run into thousands.
The desired sample size is identified, for example 10% of the
cases. The first card would be selected at random and thereoft_
every 10th card selected. Supose the first card was the 6th
card, the next selected would be the 16th, 26th, 36th, 46th etc,
until all the cards have been sampled.
t.
I5
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02
10
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/2..
;t ,
^•3
_Cluster Sampling
In most developing country situations a sampling frame is \
available. Then cluster sampling is useful for selecting case^
from the community because all it requires is a map of the dio-./
Each section of the map is numbered, each street in a city,
village in a rural area. A number is selected randomly then ch?
research is carried out on the desired number of subject fr ' ‘
Street or village selected.
3.
Non
This is based on non
3.1
random metnods.
25
3^
Availability sample
If a particular, and small, group in the population is
studied for example sickle cell disease victims, drug addicts,
pregnant school - girls, every one of such cases identified
constitutes the availability sample.
3.2
Quota sampling
If you know quite a lot about your population for exam,:?.?,
proportion of- each-sex, the proportion of different educationr*
income and marital statuses, then you can select a conveneni- c
sample based bn those^proportions.
i. . .’i
•> i
3.3 Convenience Sampling
TTctTHu of ’ tlh. r. ‘.r- i:
I This is the polite name given to the most common ’methcd o ’
sample selection which is to take those nearst at hand, usur "
patients or students, without further efforts at representatax
selection. AVpID THIS METHOD. BIAS IS ALMOST ALWAYS INTROD*JC .
57
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19 85
76 93
24 28
20 22
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08 79
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98 62
75 73
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00 79
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68 3<»
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60 09
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8948
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77 80
33 62
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60 58
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5° 94
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SAMPLING NUMBERS
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22 18
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54 84
64 54
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99 34
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52 80
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21 42
01 79
11 81
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85 79
31 90
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35
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65 63
54 55
44 70
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56 07
93 75
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32 75
36 74
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69 20
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96 23
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93 44
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98 24
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I
INSTITUTE OF gHILD HEALTH AND PRIMARY CARE
FOR
WEST AFRICAN COLLEGE Ofr NURSING
COURSE IN APPLIED RESEARCH FOR SENIOR NURSES
OF THE WEST AFRICAN REGION 8£h - 12th JULY, 1985
The art of interviewing:
1.
2.
3.
4.
The aim of all research studies is to obtain RELIABLE and
VALID data. The design of the questions is an important means
to this end and so is the selection and training of intervi< n.
Selection of interviewers
BIAS may arise as a result of the Characteristics of or kin
of person the interviewer is. Women respondents may not tai':
freely about certain subject with mdle interviewers and vi?c
versa. If the respondent feeld that the interviewer approves
of certain behaviour or behaved that way himself or herself,
the respondent may not admit to behaving differently.
Consequently, nurses in uniform do not make good interviewerr
in community health surveys because the respondents will ten;1,
to give responses they feel the nurses will approve of, thus
bias is introduced.
The ideal interviewer has the following characteristics:pleasant but not striking appearance
same sex as the respondent
same sort of background as respondent, that is no major
ethnic or status differences
confident, mature personality.
Training of interviewers:
Make sure your interviewers understand the purpose of the
research and the meaning of each question. A pre-test is
helpful for ensuring the interviewers know what they are doir.r.
Try to observe each interviewer at least once during the
pre-test and discuss your observations about their performance.
Practical tips on interviewing
Always greet respondents in the appropriate fashion
according to custom of the area•
Introduce yourself and your purpose
Go ahead confidently, do not hesitate or look uncertain.
Try to conduct the interview in the privacy of the
respondents room or other scheduledplace. Otherwise,
you may not get valid answers because of all the onj.ooucr£:
who tend to gather around.
5.
3.
RAPPORT is the name given to a good working relationship
between interviewer respondent.
too much rapport leads to unreliable data
too little rapport leads to invalid data.
AB/85.
.✓Institute of child health and primary care
for
WEST AFRICAN COLLEGE OF NURSING
COURSE IN APPLIED RESEARCH FOR SENIOR NURSES
OF THE WEST AFRICAN REGION 8th - 12th JULY, 1985
The art of interviewing:
1 .
The aim of all research studies is to obtain RELIABLE and
VALID data. The design of the questions is an important meaf.s
to this end and so is the selection and training of intervie*. ...s.
2.
Selection of interviewers
BIAS may arise as a result of the characteristics of or kind
of person the interviewer is. Women respondents may not talk
freely about certain subject with male interviewers and vice
versa. If the respondent feels that the interviewer approves
of certain behaviour or behaves that way himself or herself,
the respondent may not admit to behaving differently.
Consequently, nurses in uniform do not make good interviewers
in community health surveys because the respondents will tcr.:i
to give responses they feel the nurses will approve of, thus
3.
bias is introduced.
The ideal interviewer has the following charactaristics
pleasant but not striking appearance
same sex as the respondent
same sort of background as respondent, that is no ma-or
ethnic or status differences
confident, mature personality.
Training of interviewers:
Make sure your interviewers understand the purpose of the
research and the meaning of each question. A pre-test is
helpful for ensuring the interviewers know what they are cloirz-.
Try to observe each interviewer at least once during the
pre-test and discuss your observations about their performanTt- .
L
4o
Practical tips on interviewing
-
5.
Always greet respondents in the appropriate fashion
according to custom of the area.
Introduce yourself and your purpose
Go ahead confidently, do not hesitate or look uncertain.
