Contents
Preface
PART I Limbering Up
CHAPTER 1 Turning Your General Aim Into a Specific Question
THE BEGINNING
WHAT ARE YOUR AIMS?
WHAT IS YOUR QUESTION?
GETTING THE QUESTION CLEAR
FINAL CHECKS
CHAPTER 2 Taking a Preliminary Look at What Has Already Been Done
IS THERE ANY POINT?
GATEWAYS – A SIMPLE WAY INTO SEARCHING
YOU CAN TALK WITH COLLEAGUES
YOU CAN TALK TO YOUR ACADEMIC OR CLINICAL LIBRARIAN
PART II On Your Marks
CHAPTER 3 Coming Up With an Initial Plan of Action
THE INITIAL PLAN
STUDY DESIGN
CHOOSING A SETTING
DECIDING ON A SAMPLE
DECIDING ON MEASURES
CHAPTER 4 Carrying Out a Systematic Search
HAVING A MUCH CLOSER LOOK
THE SYSTEMATIC REVIEW PROTOCOL
QUALITATIVE SYSTEMATIC REVIEWS
CONCLUSION
CHAPTER 5 Building a Team
THE NEED FOR OTHER PEOPLE
WHO IS TO BE ON THE TEAM?
PART III Get Set
CHAPTER 6 Choosing the Best Study Design
WHAT ARE THE RESEARCH DESIGN OPTIONS?
QUALITATIVE METHODS
DECIDING ON HOW THE QUESTION POINTS TOWARDS THE DESIGN
CHAPTER 7 Selecting Samples for Quantitative Research
WHICH SUBJECTS? – THE SAMPLE
THE STUDY AND TARGET POPULATIONS
GETTING YOUR SAMPLE SUBJECTS WHEN YOUR RESEARCH IS QUANTITATIVE
PROBABILITY SAMPLING
NON-PROBABILISTIC SAMPLING
CONSECUTIVE SAMPLING
CONVENIENCE SAMPLING
SELECTING CONTROLS FOR A CASE-CONTROL STUDY
INCLUSION AND EXCLUSION CRITERIA
HAVING GOT YOUR STUDY PARTICIPANTS HOW ARE YOU GOING TO GET THE DATA FROM THEM?
CHAPTER 8 Selecting Samples for Qualitative Research
GETTING YOUR SAMPLE PARTICIPANTS – THE QUALITATIVE RESEARCH CASE
CONVENIENCE SAMPLES
PURPOSIVE SAMPLING
AN EXAMPLE OF MAXIMUM VARIATION SAMPLING (OR SAMPLING FOR DIVERSITY)
THEORETICAL SAMPLING
HAVING GOT YOUR SAMPLE HOW ARE YOU GOING TO GET THE DATA FROM IT?
PART IV Wait for It
CHAPTER 9 Deciding What Information to Collect
WHAT DO WE NEED TO KNOW?
RECORDING INFORMATION IN QUALITATIVE RESEARCH
RECORDING INFORMATION IN QUANTITATIVE RESEARCH
CHAPTER 10 Tackling Confounders
INTRODUCTION
CONFOUNDING – WHAT IS IT?
A PLAUSIBLE EXAMPLE OF POSSIBLE CONFOUNDING
SOME WAYS TO DEAL WITH CONFOUNDING
CHAPTER 11 How Many People to Study?
SAMPLE SIZE
GETTING THE APPROPRIATE SAMPLE SIZE IF YOUR RESEARCH IS QUANTITATIVE
GETTING THE APPROPRIATE SAMPLE SIZE IF YOUR RESEARCH IS QUALITATIVE
A WORD OF WARNING ON SATURATION
WHAT YOU NEED TO DO NOW – A CHECK LIST
CHAPTER 12 Getting Ready for a Qualitative Analysis
BE PREPARED
CHAPTER 13 Getting Ready for a Quantitative Analysis
GETTING READY
WHICH METHOD OF ANALYSIS?
CHAPTER 14 Writing Your Final Protocol
ANNEX DINESH’S AND ANNA’S RESEARCH PROTOCOLS
CHAPTER 15 Arranging Funding
DECIDING WHAT FUNDING IS REQUIRED
WHERE TO APPLY
CHAPTER 16 Getting Permission to Go Ahead
WILL MY RESEARCH NEED ETHICAL REVIEW?
