Scholarly Peer-reviewed Articles on Observation Four Yr Olds

ORIGINAL ARTICLES

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Discover Before You Jump: Why Ascertainment Provides Disquisitional Insights for Determinative Research and Intervention Pattern That You'll Never Get From Focus Groups, Interviews, or KAP Surveys

Global Health: Scientific discipline and Practice June 2018, vi(ii):299-316; https://doi.org/10.9745/GHSP-D-17-00328

Four case studies show how observation tin uncover bug critical to making a health intervention succeed or, sometimes, reveal reasons why it is likely to fail. Observation tin be specially valuable for interventions that depend on mechanical or clinical skills; service delivery processes; effects of the congenital environment; and habitual tasks that practitioners find hard to articulate.

ABSTRACT

Formative enquiry is essential to designing both report instruments and interventions in global health. While formative inquiry may employ many qualitative methods, focus group discussions and in-depth interviews are the most common. Observation is less common but can generate insights unlikely to emerge from any other method. This article presents 4 example studies in which ascertainment revealed disquisitional insights: corralling domestic poultry to reduce childhood diarrhea, promoting insecticide-treated bed nets (ITNs) to prevent malaria, evaluating skilled birth attendant competency to manage life-threatening obstetric and neonatal complications, and assessing community health worker (CHW) ability to use malaria rapid diagnostic tests (RDTs). Observation of Zambian CHWs to pattern malaria RDT training materials revealed a need for training on how to take finger-stick claret samples, a procedure second nature to many health workers simply ane that few CHWs had e'er performed. In Lima, Peru, study participants reported keeping their birds corralled "all the time," but observers frequently plant them loose, a departure potentially explained by an alternative interpretation of the phrase "all the time" to mean "all the time (except at some specific seemingly obvious times)." In the Peruvian Amazon, observation revealed a potential limitation of bed internet efficacy due to the congenital environs: In houses synthetic on stilts, many people sleep directly on the floor, allowing mosquitoes to bite from below through gaps in the floorboards. Observation forms and checklists from each case study are included as supplemental files; these may serve equally models for designing new observation guides. The case studies illustrate the value of observation to conspicuously understanding clinical practices and skills, details about how people acquit out certain tasks, routine behaviors people would nigh probable not retrieve to describe in an interview, and environmental barriers that must be overcome if an intervention is to succeed. Observation provides a way to triangulate for social desirability bias and to measure details that interview or focus group participants are unlikely to recognize, remember, or be able to depict with precision.

INTRODUCTION

Permit's play a quick game of discussion association: If I say "formative research," what's the first word or phrase that comes to mind? Some of you, thinking of purpose, might say that formative research is what you do before designing a behavior change campaign. Others, thinking of methods, might say "focus groups." Both would be wrong. Well, at to the lowest degree partially wrong.

Determinative research is important to the design of behavior modify campaigns, but it serves many other purposes as well. Information technology is essential to developing research instruments and global wellness interventions of many kinds.^{one – iv} It can provide the basis for assessing clinical practice, determining how to measure intervention outcomes, planning quality improvement initiatives, and understanding many other aspects of global health programming.^{v – fourteen} Every bit medical anthropologist Margaret Bentley explains¹⁵:

The purpose [of determinative research] is to provide input into the design of a research written report or intervention, including the identification of target populations and appropriate recruitment, retention or consent strategies, development of assessment or evaluation measures, and refinement of intervention components. Determinative research allows community participation in the design of enquiry and program protocols, which leads to greater community acceptance.

So formative research is about much more than merely behavior modify interventions.

Now, what about methods? If y'all want to do formative research, how should you get about it? Formative research can contain many methods, both qualitative and quantitative. Focus groups tend to exist the most common, perhaps because they are most familiar. Interviews and knowledge, attitude, and practice (KAP) surveys are as well popular. However, as you've probably gathered by now, I'm going to argue that those methods are often insufficient. If you're doing formative research, you should likewise consider observation.

If you're doing formative enquiry, yous should consider ascertainment.

Researchers seem more hesitant about observation than other methods, perhaps because they don't know how to do it, consider it as well labor-intensive or costly, feel uncomfortable with the idea of watching other people, or worry about reactivity—the phenomenon where those beingness observed change their beliefs due to the observer'southward presence.^{16 – 18} But observation can generate insights you lot won't get using any other method. And those insights can oft prove disquisitional.