Try to conduct the interview in the privacy of the
respondents room or other scheduledplace. Otherwise
you may not get valid answers because of all the onlookers
who tend to gather around.
RAPPORT is the name given to a good working relationship
between interviewer respondent.
too much rapport leads to unreliable data
too little rapport leads to invalid data.
AB/85.
10'197
AND PRIMARY CARE
institute OF CHILD HEALTH
FOR
WEST AFRICAN COLLEGE OF MOUSING,
COURSE IN APPLIED RESEARCH FOR SENIOR NURSES
O^HE'WEST AFRICAN REGION- BTH - 12TH JULY, 198
Analysing data_:
tabulation and basic statistics
Tabulation procedures:
once collected, must be arranged in an orderly
Ston Eo? analysis and report writing purposes.
1.
Hand analysis using the tally method
1.1
____register
" or
n
in Example I is imaginasy data from the
showing
their State
Below in Exampx
school of Nursing l
.._
SfUo?iaInenrAs you go through the list you place• a vertical
_______ In order to
stroke^against "each student-s State of orgin.
j arrangement of the d?.-a,
always represented as a
the Sth, 10th, 15th etc.
horizontal stroke. Using vertical and horizontal strokes
analysis is known as the tally me^££2
to organise
data for 1 < Utndthisdexample the nu^er of girls
_____
The term frequency is
kl”a 01 ■1“t"
a v
from a particu
is
ofi
an
called
a
freguency
table.
analysis i-
^%^^orh,eirthanet!0caredis [
culate percentages for greater understanc.fr.'
In Example 2 < K >te that percentages are ALWAYS ad e
of the data,
vertically to a total of 100.
Exaple 1:
Tally met tod of analysis
Frequency
State of_oric£in
/
s
L.'
Oyo
////
///
//
Ogun
Ondo
///
Bendel
and percentages
Example 22_zNumber
--------No.
State of__origin
Lagos
Og
Ondc >
Bendel
Total
Percentages rounded.
%
16
36
8
18
12
27
3
7
5
15
144
99
Si
i
/2..
, , .
whole
•--- ; in Example 2 are rounded to a
Notice that the percentages
This explains why
number because the population is small (44).
;
total
99
and
not
100.
the percentages
Cross - tabulation
kinds of dnt.- cA more complex kind of analysis is when two
data on woman:
analysed together, In Example 3 we show imaginary
contraceptive
knowledge.
education and c—
1.2
■
i!
a
1
Contraceptive
none
knowledge
Woman's education
some education
//
////
can name no
modern contraceptive ////
can name one or
contraceptive
more’ modern
i---methods
■
////
22
19
Total
////
////
HH
-i „
-» total ot 41 women were studied. A woman
in Example 3a total of
o
rn contraceptive methods wc ■
education and_ no-> knowledge
knowieage of modern R woman with sonle eaucatr^..
category.
be counted in
in the
the top
top left
le
^nntraceotion would be counted ir. ■; ?
and some knowledge of
of modern
"r"contraception
C™traTh?skind of analysis is cal—
bottom right category and
and aso
SOsOn.
on. reThiSekthan preparing froquoncy
It takes more
gg^E^^h-it because of the greater understanding wo
3 I
1
gain of the data.
2.
Constructing a table
into tables for your report,
Once analysed data must be put
the
following
components:?
“
Every table has t— 1-11.
Title (what, where, when)
2.
Captions ( side and column headings)
3.
Body (the data itself)
4.
Notes (anything else we need to know)
si
I
immunisation at Oguntolu
In Example 4 we have imaginary data on
Street Clinic..
Example 4
Table 1: Age at which BCG vaccine received, Oguntolu Stree1.
Clinic, 1984
2
Age at which
received
3
on/before 3 months
of age
above 3 months of age
Total
BCG immunisation
no.
125
83
25
17
150
100
14
r
/3..
Source: 10%
10% sample
sample of
of immunisation records of children bcm
in 1983,“ Oguntolu Street Clinic, Lagos (imaginary data),
4.
Can you identify the four component part of the table ?
3.
r.
Basic Statistics
income,, no. of vaccine doses,
If your data is numetical (aae, useful
It is U««■»-——— to know the ’‘average’1.
weight, height, lib etd)
Average refers to a "measure Of denttal tendency"
The 3 measures We will examihe are the MEAN, MEDIAN and MODE.
Terms to learn
■"—
Value, sum of values
_ Case, sum of cases, frequency of cases
- Frequency distribution
3.1
Mean
Example 5
Numbers of women
Aae in years (values)
25
22
15
18
30
1
1
1
1
1
110
5
sum of values
(cases)
sum of cases = 5
110
Mean = sum of values
sum of cases
= 110
5
22
?'■
the mean age of the women is 2; years.
Example 6
What do you do when you have several cases for each value ?
Age (value)
No. women (frequency of
cases)
1
2
3
2
"S- = sum of cases
30
24
26
22
mean
= 200
4
value X frequenc;
30
48
78
44
! 200 - sun
I
sum of values
sum of cases
25
K
mean age - 26 years.
I
i
I
/4..
3.2
i
Median
The median is the VA1>UE at the mid - point of a frequency
the VALUE
distribution, tue
v«--- which has half the cases or one side oi
it and half thecases on the either side of it..
To find the median
1.
Arrange the values in Example 6 in rank order
Value (age)
Cases (No. wonen)
2
2
22
24
mid_-_point
3
26
30
8 sum of cases
1.
Find the sum of the cases i.e 8
3.