RESEARCH GOVERNANCE
APPENDIX
PART V Go!
CHAPTER 17 Recruiting the Participants
WORKING WITH THE HEALTHCARE SYSTEM
DOCUMENTATION
WALKING THOUGH THE RECRUITMENT PROCEDURE
NON-PARTICIPATION
CHAPTER 18 Collecting and Recording the Data
DATA COLLECTION FORMS
CODING OF VARIABLES
MISSING INFORMATION
PRIMARY USE OF COMPUTERS FOR COLLECTING AND CODING
SECURITY
DATA COLLECTION DIRECTLY FROM THE STUDY PARTICIPANT
DEALING WITH THE DATA ONCE COLLECTED
CHAPTER 19 Living With (and Without) the Data
QUANTITATIVE DATA AND THE COMPUTER
REFUSALS TO PARTICIPATE, DROP-OUTS AND OTHER MISSING PERSONS
MISSING A LOT OF DATA
QUALITATIVE RESEARCH AND MISSING DATA
PART VI Staying the Course
CHAPTER 20 Taking Stock
A PROGRESS REPORT
CHAPTER 21 Making Sense of Your Results – the Quantitative Case
INTRODUCTION
AFTER THE TABLE OF BASIC CHARACTERISTICS – WHAT NEXT?
RE-VISITING THE CONFOUNDING PROBLEM – STRATIFICATION AND MODELLING
CHAPTER 22 Making Sense of Your Results – the Qualitative Case
INTRODUCTION
PART VII The Finishing Line
CHAPTER 23 Writing a Research Paper
THE INTRODUCTION
THE METHOD
THE RESULTS
THE DISCUSSION
AUTHORSHIP – WHICH AUTHORS WILL HAVE THEIR NAMES ON YOUR PAPER?
CHAPTER 24 Setting Out Your Findings
FIGURES
TABLES
TEXT
CHAPTER 25 Writing Your Discussion
CHAPTER 26 Writing a Thesis or Other Report
A THESIS OR DISSERTATION
WRITING A RESEARCH REPORT
CHAPTER 27 Dealing With Journals
Further Reading
Index
This edition first published 2011 © 2011 by David Bowers, Allan House and David Owens
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Library of Congress Cataloging-in-Publication Data
Bowers, David, 1938–
Getting started in health research/David Bowers, Allan House, David Owens.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-9148-7 (pbk.: alk. paper)
1. Medicine-Research. 2. Biology-Research. I. House, Allan. II. Owens, David, Dr. III. Title.
[DNLM: 1. Biomedical Research-methods. W 20.5]
R852.B69 2011
610.72–dc22
2011002193
A catalogue record for this book is available from the British Library.
This book is published in the following electronic formats: Wiley Online Library 9781444341300
Preface
This book is aimed mainly at those healthcare professionals who want to do some research but have little or no previous research experience – and don’t really know where or how to start. If you are decided on your particular research idea this book will be of very great help. We describe all the procedures that are necessary to achieve a successful outcome, and we cover both quantitative and qualitative research projects.
Why might you want to do some research?
Of course there may be other ways to promote your career prospects or to keep up with your peers, doing research is not an easy option and unless you have a strong motivation to do it, it is probably best to find an alternative.
We will take you through the whole research experience, step by step, from the very beginning when that question first pops into your head, ‘I wonder why... ?’, or ‘I wonder if... ?’, to the very end – writing up your idea for publication in a journal, as a paper to be read at a conference, or for submission as part of a thesis or dissertation. The book will provide you with a map of your research journey, telling you what you should be doing at each stage of the process, so that you don’t overlook something crucial until it’s too late.
As you will see, we have illustrated the various stages of the research process with a blow-by-blow account of the questions, tasks, and potential difficulties of two (fictitious) new researchers, Dinesh (a nurse) and Anna (a general practitioner), who are embarking on their first piece of research. The decisions that they have to make as they progress through their research projects are the same as the decisions you will have to make.
In a book of this size we obviously can’t go into a huge amount of detail (particularly about methods of analysis, for example), but we aim to tell you what it is you need to know and do, and when you need to know and do it. We also suggest how to set about getting the help you need from a supervisor, a librarian, a statistician, other clinicians, colleagues, and so on.