In this article, I present 4 case studies on different global health topics, from corralling domestic poultry to measuring the competency of skilled birth attendants (SBAs).^{19 – 21} These examples illustrate some of the scenarios in which observation—both structured and unstructured—tin be useful, and they highlight the types of insights it can provide. In each case study, ascertainment yielded critical information that would have been difficult or impossible to obtain any other manner. For each case report, I provide a brief clarification of the research and the context from which information technology was drawn, then focus more extensively on the observational methods used and the unique insights they generated. Consummate descriptions of the original inquiry tin can be constitute elsewhere.^{22 – 28} I've provided the observation instruments used for each example study every bit supplemental files.

Ethics Review

The enquiry cited in case studies #1 and #2 was reviewed and approved by the Institutional Review Board of the Johns Hopkins Bloomberg Schoolhouse of Public Wellness in Baltimore, Dr., USA, and by the Ideals Committee of the Asociación Benéfica PRISMA in Lima, Peru. The research cited in case study #3 was reviewed for compliance with the ethics guidelines of the Quality Assurance Project funded by the United States Agency for International Evolution and approved by Ministry of Health ethics committees or their equivalent in each report country. The research cited in case study #4 received ethics approving from the Globe Wellness Organization Special Programme for Research and Grooming in Tropical Diseases (WHO/TDR) and by the Tropical Disease Research Centre Ethics Committee – Ndola, Zambia.

CASE Study #1: CORRALLING DOMESTIC POULTRY TO REDUCE CHILDHOOD DIARRHEA IN LIMA, PERU

Background

Campylobacter jejuni is a mutual bacterial contributor to diarrheal affliction worldwide.^{23 , 29 – 31} The bacteria is found near universally in the intestinal tracts of chickens and can exist transmitted to humans from contact with craven carrion or consumption of undercooked chicken.^{23 , 32 – 36} In the shanty boondocks exterior Lima, Peru, where this study took place, the link between C. jejuni in domestic poultry and childhood diarrhea has been established for decades and confirmed repeatedly.^{23 , 32 , 37}

Study Context and Observation Methods

The observations described here took place as formative inquiry for a trial to test whether corralling free-range chickens and other domestic poultry would reduce Campylobacter-associated diarrhea past minimizing contact between children and birds.²³ The research squad recruited 12 local families raising domestic poultry, built corrals for the poultry at each household, and asked each family to test the corral for 8 weeks. A study team fellow member made weekly visits to each household to complete a 19-detail structured observation class (Supplement ane) with infinite to record variables such as number of birds present; number inside and outside each corral; visual evidence that birds might have been outside the corral recently (east.1000., feathers or bird droppings in the m or inside the house); interaction, if any, between birds and children; cleanliness and structural soundness of each corral; and presence and cleanliness of food and water. The weekly visits were carried out at preselected random times during daylight hours Monday–Saturday. Participants were not notified of visits in advance. This unannounced random schedule made it possible to observe the natural state of each household and corral on unlike days of the week and at different times of day. In improver, the project sociologist made 3–four random semi-structured spot checks per household over the 8-week period (30 total across the 12 participating households) noting whether, at the moment of inflow, birds were corralled, children were interacting with birds, birds had adequate food and water, and corrals were in skilful condition. The sociologist took unstructured notes on anything he judged relevant to feasibility or acceptability of corralling.

Critical Findings

Extent of Corralling

In interviews, participants stated that they kept their birds corralled "all the time." However, observers found birds loose during 13% of observation visits and 33% of spot checks. Asked about this difference, participants antiseptic that they permit the birds out at certain times such every bit while cleaning the corrals or to requite them time to play (recrearse)—an activity owners considered essential to their birds' well-beingness.

Why did participants say they kept their birds corralled all the time when they really didn't? One possible reason is courtesy bias: The project had congenital them corrals, and then participants may take felt they would disappoint united states or seem ungrateful by admitting they didn't e'er utilise them. Another possible reason is that they meant something different than we did by "all the fourth dimension." Participants took for granted that—like themselves—everyone would sympathise the need to let birds loose at sure times for practical or health reasons, a "fact" seemingly so obvious as to be unworthy of mention. "All the fourth dimension" actually meant "all the time except at certain (presumably obvious) specific times." Had we relied solely on interviews (reported beliefs), nosotros might never have known that birds were sometimes loose or might never have thought to inquire why. Triangulation between what people told usa and what we observed revealed critical information most why the intervention might not work.