Divide 8 by 2 to find the mid - point
i.e 8 =4
”2
Start at the top of the column of cases and count down 1
a rive at the mid - point
5
Find the VALUE which corresponds to the i.e mid - way
between 24 and 26 = 25
The median age is 25 years
3.3
The MODE is the VALUE which appears most often in a
frequency distribution.
What is the value in Example 6 which appears most often. ?
A
Answer
26.
The mode in this example = 26 years.
Example 7
Heights (value)
4 5 cm
49
53
54
55
No children (cases)
2
4
5
1
5
*
i
Two values occur most frequently ie 53 cm and 55 cm both occurs
5 times. This is a BI - MODAL distribution. The rule is to ta?.
the lower value. The mode .
is 53 cm.
L
J
: 7
•J
1.0^3-
A’
/5..
3.4 The RANGE is the distance between the highest value
lowest value in a frequency distribution.
and t?.
In Example 5 the values were 22,22,15,18,30.
What is the range ?
The range is 3C
15 = 15 years.
In Example 6 the values were 30, 24, 26, 22
What is the rance ?
In Example 7 the values were 45, 49, 53, 54, 55.
What is the
When do you use the different measures ?
4.
The MODE is the easiest to use since you obtairi it merely by
looking at the data, for the most frequently occurring value.
it is also the least useful for most purposes.
The MEDIAN is the true mid - point of the data,
affected by very high or very low values.
?
Lu
It is less
The MEAN is Used particularly if more elaborate statistical
analysis will be done later.
Do NOT use the term average.
Always specify the measure you are using.
5.
Two rules for statistical analysis
5.1
Always state your formula before doing the calculation
5.2
Do every calculation twice to ensure accuracy.
AB/85.
.f
'l
li
i
I
INSTITUTE QF CHILD HEALTH
ND PRIM RY C\RE
FOR
’ - N.
Pf NU - s 1
p£urse in tp'^iied Research for Senior Nurses of the
!985
PrA^ipA'l. exorcise on sampling service records
Js
Group |
Select a 10% sample of 1981 immunisation cards
Group 2
Select a 10% sample of 1982 immunisation cards
Group 3
Select a 10% sample of 1983 immunisation cards
Group 4
Select a 10% sample of 198^ immunisation cards
1.
Take each sampled card in turn.
One member should call
out the immunisations received by each child,
table below using the tally method.
Fill th?
before replacin''
'.he card count up the £.otal number of immunisations
received by the child and fill in table 2,
Immunisation '
•
No.
..I____
BCG
0
1
Total
DPT
Tally
0
1
2
3
Total
i-
I
Polio 0
1
2
3
Tot.nl
Measles 0
1
Total
I
■
--
r
I
I
All immunisations ’
Some immunisations •
None
Total
I
*
—fi
i
„.J. .
T- 12
Inriu.nl sation score
Tally
0
1
9
4
6
7
p
Total
Olcul^te the m^an, median ?nd mode of immunisation scores.
No
c'
I
?
A^SE^^M^h’T
STnFT P^^poh’5 ’ *»CE
S'' S-IOM i?0R W/.CP A?'9 'i ,?N
INTRO DU CT I OH:
To evaluate means to estimate the 'tIuo of
The word ’appraise’ and 'appraisal* are of’.gn used instead of
nij^.
.1
•evaluate* and ’evaluation’ or assess ^nd assessment when the perfor
mance of staff is being judged.
The main purpose of evaluation is to 1?arn from experience.
Staff performance is appraised in order that staff may learn from
experience and therefore perform more efficiently. Appraising
performance is not done to find fault with staff, even when results
are not as good as intended.
STAFF APPRAISAL
1*
Why appraisal ?
Appraisal is necessary in any organization in order to :
a.
reward to those who work harder than others
b.
collect data for promoting staff
c.
give incentive toward hard work
d.
keep discipline.
2.
3.
Factors for Appraisal
a.
Ferfo-m^nce
b.
Effort
c.
Discioline, ,\ttitude toward • »ork
. ‘
Methods of Appraisal
Measuring performance
a.
b.
Merit rating - factor by factor
c.
Overall appraisal
• •
Each method has its advantages and disadvantage^t e.g.
Measuring Performance is very clear and convincing particularly
in production or sales, however, somatimes performance does not
reflect efforts made. Overall appraisal is simple, but rather
difficult to convince a person appraised because of subjective
4.
ness involved.
Points to be noted :
Try to be objective.
a*
Appraisal cannot be totally objective as long as human
beings appraise human beings. However, efforts should be made to
which can satisfy those who are appraised.
Combine
different mehtods.
b.
If possible, try to employ not only on? method, but also two
or throe different methods and compare>‘hhem before an appraiser
a ;system
reaches a conclusion.
Obligation of an appraiser.
c.
An appraiser is obliged to tell frankly a person to be
appraise! in cqhc ho is asJc-ecH tV T-igSrecommended that a manager
should produce otmosphore In^which the manager can point out
weaknesses of his/h 'r subor'OfTates and discuss how to overcome
them. Evaluation of sta^f parformsnen using systematic observa
tion technic.‘ particular rer
nc;. t? the development and
use of a cli-'i’’’ill..- ?’? o’: ir’.st -3 -• .rc^ri-le. Let us
i
XNSTI'fUTE OF CHILD HEALTH /-UP rRIH/.RY C-\RE
(jpLLEGE OF MEDICINE, UNIVERSITY OF LAGOS
FOR
v)EST
AFRICAN
COLLEGE
OF
NURSING
Ct<gylrce in Applied Research for Senior Nurses from
the J;/est African Region: July Sth
12th, 1985
Introduction
ho
fiperaticns. Analysis
Operations analysis simply meads the systematic study of
health service operationsii Bedause it is systematic it
requires us to be empirical, that is collect data about
service activities. Since we are collecting’"d’a’Ea, operations
analysis also requires us to be quantatative rather than qualitative
in our reports. A quantitative a p pr o a c h me a n s that we describe
activities in numerical terms e.g.