We have aimed the book at the health research novice who may be working in any one of the many disciplines in health care, for example as a doctor, nurse, physiotherapist, health visitor, dietitian, occupational therapist, health promoter or health educator, to name a few.
We hope the book will also be of use to those who are acting as research supervisors for the first time (or who have a limited amount of supervision experience) – this book will provide you with a helpful framework of how a successful research project should be carried out.
The three authors have between them many years of experience of carrying out, teaching about, and supervising health research in a medical school attached to a major teaching hospital, and have themselves published a great many research papers.
David Bowers
Allan House
David Owens
University of Leeds, Institute of Health Sciences, 2011
PART I
Limbering Up
CHAPTER 1
Turning Your General Aim Into a Specific Question
THE BEGINNING
Most people have a pretty good idea of the general area in which they want to research. A useful starting point is to ask yourself, ‘What interests me about my own area and why?’ You should keep this thought in mind as you plan your research – otherwise there is a real risk of getting drawn into doing something because it is feasible, or because somebody else wants you to, rather than because it answers your own questions.
WHAT ARE YOUR AIMS?
The next task is to start framing a question – to begin with in quite general terms. For example, suppose you are interested in the observation that not everybody goes to a doctor as soon as they have symptoms suggesting cancer. Your question might be: why is that? What are the personal, social and clinical factors that influence time to presentation of cancer? Or you might ask: does it matter? Do people who present quickly with symptoms do better than people who present late? And if so, why? Or you might decide you know enough about the answers to these questions, and you want to do something to reduce late presentations with cancer. So your question is: what could we do to reduce the time it takes for people to present symptoms to a doctor?
These general questions can be restated as the AIM or AIMS of a project. Aims are typically expressed as statements, such as this:
To determine whether a public education campaign reduces rates of late presentation with symptoms of bowel cancer.
Typically a study should have only one main or primary aim. It may have a couple of subsidiary or secondary aims. A good rule is that the smaller your study the fewer aims you should have. Most studies that have more than three or four aims do not achieve any of them.
WHAT IS YOUR QUESTION?
Once you have decided on your main aim, you need to frame one or more specific questions related to it. We will give an example a little later, but first a word about hypotheses.
Hypothesis is a Greek word that refers to a scientific proposition. For example, a hypothesis might be a theory put forward to explain a number of experimental observations. For our current purposes, we can think of it as a proposition about the likely findings of a piece of research. For example, we might hypothesize ‘People who present late with symptoms suggestive of bowel cancer are less likely to have a relative who has had bowel cancer than are people who present early with symptoms.’
There used to be a vogue for expressing all hypotheses in the negative, the so-called ‘null hypothesis’, even when it was pretty obviously not what the investigator thought. Thus, ‘People who present late with symptoms of cancer do no worse than people who present early.’
The reason for this convention is that certain statistical tests are designed to prove something isn’t the case – typically that two groups of people or measurements have not come from the same population (for more on this you could do worse than look at Chapter 21 in Understanding Clinical Papers by we three authors (Bowers, House and Owens, 2006)). However, the null hypothesis convention does not make for easy reading and can lead to some pretty absurd-sounding propositions.
Not all hypotheses are tested by the use of statistics that refute a null hypothesis, and not all research questions are hypotheses. So the simplest way to proceed is always to think of your research as being designed to answer a simple and unambiguous question.
Sometimes researchers talk about aims and objectives rather than aims and hypotheses. This makes sense when what you are doing is just as well put as a statement. Here are some examples of research objectives:
In the next section we want to introduce you to Dinesh and Anna, two (fictitious) characters, who are also about to start doing some research for the first time. We will use their research stories to illustrate, step by step, the tasks and challenges – and their solutions – which are commonly encountered by inexperienced (indeed by all) researchers.
GETTING THE QUESTION CLEAR
This is a two-stage process. Step 1 involves linking your aim to a starter question. Then Step 2 involves clarifying the meaning of every term in your starter question. As an example we can see how Dinesh and Anna got started with their research questions. We’ll start with Dinesh.