Participants took for granted that—like themselves—anybody would sympathise the need to permit birds loose at certain times for applied or health reasons, a "fact" seemingly so obvious as to be unworthy of mention.

Sufficient Food and Water

For the local population, one advantage of raising loose poultry was that the birds could find their ain food and h2o. With a corral, the household needed to provide a abiding supply of food and water and maintain hygienic weather condition. Equally shown in Figure ane, both structured observations and spot checks revealed that over the 8-week surveillance just 46% of corrals had food and only 43% had water. Further, corral floors were often wet after birds overturned their water dishes, and food was oft rotting. In earlier interviews, participants had expressed business concern that corralling would be unhealthy for their birds. Observations made clear that a corralling intervention might validate these concerns unless participants received training on how to go along corrals clean and corralled birds good for you. The information also showed that corralling took more than fourth dimension and effort since someone had to clean the corrals regularly and ensure availability of food and water.

Contact Between Poultry and Children

The primary objective of corralling was to break the Campylobacter transmission bike by separating birds from children. Observations demonstrated that children took a keen interest in the new corrals, oftentimes swinging on the doors, sticking their fingers through the mesh, or entering to play with the birds. Attempts to childproof corrals with latches or convince parents to proceed children away were largely ineffective: Observers continued to encounter children inside. Parents explained that this was natural and advisable: They wanted their children to grow up effectually animals. Children as young as 3 were assigned to collect eggs every day. Instead of isolating children from C. jejuni, observations suggested that corralling really concentrated exposure. This may help explain the finding from a later study that rates of Campylobacter-associated diarrhea among children under half dozen were ii to seven times higher in corralling households than non-corralling households with the same number of chickens.³⁸ Without ascertainment, nosotros might have missed the child-bird contact.

Treatment of Poultry Manure

One contributor to kid Campylobacter exposure not revealed in interviews was household handling of craven manure. With manure now full-bodied in a smaller space, poultry-raising households began to collect it to use as fertilizer. Observers documented that manure removed from coops was oft stored in tin cans or buckets outside the coop within easy reach of children. Uncovered storage as well allowed the wind to scatter dried manure around the outside of the living area, thus increasing potential contact.

Contrast Betwixt Human and Bird Habitation

Though not part of formal data collection, observers also noted the contrast betwixt human being and beast living space. Residents of this area had settled outside Lima every bit squatters, often after fleeing rural terrorism in the 1980s. Virtually worked as casual laborers, domestic servants, or textile piece-workers earning the equivalent of $4.00 to $v.00 per day. Many lived in houses cobbled together from discarded materials, frequently scavenged from construction sites or garbage dumps. Corrals, though built as cheaply every bit possible, were fabricated from new material at an average cost of $60.00 per household. Figure ii shows a projection-constructed corral to the left with the human dwelling house in the center. Subsequently receiving their corrals, more than 1 participant joked that their birds now enjoyed a higher standard of living than the man members of the family unit. Documenting this contrast offered a perspective beyond that probable to be achieved through interviews or focus groups alone.

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Figure two

Contrast Between Human and Animal Living Spaces Documented Through Observation, Las Pampas de San Juan de Miraflores, Peru

Projection-constructed poultry corral (left foreground) vs. homo habitation (centre background). Project participants sometimes joked that the birds in the projection enjoyed a better standard of living than the people. © 1999 Steven Harvey.

Example STUDY #2: BED NETS FOR MALARIA PREVENTION IN THE PERUVIAN AMAZON

Background

Malaria was well-nigh eliminated from the Peruvian Amazon during the 1970s and 1980s but began to reappear sporadically in the mid-1990s, culminating in an epidemic outbreak in 1997.³⁹ In response that year, the Peruvian Ministry of Wellness began distributing ITNs to affected communities. This instance study involves observations carried out to evaluate the social acceptability of ITNs and to assess their potential efficacy based on human behavior during the summit biting hours of local malaria-transmitting mosquitoes.