1.
32% of staff time is devoted to direct service
average waiting time in the clinic is 2 hours
27 minutes and average service time is 7 minutes
in 12% of weights measured the finding was not
recorded on the child’s card.
All the above are ouantatative statements because they
are written in numerical terms based on empirical dataf
that is data collected in the actual service situation.
Qua!itative statements are descriptive statements which use
ad j e c t ive s r a th er than numbers. The foregoing statements
can be phrased cua1it?tiye1y as follows
a fairly small proportion of staff time is devoted
to direct service.
' 1
mothers wait Quite a long time at the clinic and
actually receive service for a short time only.
the greater part of all weights measured are charted.
It is obvious that quantatative statements are much more
authoritative and informative than qualitative statements.
In addition quantatative statements are objective because
they are based on empirical facts whereas qualitative
statements are usually subjectiye, being based on the
observers impressions rathers than on any empirical
data-collection.
i
I
I
2
Consequently operations analysis or systematic fact-finding about
service operations is the best basis for evaluating the on-going
work of a health service or, in other words, the process of health
service delivery. And ideally, no modifications in clinic
activities should take place without evaluation. Operations
analysis is a very important technique for management of health
services.
2.
There are 3 major methods of operations analysis we shall be
concerned with:-
1.
work - sampling
2.
patient flow
3.
task analysis
The first two are described below.
2.1
Work - sampling
This is a method of studying the total pattern staff
activities in a service setting, in particular the
different proportions of time devoted to different
activities. The idea is that the total working time each
day, in minutes, is regarded as the universe for sample
selection purposes. Moments of time are systematically
sampled, or selected, and it is at these moments that
observations are made of staff activities on-going. For example
exan;: e observations may be every 2 minutes at 3.00; 8.02;
8.04; 8.06 and so on until the end of the working day, The
observer selects before hand the different stations in the
clinic where the observations will be made every 2 minutes
and enters them in on the observation form. The observation
form has a line for each moment of observation. For example
the prepared form could look as follows:-
8.00
8.03
8.04
8.06
8.08
8.10
8.12
8.14
8.16
Reg. Table
Weighing
Interviewing Cubicle
Exit Table
Injection Room
Drugs and Dressing
Re$. Table
Weighing
Interviewing, etc.
Thus an observation is made of staff at work every 2 minutes
even although each station is only observed every 12 minutes
in this example.
o../3
3
When there is more than one than observer at work it is most
important that watches be synchronised, that is checked that they
are keeping identical time. The stations observed are never
identified in terms of the staff member present, work-sampling
is not a study of individuals at work r-ther of tho total pattern
of activities at a station and in the clinic overall. The
observed activity is categorised under 8 headings by putting a
tick in the appropriate column on tho form as follows:—
Direct Service:
e.g. interviewing patients, weighing,
registering patients, giving an injection/
immunization, giving drugs, etc.
Supportive Service:
e.g. clinic record keeping, preparation
of service area, administrative work generally.
Training:
on-the. job training of staff members or
health personnel/students from other
institutions.
Supervision:
on-going supervision of staff members.
Staff interaction:
assisting each other* consultation, etc.
Waiting:
Waiting for patientso
Transit:
Moving from one part of the clinic to another
on an essential task.
None:
Non-productive time devoted to personnel
rather than work activities e.g. eating,
chatting, buying items, etc.
The last column of the form provided for a very brief
description of the observed activity as necessary. For
example if staff interaction is checked the description
might read ’’Sister helps Clinic Assistant to adjust
haemoglobinometer”. At the end of the observation period
the forms are analysed by adding up the total number of
ticks or observations and then adding the total number
of ticks or obervations under heading. For example, in one
hour there will be 30 observations if the interval between
observations was 2 minutes. If 10 people are observing
for one hour, each this will be 300 observations overall.
Direct Service might be 62 observations, Supportive Service
39, Training 10 and so on. These totals should then be
calculated as a percentage of 300 to give the proportions
of staff time devoted to each activity. The same method
can be followed for calculating activity pattern for each
separate section.
o../4
»■
4
2.2
Patient Flow:
In patient flow studies the focus is on the client or.user
of the service. The aim is to estimate waiting time in the
service both overall and for each station. Mothers are
selected at random or on a systematic basis and then given
a distinguishing card, both to enable them to be picked out
by the observers and on which the waiting time information
may be recorded. Each station appears on the card against
3 columns as below
Receives
Arrives
Service
Depart5
Weighing Table
Interviewing
Cubicle
Exit Table
Injection/
Immunization
Drugs & Dressing
Departure
Note:
the list of stations has been abbreviated to
simplify the exercise
The time of arrival at the weighing station is fixed for
8 a.m. since that is the official start of the clinic. As
each mother selected goes through the clinic an observer
■ '’
‘
posted at each station
notes
oni her card the time she
leaves• The final observation is of the Departure from the
clinic. For analysis purposes the waiting and service time
at each station is calculated. For example, if a woman
reaches the Interviewing Cubicle at 9.14, receives service
at 9.21 and leave at 9.40 the waiting time will be 9.14 9.21 i.e. 7 minutes and the service time 9.21 - 9440 i.e.