Dinesh
Dinesh works as a nurse in the emergency department of a big inner-city hospital. He notices a problem with people who come to the department after they have harmed themselves, for example by cutting their arms or taking an overdose. Communication between these people and staff may be tense or difficult, and it is clear that both sides find the encounter unsatisfactory. One day he is talking to a friend who works in a health centre for asylum seekers where there is an advocacy service and the friend tells him how helpful it is.
Dinesh decides to plan a project. His aim is to establish the benefits of an advocacy service in his department. He decides his research question is as shown in Figure 1.1.
FIGURE 1.1 Dinesh’s first version of his ‘starter’ research question.
This seems a good start, but then he discusses his idea with another friend who is training to be an eye surgeon. This friend has no idea either what an advocacy service consists of or what constitutes good outcomes after an episode of self-harm. During their talk Dinesh scribbles some notes on his question (Figure 1.2).
FIGURE 1.2 Dinesh realises that he needs to define some of the terms in his starter question – his proposed intervention and his desired outcome.
Next he goes to talk to his head of department, who asks some more questions. Who exactly might be offered this advocacy service? And at what stage in their journey through the department? So Dinesh does some more scribbling (Figure 1.3).
Dinesh’s next step is a coffee with one of the more friendly psychiatrists who visits his department. The psychiatrist tells him that in his experience self-harm is quite diverse, so that Dinesh will need to decide what counts as an act of self-harm. And he also points out that delivering treatments can be a bit hit and miss, so that Dinesh needs to decide how much advocacy is enough to give it a fair trial. This is a bit like deciding what is a fair trial of physiotherapy after stroke. Dinesh has another go (Figure 1.4).
FIGURE 1.3 Dinesh defines who the participants in his research will be.
FIGURE 1.4 Dinesh looks at two terms in his question and tries to clarify what they mean.
Now Dinesh is in a position to state his question much more clearly and specifically – exactly what he means by advocacy, who it’s for, how it’s going to be delivered, and what outcomes he is interested in. This basic starter question may not change much, but Dinesh will spell out its meaning as he subsequently describes the methods of his study (see Chapter 6 onwards).
Anna
Anna is a general practitioner. She has a particular concern about the low take up of the MMR vaccine in her practice. In this she includes not only parents who won’t bring their children at all, but also those who ask to have the components as individual jabs. She would like to find some way of improving the MMR take-up rate. She has tried writing to parents who have not brought their child for the jab, and has put posters up in the waiting area, and in all of the consulting rooms. She has also discussed the issue with those parents asking for separate jabs. But there has been no discernible increase in the MMR take-up rate. She realises that she needs to investigate further, and decides to carry out a research project. Anna’s starter research question is shown in Figure 1.5.
FIGURE 1.5 Anna’s first version of her ‘starter’ research question.
Anna thinks that she could use the patients in her own group practice to answer this question.
After discussing her project with colleagues in the practice and with a friend who works in public health, Anna realises that she does not know enough about why parents are reluctant – beyond being aware of a recent unfortunate scare campaign in the national press. She therefore modifies her question as shown in Figure 1.6.
FIGURE 1.6 Anna modifies her research question.
Anna decides she needs to think about this question further and she starts by thinking about the people involved (Figure 1.7).
FIGURE 1.7 Anna notes that she needs to define some of the terms in her research question – exactly which people will be involved in her research?
Anna soon realises, however, that there are other components of her question that she needs to pick apart. She has another try (see Figure 1.8).
FIGURE 1.8 Anna also needs to define what she wants to learn from her study.
Anna now feels ready to state her question more clearly and to start thinking – about whom to interview and what questions to ask.
This approach to question setting will be familiar to anybody who has ever sat an essay exam because it is exactly the same as the approach to question answering. It helps you make sure you have not forgotten anything and it’s an extremely useful way of helping with planning the next stage – in our case, deciding on a design, subjects, measures, and so on. We will return to Dinesh and Anna in later chapters.
FINAL CHECKS
If you have followed this approach for your own project, you should by now have three statements:
The commonest mistakes people make at this stage are:
If you are confident that you have not made these mistakes – you are ready to move on. However, before you expend any more time and effort fruitlessly, you need to see if any other researcher has already tackled your proposed area of research. You can begin with a quick look at what’s already been done – the subject of the next chapter.