Study Context and Observation Methods

The study took place in one peri-urban community and iii rural villages, all within 30 km of Iquitos, the Peruvian Amazon's largest city. Over nine months, 4 observers carried out 1 dusk-to-dawn observation in each of sixty households. Upon inflow, the observer used a structured grade (Supplement two) to collect information about the number, ages, and relationships of household occupants; the number and types of sleeping spaces; and the number and types of bed nets. The observer so took unstructured notes at v-minute intervals throughout the night, recording the location and activities of each household fellow member. Most households consisted of a wooden platform on stilts raised well-nigh 2 meters off the ground and covered with a thatched roof. These structures had few rooms or interior dividers, then observers could follow most household activities from a single vantage indicate.^{17 , 40}

Critical Findings

Net Use During Peak Bitter Hours

A key concern about ITN effectiveness in the Americas is whether people are probable to exist within a net during the hours when local malaria-transmitting mosquitoes bite. Observation allowed us to systematically document internet utilize. Equally shown in Figure 3, people began to enter their nets for the nighttime as early as 7:00 p.grand., but only nigh half the population was inside a net by 8:30 p.m. and slightly less than 80% by 9:30 p.m., the peak bitter hr for Anopheles darlingi, the Amazon's almost important malaria vector.⁴² This suggests that ITNs might be somewhat effective, but non as effective equally in Africa where principal vector species feed afterward at night. Rather than observing all night, we might accept simply asked people what time each fellow member of the household went to bed the previous night, but in a setting where few people had watches or clocks, information technology would take been difficult for them to respond with much precision. Social desirability bias might as well have affected people's reports well-nigh their own behavior: At the fourth dimension, the Ministry of Health was running a entrada encouraging people to enter their nets at dusk—a practise unlikely to be feasible in an surface area near the equator where the dominicus sets around 6:30 p.one thousand. throughout the year.

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Effigy three

Percentage of the Population in Bed by Half-Hour (North=lx Observations) Compared With Anopheles darlingi Feeding Beliefs,^a Section of Loreto, Peru

^a Information on mosquito feeding beliefs come from Vittor (2003).⁴¹

Multiple Entries and Exits

One unanticipated finding was the number of times people enter and exit ITNs during the night.⁴³ Each time the cyberspace is lifted, mosquitoes have an opportunity to enter. Parents who share nets with children may spend considerable time exterior the net unprotected after their children have gone to sleep. The Table shows an example of a single sleeping space occupied past a 23-year-old female parent and her 2-year-old son. The net was lifted a total of 20 times between vii:00 p.m. and 6:30 a.g. The mother spent 195 minutes exterior the net between the first time she entered with her son at 7:00 p.chiliad. and the time both of them got out of bed at 6:thirty the adjacent morning.

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TABLE.

Observational Bed Net Entry and Exit Data From a Single Sleeping Infinite With ii Occupants, a 23-Year-Old Mother and Her two-Year-Sometime Son, Peruvian Amazon

An unanticipated finding from an observational study of bed net employ was the number of times people enter and exit their bed nets during the night—as many equally 20 times for i mother with a young son.

Additional Potential Risk Factors

Observations revealed other phenomena that would accept been hard to capture with interviews or focus groups. For instance, observers took detailed notes on sleeping spaces in participating households. These notes revealed that many people slept directly on cane floor rather than on a bed. The floor had gaps between the cane staves. Since many houses were built on stilts, this meant mosquitoes could enter the sleeping space from beneath. A internet alone could not provide adequate protection in this setting: An effective malaria prevention intervention would need to help at-gamble individuals discover a way to protect themselves from beneath every bit well equally from above. Observers also documented other practices that might increase exposure risk: attention evening church services during summit biting hours, bathing after dark, running small home-based stores where community members came to buy food or bones necessities in the evening hours, and other nighttime activities such every bit hunting, fishing, or charcoal production. While report participants reported some of these activities during interviews, straight observation allowed the report team to document them more than systematically.

Instance Study #iii: ASSESSING THE COMPETENCY OF SKILLED Birth ATTENDANTS IN vii COUNTRIES

Background

Nigh 90% of the 300,000–350,000 almanac maternal deaths worldwide are caused by v mutual obstetric complications: postpartum hemorrhage, pregnancy-induced hypertension, obstructed labor, perinatal sepsis, and postabortion complications.^{44 , 45} Risk for experiencing one of these life-threatening complications cannot be reliably predicted in advance, but about tin be treated successfully if the woman experiencing them has access to basic or comprehensive essential obstetric intendance delivered past an SBA. For this reason, the Globe Wellness Organization (WHO) recommends that all pregnant women be assisted past an SBA during labor and delivery.⁴⁶ Several international organizations take divers the competencies necessary to manage these complications. The observations described below were carried out equally part of developing a method to appraise these competencies amongst practicing SBAs in low- and middle-income countries.