19 minutes. The average waiting time and service time
overall and for each station can be calculated by adding
up the figures and dividing by the number of cards, i.e.
patients sampled.
/5
5
3.
Operations analysis may be simple, quick and carried out
by few staff. If done carefully it can yield invaluable
picture of what is happening in a service. But we must
remember that it only describes service operations it
does not explain the pattern of findings. To determine
the reasons for long waiting time or high non-productive
time the findings must be discussed with staff and also
set against the background of e.g. the drugs and supplies
situation and community utilization patterns.
Operations analysis should never be seen as a punitive
exercise or exercise in criticism. To guard against this
service staff should be involved at every stage of the
study planning and discussion of findings.
A. Bamisaiye,
?
A^SE^Prh’T
ST” PF P^FO^'NCE
SESSION FOR W/\CP AHO ’•/.•.ON
INTRODUCTION;
To evaluate means to estimate the 'rrlua of
The word ’appraise* and ’appraisal’ are of'?'n used instead of
’evaluate* and ’evaluation’ or assess ^nd assessm-nt vzhen the perfor—
nance of staff is heinc judged.
.1
The main purpose of evaluation is to 1>arn from experience.
Staff performance is appraised in order that staff may learn from
experience and therefore perform more e^fici'ntly. Zvppraising
performance is not done to find fault with staff, even when results
are not as good as intended.
STAFF APPRAISAL
i;
2.
3.
Why appraisal ?
Appraisal is necessary in any organization in order to :
a,
reward tn those who work harder than others
b.
collect data for promoting staff
c.
give incentive toward hard work
d.
keep discipline.
Factors for Appraisal
Perto-m^nce
a.
Effort
b.
c.
Discioline, Attitude toward -'ork^„f
Methods of Appraisal
a*
Measuring performance
b.
Merit rating - factor by factor
c.
Overall appraisal
• •
Each method has its advantages and disadvantage^, e.g.
Measuring Performance is very clear and convincing particularly
in production or sales, however, sometimes performance does not
reflect efforts made. Overall appraisal is simple, but rather
difficult to convince a person appraised because of subjective
4.
ness involved.
Points to be noted :
Try to be objective.
a.
Appraisal cannot be totally objective as long as human
beings appraise human beings. However, efforts should be made to
a .system which can satisfy those who are appraised.
Combine different mehtods.
b.
If possible, try to employ not only on' method, but also two
or■ throe different methods and compare.xthem before an appraiser
reaches a conclusion.
Obligation of an appraiser.
c.
An appraiser is obliged to tell frankly a person to be
appraisal in case ho is askgd;; j^t i^srecommended that a manager
should produce atmosphere in^which
in^’^iich the manager can point out
weaknesses of his/h'r subordinates and discuss how to overcome
them. Evaluation of sta^f perform'-nee using systematic observa
tion technic.’A’ particular re^^r no. t:- the development and
use of a cl A'"I1 -’'il?..:
list -c. -•
Let us
.1
.1
f
2
/assume that two of the functions- of & staff in h§r ioh
^©ighlog and ’’patient management by the u.s.e of standing orde®#%
qbservable behaviours- that can be. appraised .c.an be broken dwn lijfe®
steps she/he will take in the process of patient mana^fReht^
Also th© level of competence can he measured by the rating, .scale pe 1*4. ♦
Let us use these samples for practice I
A.
'
L
Explanation pf purpose
and procedure
2.
mIJ ‘
§2!
L.4
■*-*-* ’?rr—r
l-U-
‘
|
------ r
rr-
gliding a^d. Ree©.i?di.ng
C.
REMARKS
,
.-
..L.
|
Tit”r"rr4 “ ’
:
at weight
4
I
iffo--------- /
■ i v‘—' - - T» T-y.-rT-^.. F,;^
Placement of patient
Bulacvstag
■°
'
balancing scale at zero
ytr -yr:
3.
1 t 2 1 3
o
!
WEIGHING INF iIT,
TODDLLSR, MOTHER
-> t-m *7T
!
F- ...Ui
r
<
-r-.T’•»■ yiy 'fy^' •
■-- ■• —r
Patient Management by the use of standing orders
Bi
-- f
■^■Approach to ‘paty^gt
’"pbc'k up-Clih fe-p!5rpBrl--.tp
Steps;
: ■ -.. f
;
.I
. j.
1-t
• ■’W
r-r-
1.
2.
3.
4.
~ gflf-y • t-- «-*
ri-’—-
Wm¥
K$y
. r-r-^
•jr* -
TT'r ’ Perform pHysical examina-;
tion as listed
___ L
’S'. '■'-r Selects appropriate’
'
Hndings .......
_ ___
Selects apprbprlWe
___ correspopd^in^^a^tipn...........
T,'' “ Check for co'rrcct drug
.a>-)prpprj.^te use of
drugs
Advise on follow-up
1
- -v' r-r ■
Poor performance
Average performance
Satisfactory performance
Excellent performance
PRIMC3 S.O. OY^DEJI
INSTITUTE OF CHILD HEALTH AND PRIMARY CARE
FOR
NEST AFRICAN COLLEGE OF NU.L3.rFG
COURSE IN APPLIED RESEARCH '"OR SENIOP. NURSES
OF THE VJEST ...I’RICAN PTGICU. JULY cth • 12th, 1985.
Work Sampling Exercise
1.
Postings
Weighing Table
Interview Cubicles -( 2-3;
Exit Table
Cash Desk
Immunisation
Injection
Family Planning
Drug s/Dre s sinc
2.
Analyse your C?.N d.ita as follows
2.1
Place
At station
El sovzhere
Away
No ob acrvations
Total
2.2
Activity
Direct si.rvic..;
?Jc-. Observa tions
Supportiv;
St?, f f in t e r ? c I ion
Traininc
Supervision
■‘Jaiting
Transit
Non • Productive
Total
2.3
Work together v.-ith the rest of the group and droduce
COMBINED tables., Show number and percentage.
/2..
2.4
Produce a final table combining the data as follows
Activity
Direct service
Supportive service (Including staff
Interactiontraining,
Supervision).
Non ■■ Productive
(Include waiting and
transit)
r;o. Observations
Total
2.5
Give the final table a proper title.
%
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&
II
3
u?
c-
I
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<
♦
O
Pu
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At Station
t
I
X
I
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I
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i
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+
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Elsewhere
I
Ti
1
*
rT
Direct
Service
>
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INSTITUTE OF CHILD HEALTH AND PPIMARY CARE
FOR
WEST AFRICAN COLLEGE OF FUPSIUG
COURSE IN APPLIED- RESEARCH FOR SENIOR NUT.SES
OF THE WES'? AFRICAN REGION !Jth - 12C.:. JULY, 19C5
Patient flow exercise
Postings (2 participants per station )
1.
Weighing table .(note: enter time of arrival for ALL
patient at the station as 8.00)
I
Interview Cubicle
Exit Table
Injecticn/Immunisation area
Drugs/dressing (1 participant)
Clinic exit ( 1 participant, This is a very important
position to record the final departure time from the
I
clinic)
2.
2.1
Analysis of data
For each station calculate the waiting and service
time for each patient and the total waiting and service
time at that station.
2.2
Arrive at the mean waiting tine and the mean service time
by dividing the total waiting and total service time by
the number of patients observed.
2.3
Prepare a table (with ALL components) for mean waiting
and service time at each station.
Get data from your
colleagues.
• j
i
2.2. Calculate the mean waiting time overall. Total up the
waiting time of ALL patients and divide by the number
of patients observed.
i
the same way for the mean service time.
2.3
Proceed in
2.4
Using 8.00 as the entry time calculate the length of time
spent in the clinic for each patient, Calculate the mean
length of time spent in the clinic by dividing the total
of length of time by the number of patients observed.
2.5
Prepare a final table showing the moan time spent overall»
mean waiting and mean service time.
ZiB/85
COST DIALYSIS OP OGUITIOLU miLY lEALIH FROJ^T
PATIENT FIOW ANALYSIS FORM
SERVICE
Patient
Identification
Number
ST A T I 0 II
Time of
Arrival
at Station
M AKE
Time
Time
Service
Begins
Service
Ends
OF
OBSERVER
Name
B^TE
PAGE
and Category
of Health Worker
Comments;
\
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Sa.
INSTITUTE 07 CHILO HEALTH AND PRIIURY CARE
COLLEGE OF MEDICINE, UNIVERSITY OF LAGOS
PRIMARY HEALTH CARE:
UNIT 7.2
EVALUATION OF PRIMARY
HEALTH CARE SERVICES.
Group Exercise 4 - Coinmunicatinc the rosuits of evaJ-uation
of individual performance.
It is 9.00 on a Monday morning in Ajido Health Clinic.
It is a very busy time and there are many patients waiting
for attention.
The sister-in-charge, Sr. Adebayo, has about 3 patients
crowded around her consultation table. Sr. Adebayo sees
one of her staff, Sr. Onayemi, passing and interrupts her
interview with a patient to call her over.
Sr. Adebayo:
Sr. Onayemi, come, come, come
Sr. Onayemi:
Good morning, sister
Sr., Adebayo:
(waving a paper at her)
I have just seen the results of the
assessment of you.r clinical performance.
Its not good at all, not good at all.
o . <• e r.
oc
Sr. Onayemi:
Please sister► v/hich assessment is this
Sr. Adebayo:
Dont interrupt, I have told you over and over
again that you must improve your work and
these results show you arc not trying.
They are not good, not good-
Sr. Onayemi:
Please sister, I dont know e,
Sr. Adebayo:
I said don’t interrupt: Have you no respect ?
Did you learn nothing t Nursin •' School ?
What kind of parents do you have that they
did not teach you how to behave towards your
seniors 2
Sr. Onayemi:
Sister ..
Sr. Adebayo:
Just because your husband is a big man and
you come to work with a driver you think you
need not take correction. Well, this
assessment shows it all. You better get
straight back to your patients and do better.
Unless I watch you Nurses all the time you
don’t want to do any work at all.
Assignment:
1.
List the negative ways in which Sr. Adebayo communicated
with the member of her staff. There are at least Q "bad"
communication and supervison practices described.
2.
What factors in the Nigerian culture contribute to poor
communication between superiors and their staff ?
3.
Re-write the situation and the dialogue to reflect effective
communication skills in reporting back on the evaluation of
the performance of a particular member of staff.
i
-INSTITUTE OF CHILD HEALTH AND PRIMARY CARE
*’COLLEGE GF IF -CIIE OF THE UNIVERSITY OF LAGOS
PRIMARY HEALTH CARE: UNIT 7C2 EVALUATION OF PRIMARY
HEALTH CARL SERVICES:
Group-Exercise 5:
"mpiementing evaluation findings:
At Headquarters;
Dr. Lawson,--the manager of the Ajido Integrated Community
Health Project, is setting at His desk in the Ministry of Health.