Study Context and Ascertainment Methods

Testing a clinician'due south competency to manage a complication co-ordinate to standards requires assessing not only abstruse noesis but besides physical or transmission ability. Knowledge tin can exist measured using a written exam, but the only style to appraise manual skill is by watching someone perform a task to see whether she or he does it correctly. Assessing skills on actual patients, still, is problematic. Ethically, an observer qualified to evaluate clinical competency would demand to stop observing and intervene before allowing an insufficiently skilled provider to endanger a patient's life or well-being. Moreover, fifty-fifty mutual obstetric complications are relatively rare. This makes information technology impossible to appraise the skill of more than a handful of providers using actual patients.

While knowledge can exist measured using a written examination, the only fashion to assess manual skill is by watching someone perform a task.

The observations discussed here were designed to test SBA competency at performing iv critical procedures. The first three procedures—active management of the third stage of labor (AMTSL), manual removal of the placenta, and bimanual uterine compression—are performed to prevent or control postpartum hemorrhage in a female parent who has just given nativity. The fourth, neonatal resuscitation with an Ambu bag, is used to care for neonatal asphyxia. The project, eventually carried out in Benin, Ecuador, Jamaica, Kenya, Nicaragua, Rwanda, and Tanzania, used skillful obstetrician/gynecologists and pediatricians from host countries as observers. SBAs beingness assessed performed each process on an anatomical model (Gaumard S500 Advanced Childbirth Simulator and Simulaids Sani-Babe CPR mannequin or Gaumard S320 Newborn Airway Trainer); observers assessed competency using a structured step-by-step checklist (Supplement iii).^{27 , 28}

Critical Findings

Correct mitt position and move are essential to successfully performing all four tasks. Controlled cord traction, an elective component of AMTSL, requires exerting a gentle downward pull on the umbilical cord with i mitt while using the other to prevent uterine inversion past applying counter-traction just higher up the pubic os.⁴⁷ In instance of retained placenta, transmission removal requires inserting the mitt through the vaginal canal and using a gentle lateral motility to detach the placenta intact, leaving no fragments that could provoke continued haemorrhage or cause sepsis. Figure 4 shows an expert observer demonstrating manual removal with the Gaumard Avant-garde Childbirth Simulator. The open abdominal crenel allows the observer to assess the technique of the SBA being observed. Some SBAs might be able to describe these or similar procedures, but even a precise detailed description would not necessarily bespeak ability to perform them.

Observations across the 7 study countries revealed the following:

• Though AMTSL is commonly included in national standards for managing uncomplicated commitment, about SBAs did not know how to perform controlled cord traction.

• Similarly, most SBAs could not demonstrate the correct hand positions for carrying out the transmission removal of a retained placenta. Although bimanual uterine pinch is a relatively simple process requiring no instruments or equipment, nearly no SBA was familiar with it.

• Neonatal resuscitation with an Ambu purse—in add-on to requiring a neonatal-sized handbag, valve, and mask, which many wellness facilities lack—requires the person performing it to identify the mask over the newborn'south mouth and olfactory organ and position his or her hand over the mask correctly to attain a proper seal. Failure to do and then tin result in air escaping out the sides of the mask rather than entering the newborn'south lungs. Proper head position is also critical to ensuring that the newborn's airways are open, non blocked. In Effigy v, the left image shows correct positioning of the purse, mask, and head while the right image shows incorrect positioning: Placing the bag vertically with respect to the newborn's body makes information technology more difficult to achieve a skilful seal. Both newborn mannequins used in the study were designed so that the mannequin's breast would rise when ventilated properly, similar to the breast of an bodily newborn receiving right ventilation. This immune both the observer and the SBA to determine if the SBA was performing the procedure correctly.

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Effigy 5

Neonatal Resuscitation With an Ambu Handbag: Correct vs. Wrong Positioning

Left: Correct positioning of mask, bag, and newborn's head to accomplish a good seal, with handbag perpendicular to the newborn'due south body. © 2006 Steven Harvey.

Right: Incorrect positioning, with bag parallel with the newborn's body, making information technology more difficult to accomplish a proficient seal. © 2002 Steven Harvey.

Using checklists adapted to each state's norms, observation besides enabled the report team to appraise whether SBAs followed prescribed infection prevention guidelines including handwashing, gloving, and post-process decontamination. Participating SBAs were provided with all necessary supplies and equipment. At the commencement of each assessment, the observer instructed each participant to "brainstorm by preparing yourself, the equipment, and the patient," and so noted if the SBA proceeded in accordance with norms. At the terminate, the observer similarly instructed each participant to "please tell me what more you lot would do or inquire someone else to exercise in one case y'all accept finished the process."

Information technology's tempting to classify this research as summative since its initial objective was to assess existing health worker skills. But it was also formative, because the results helped shape interventions: In the curt term, observers offered feedback and retraining to each participant, and sometimes—when many participants had a detail weakness in mutual—to the entire group. In the longer term, findings accept influenced training programs and assessment methods in participating countries and around the world.

Instance Study #4: ASSESSING CHW Ability TO USE MALARIA RAPID DIAGNOSTIC TESTS IN ZAMBIA

Background

For decades leading up to the early 2000s, malaria in sub-Saharan Africa was diagnosed presumptively: Anyone with a fever was presumed to have malaria and treated with antimalarials. This practice developed considering the supply of both microscopes and trained microscopists was likewise limited to diagnose more than a tiny fraction of febrile patients. In add-on, beginning-line antimalarial drugs were cheap and adverse effects negligible, so presumptive treatment involved minimal cost and risk. After introduction of artemisinin combination therapy as beginning-line handling for malaria starting effectually 2004, WHO recommended parasite-based diagnosis get-go for adults and older children, and then for all suspected cases of malaria regardless of age.⁴⁸ Malaria rapid diagnostic tests (RDTs) brand parasite-based diagnosis possible fifty-fifty at health facilities with no laboratory, microscope, or microscopist. In many areas, however, febrile patients seek treatment at the community level without e'er visiting a health facility. The observations described in this case report were carried out to determine whether volunteer community wellness workers (CHWs) could use RDTs safely and accurately and, if then, what sort of grooming materials they needed.

Study Context and Observation Methods

Based on focus grouping discussions with Zambian CHWs, the study team designed a task aid and cursory preparation curriculum. We used structured observation to pilot exam these materials. Study team members observed 79 CHWs prepare 3 RDTs each and recorded the results on a 16-particular checklist (Supplement 4).^{24 , 25}

Disquisitional Findings

• Malaria RDTs crave using a sterile lancet to depict a finger-stick blood sample, a procedure that is 2d nature to many professional person health workers. Due to concerns about HIV and other blood-borne diseases, however, most African CHWs were prohibited from taking finger-stick blood samples. The Zambian Medical Council authorized the practise for this study, just few participating CHWs had always taken a sample or used a lancet. During training, observers noticed that instead of drawing blood with a quick stab—the preferred arroyo—many CHWs ready the signal of the lancet on the patient's fingertip, then pushed it into the peel. Participants explained they were doing this for fear that stabbing would cause the patients too much hurting, merely the consequence was just the opposite: Pushing was more than painful. In add-on, information technology often produced likewise picayune blood, thus necessitating a 2d, tertiary, or even quaternary finger prick. Observing this made articulate that CHWs needed specific training on proper lancet technique. The report squad subsequently adult a training module demonstrating how to extract sufficient blood with a single prick. Improved CHW technique reduced patient discomfort and increased testing quality.

• Watching CHWs transfer blood from fingertip to test cassette yielded a like revelation. The project RDT came packaged with a loop-shaped blood transfer device designed to collect a 5 μl picture of blood beyond the width of the loop. CHWs did the finger prick with the brawl of the patient's finger facing up, and so tried to collect the drop from to a higher place. This often conveyed too little claret to the test cassette even after multiple tries. Noting this, an experienced observer suggested pricking the finger, rotating the patient'south mitt 180°, then collecting the drop from underneath with the ball of the finger facing down. In most cases, this made it possible to collect and transfer the precise volume of blood required on the first attempt.