He turns to the next file on his cable a: d sees it is the report
gf a study carried out by the newly forc.ed evaluation Unit of
.the Ministry. The Uni: is the brainchild of a colleague recently
returned from overseasj Dr. Lauson was elseat from the briefing
sessions before the Evaluation Prograr;..e \.as lav.nched and is
unclear about the objectives of the prosrarrrr.e and how it affects
.his,own work.
$
The report is of a work-sampling study at Ajido Clinic.
It is closely typed and a mass of tables., graphs and figures.
Table I (below) catches his attention^
Table I :
Overall brea'cdo’.-’n of staff
activities, Ajido Clinic, 1334
___ Acj^.vitv_catenor j ■- s
Lirect service iurportivc service NonProductive
Total Staff effort*!
32
33
30
Dr. Lawson has often expressaa h: s on r/.nn tl.-’t the Ajido Clinic
is oven-staffed and that tn.«sf of the- h -.1 :h •■r’ ers are more
interested in their pri va-r—ectav-i .R s i.’.e'i ii -.arrying out their
job responsibilities. Table I in the report
rc-oort appears co support
this view.
He flips through the rns-l of the longery report, looks
for the recommendations and doesn’t see any. He puts it to one
side and decides to call a meeting-with the Ajido Clinic Staff
right away.
(In fact the repox-t goes on to argue that the main reason for
such a sizeable propor t.ion of ndn-pi oductive activities on the
part of the staff is the we.^: the Clinic is organised, Particularly
the requirement that all patients must be assembled before the
clinic startso The report S^ts^pto studeies from East Africa
which have showed great increases in'direct service contact tim£
by changing to a system whereby a patients can come to the clinic
any time up to hour before the clinic ends,. Specific
recommendations are not made in the Evaluation Report, since this
is outside the terms of reference of the Evaluation programme.)
At Ajido Clinic:
A colleague from-jMvM’has called in at Ajido Clinic to say
that an evaluation report is going, around at Headquarters w&ibh says
that the staff at Ajiac spend most of tucir tine idling around.
The Ajido staff are highly indignant . They recall the day the
Evaluation Unit carnet, nobody knew who they we.^e,,- they were not
introduced, nobody know what tl}ey were were doing and anyway what
qualifications did they have-to observe the nurses wotk since they
were not trained peoplew One nurse recalled how she had quarrelled
with the observer from tne Evaluation team who had marked her
’’idle” while she was waiting to rer.d a patient’s temperature.
Another nurse said ’’why should Div Lawson send people to spy on us
like this 3
/ 2..
-
/2..
He’s going to use this as an excuse to block our promotion”
By the time Dr. Lawson arrives at Ajido Clinic for the meeting the
staff are in a state of annoyance and tension. Dr. Lawson is _
accompanied by the Assistant Project Manager, Dr. Giwa. Dr. Giwa
on the
has read the report and is hoping for a good'discussion
.
implications of the findings. He was interested in the studies
from East Africa quoted and would like to see a re—organisation or
clinic hours. He believes it would increase coverage of the community.
The Clinic Meeting:
Dt* Lawson
:
You have all read this Evaluation report
by now, I sent copies yesterday.
Sr. Adebayo
We did^t get them until this morning
but--- —----
Dr. Lawson
Well we just have to discuss it this
afternoon, I will be away for the next
one month.
Sr. Adebayo
Anyway, my staff were too busy but I
looked through it. In fact, there were
too many tables and statistics and I
could’fat see where the report was leading
But I did see somethign about ’’non-productive”
time which I didn’t like.
Dr. Lawson
Of course, you wont like it because it shows
your nurses are’nt working. You are too
many, consequently you’re non-productive.
Dr. Giwa
Autucilly,
Actually Sir, the report does point out
that the main reason for non-productive time
Sr. Adebayo (Interrupting Dr. Giwa) : My staff do not accept this
report because they were not satisfied about
how the study was done, Who are the people
who carried it out. ’.That are their
qualifications, why are’nt they here to meet
us now ?
Dr. Lawson
The Evaluation team is in Borno now. They
are specialists, they cant take time giving
feedback to each and every clinic. Anyway
they are coming back next month to do a
study of patient waiting time.
Sr. Adebayo
Well, we will be ready for them. And anyway
we know that our patients only wait for about
\ hour, if they find something different
it is because they are just out to make trc’-:trouble.
Dr. Giwa
Sr. Adebayo, there is a very interesting
suggestion in this report, that it would be
nice to discuss here, that is to have the
patients come in to the clinic freely at the
time they wish ---------
Sr. Adebayo
But what about the Health Talk ? Unless all
the patients are together we can’t give the
Health Talk.
Dr. Giwa
Is that so important ? Dont we give health
education in other ways ?
ka
Another nurse said ’’why should Dr
like this 3
j -* •------ o
Genipei. <auure.
Lawson send people to spy on us
/ 2. v
Sr. Adebayo
Ah no, we must have the Health Talk first for
eveyone. That
--- ’s how we have always done it
the patients know it, they prefer it.
Dr. Lawson
It would require a decision by the Chief
Consultant to alter clinic hours. Anyway, we
can’t just have patients wandering in and out
as they please. At least this way we know
our service starts at 8. a.m. prompt.