• A key business organization related to blood rubber was right disposal of the claret-contaminated lancet. To minimize danger to patients, CHWs, and the community, the inquiry team distributed sharps boxes to all participating CHWs and instructed them to deposit the used lancet into the sharps box immediately afterward pricking the patient's finger. Setting down the used lancet prior to disposal heightens take a chance of finger-stick injuries. Observers noticed that positioning the sharps box appropriately made immediate disposal convenient: For a right-handed CHW, this meant placing the sharps box on the right side of the work infinite, and vice versa for a left-handed CHW. Placing the box on the contrary side of the CHW'southward dominant hand forced the CHW to reach beyond both his or her own torso and that of the patient. This made handling the used lancet more than risky and immediate disposal more than difficult.

• Assembling supplies prior to conducting a test revealed a similar issue. Most CHWs work from home. Defective permanent piece of work space, they take out their supplies and so put them away once again for each patient. In pilot testing, observers noticed that CHWs would often forget i or more items prior to starting a test. In some cases, this posed only minor inconvenience: CHWs might open a examination kit, realize they had forgotten to bring a pen or pencil, and inquire the patient to wait while they retrieved one. Other cases presented greater take chances: CHWs might open a sterile lancet, realize they had forgotten an booze swab or the sharps box, and set the open up lancet down on a tabular array while going to retrieve the missing item. This finding led the squad to modify the job help by listing all necessary supplies and equipment at the top and adding an education to get together everything before starting the procedure (Effigy 6).

• Watching CHWs provide services from home led to some other observational finding: Many CHW homes lack electricity and thus have poor-quality bogus lighting. This fact can touch the accuracy of test interpretation when RDTs are prepared within, especially subsequently dusk or during inclement weather. The RDT'due south positive exam line—indicating that a patient is infected with malaria—can often be quite faint. With inadequate bogus lighting inside and bereft natural light outside, a CHW could hands misread a faint positive issue as negative, thus leaving an infected patient untreated. Realizing this led to added emphasis during training that positive lines are sometimes quite faint and that CHWs should read results in the brightest light possible to avert missing a faint positive.

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FIGURE six

Malaria Rapid Diagnostic Test Job Assist

A task aid for community wellness workers lists at the top all supplies and equipment that the worker needs to get together prior to conducting a rapid diagnostic examination for malaria.

Word

Ascertainment produced novel insights in the case studies simply described, merely how do you decide when ascertainment might be valuable or even essential for your intervention or study? To answer this, it's useful to think in terms of categories of events or processes. Among others, these might include mechanical skills, health service delivery processes, effects of the congenital surroundings, and habitual practices that people would accept difficulty articulating, sometimes known as "tacit cognition."^{49 , l}

Ascertainment can produce novel insights, merely how do you decide when it might be valuable or even essential for your intervention or written report?

Mechanical Skills

The SBA and RDT instance studies both illustrate the value of ascertainment to understanding mechanical skills, including critical details such as the correct hand position needed to effectively bear out a lifesaving obstetric or neonatal intervention. Transmission removal of a retained placenta or resuscitation of an asphyxiated newborn are two examples. Although lancet technique, sharps box position, or collecting blood with the fingertip facing upwards or down might seem like minute details when preparing an RDT, they can make the difference betwixt constructive, efficient, prophylactic practices and practices that lead to incorrect results or endanger the patient, the health worker, or the community. Observation in these cases is critical non merely to diagnose lapses but likewise to identify interventions that tin address them. Observation thus led to additional applied training for SBAs and to evolution of specific training modules and revised job aid illustrations for malaria RDTs. Beyond their specific noun findings, these 2 studies highlight the value of observation to understanding both wellness worker and customs beliefs.