Assignment:
1.
Before evaluation findings can be utilised they must be
discussed fully by all concerned. Identify the factors
in the example above that hhve prevented full discussion.
There are at least 8 factors, you may find more.
2.
If the suggestion to re-organise clinic hours had been
discussed fully, what factors can you identify which would
have prevented a decision being taken to do so ?
3<
Suppose the Ajido Clinic was re-organised such that free
entry of patients up until 12 noon was introduced, which
two activities would be essential to make the change effective ?
AB/85.
co re~.a a pati.ent’s temperature.
Another nurse said ’’why should Drc Lawson send people to spy on us
like this 3
I
INSTITUTE OF CHILD HEALTH AND ?RIMARY CARE
FOR
WEST AFRICAN COLLEGE OF IHJF^IjTS
COURSE IN APPLIED RESEARCH FOR SENIOR NURSES
OF THE WEST AFRICAN REGION JUIiY STH -- 12Tilz 1985
How to write a research report:
A Scientific report should have the following sections:
Introduction
Materials and Methods
Results
Discussion
Summary
Acknowledgements
References
INTRODUCTION
1.
_
What is the report about ?
What purpose is it fulfilling
State the problem you have investigated
The fundamental purpose-of a scientific report is to give the
reader everything he needs to know about the work you have done.
2.
Materials and Methods
WHAT instruments did you use for data collection ?
HOW were they designed and tested and by whom?
If diagnostic instruments
used, describe briefly.
WHO carried out the.study ?
WHERE was it conducted ?
WHEN was it conducted ?
J
^ntropor.etric measuring devices
WHAT problems occurred during field work ?
HOW were they resolved ?
3.
RESULTS:
This is the most important part of the report,
it includes
BOTH the tables AND a sentence describing each table
E¥EE¥. Table or graph/histografn/pie chart etc must be numbered,
have a title (what, where, when) captions, data and any necessary
notes.
EXAMPLE*
Table II Distribution of^ype of bathroom Scmolu, 1983
Typ6 Qf bathroom
Room with bath tub .
Room with tap or shower
Number
44
15
15
%
4
-j 5
Room without tub/tap/shower
80
39
100
100
Total
Note :
93% of the above facilities were shared.
/
/2.
Points to remember when presenting data
Where the data set is small i.-c less hhaiT-209 -300, round % to
nearest WHOLE number
Where the data set is very smcJ.I i.o 20 or less, do not
calculate %
Always have a Total-for each table
For cross - tabulation have a Total both horizontally and
vertically Table 10 "Is there any medicine you give your
child every day" by age of responceni, Somolu, 1983
grouo
Response
Total
15- 29
<30
Yes
35
33
32
68
%
81
No
9
20
7
18
16
19
Total
44
100
40
100
81
100
arrange categories in logical order
age chronologically
less 15 years
15 - 29 years
more than 30 years etc
other categories either in descending or ascending order
of magnitude
collapse categories.when possible.
Generally speaking f do not have more than 4 -• 5 categories
per table:
EXAMPLE:
Level of education
none
same primary
primary vi
same secondary
completed secondary
post secondary
CAN BECOME
frequency
41
12
22
11
6
3
frequency
Level of education
41
none
34
primary
20
secondary or. more
Note : or.lv 3 respondents had ocst-secondary education.
r
/3. .
Always put residual categories i.
DK
NR
(no response)
NA ( no t app.l i o ab 1 c.}
Other (specify)
at the bottom of the tabic if included
Decide whether or not to include residual categories
EXAMPLE 1
Residual category excluded
Table 2
Whether health discussed at PTA meetings,
Somolu 1983
Whether health discussed
Yes
NO
frequency
28
?7
I
% s
43
57
Total
100
Note: NA - 20 i.e respondents without children at school age.
In this example LAA is excluded because does not represent
valid data.
EXAMPLE 2:
Table 4
Recidnal date included
What do you do ut once to treat diarrhoea at home ?
Somolu, 1983
Response
Correct
Partially Correct
Incorrect
Dont know
Total
7
%
25
35
18
22
85
100
Pregnancy
45
21
12
In this example ,;Dont know” is a substantive r.esponce i.e. it
has a valid meaning in this table therefore it is included.
ALWAYS exclude NR (ho response) from tables, It is not data.
by definition. Put a note at bottom "missing values
the Notes at the bottom of a taple should include any additional
information the reader requires to understand and interpret
the data presented in the table.
If data Other than your own is also presented in a Table,
indicate source.
EXAMPLE:
Table 9:
Distribution of type of toilet, Somolu and
Lagos State.
Type
Bucket
Pit 1-'trine
/Area
Somolu (Apat? St.) Lagos State*
51
32
13
9
<:7
<4
1
*.vO'dr<7..- r
%
I
//
/
//
//
4.
DISCUSSION
This concludes your report
interpret vcxir. .rogiiJts ? referring to tho ’fr-hle
highlight you rjsultn
anything noteworthy
fi
surprising
in 3.ine with other findings
contradicting other findings
>
tt
State the:
5.
6.
7.
8.
inplications for health and health service delivery
make recommendations
SUMMARY
brief review, no more than 10 line
REFERENCES anthor (date) title- publisher, place of
publication
ACKNOWLEDGEMENTS: .
everyone who has helped you do your study, Zin important
academic coustcsy, Do net omit.
APPENDICES:
any other relevant material or extra tables or additional
decumentation
X
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