Sequential Processes

Many public health interventions involve sequential processes: Not only must each step be performed properly, it must also exist performed in the proper lodge. Again, the RDT case study offers an illustrative example: The written report team identified 16 discrete steps necessary to correctly ready and interpret the examination; performing them in the incorrect guild (e.g., opening the sterile lancet before cleaning the finger with an alcohol swab) or the incorrect mode (depositing the blood driblet where the buffer solution is supposed to go) could compromise test accuracy or patient or health worker safety. The observation checklist (Supplement 4) enabled the squad to decide the proportion of health workers who completed all steps correctly, identify specific steps where health workers had issues, and modify preparation to address the problems observed. Greenland et al. used a like approach in Zambia to determine what proportion of caregivers of immature children with diarrhea could prepare oral rehydration solution correctly.⁵¹ Hurley et al. used a combination of structured and unstructured observations to track the flow of meaning women through antenatal care in Mali and amend sympathize why many completed their visits without receiving intermittent preventive treatment for malaria in pregnancy (IPTp) or received it without whatever information about the purpose of IPTp.⁵² Hermida et al. establish ascertainment to exist more than accurate than patient exit interviews or medical tape review for assessing facility-based provider adherence to standards of care for acute lower respiratory infection, diarrheal disease, and family planning counseling.⁵³ For this reason, observation is often a central component of quality improvement enquiry.^{53 , 54} In sum, observation tin be an invaluable tool for documenting the necessary steps in a process, identifying where breakdowns occur, and thus pinpointing where intervention is needed. This type of analysis can exist useful at the household, community, and health facility levels.

Agreement the Congenital Environment

The built environment—and sometimes its relationship to the natural environment—can significantly affect disease risk, health service delivery, and the feasibility of health interventions. The Campylobacter study setting consists of dusty desert hills where water is scarce and rain nonexistent (natural environment). Since the poorest people live at the top of those hills with neither wells nor piped water (congenital environment), many families struggle to provide water for themselves. H2o for corralled birds becomes, at best, a secondary priority. Observing the difficulty of obtaining water helped study team members ameliorate understand owners' concerns well-nigh the upshot of corralling on birds' health. Wind (natural surroundings) combined with open up storage of concentrated chicken manure cleaned from the corrals (congenital environs) turned out to exist i class of connected contact betwixt humans and Campylobacter despite corralling.

The congenital environs was likewise a disquisitional attribute of the bed internet study. The structure of a typical bed in the study setting—no mattress and gaps between the wooden or bamboo slats that immune mosquitoes to bite from underneath—might never have occurred to public health practitioners, most of whom presumably sleep in beds with mattresses. Fifty-fifty had it occurred to them, they would non have been able to collect systematic data on bed configurations without ascertainment. Thus, observation revealed one potential limitation of bed cyberspace efficacy in the study setting. This, in turn, revealed a necessary component of any comeback intervention: effigy out how to block the gaps between floor that immune mosquitoes to enter.

Systematically observing the built environment can exist revealing in many settings. By documenting patient flow at health centers and hospitals, maternal health researchers from the Quality Balls Project helped explicate why women arriving with an obstetric complication might encounter significant, sometimes life-threatening, delays earlier seeing a clinician.^{55 – 58} Observing both the size of rooms in a house and their use for multiple purposes (sleeping at night, running a pocket-size retail shop during the twenty-four hour period) helped explain why some households in Republic of ghana were reluctant to permanently install bed nets over their sleeping spaces and why, in some cases, residents preferred conical nets to rectangular.⁵⁹ Observing the dim lighting in CHWs' houses helped explicate why CHWs might miss weak positive RDT results and why training programs needed to emphasize the importance of reading test results under bright low-cal.²⁵ Many U.S. researchers have used observation to study the relationships between congenital surroundings, physical action, available food choices, and chronic diseases such as obesity and diabetes.^{sixty – 63} Equally with the word of sequential processes above, it is worth reiterating that observations related to the congenital and natural environments tin can be useful at the household, community, and wellness facility levels.

Habitual Practices and Tacit Knowledge

In whatsoever setting, people perform a variety of routine activities, the procedures for which they learned at some point in the by, committed to memory, and carry out automatically, almost as if by instinct. Because these activities are habitual, those who perform them often have difficulty articulating the step-past-step procedure and even come to remember of that process as self-axiomatic. Collecting a finger-stick blood sample is a case in point. A health care provider who has washed information technology many times considers it 2d nature and wonders why a novice finds it so hard. Observation reveals that the process involves numerous steps: assemble all the supplies before starting, swab the fingertip with booze, wait for it to dry, massage the finger to work the blood upwards into the fingertip, open up the sterile lancet, puncture the fingertip with a quick stab, orient the fingertip with the claret driblet in the optimum position for the particular blood collection device beingness used, etc. The experienced provider has internalized all this and performs information technology without needing to think. The novice may fail to massage the finger, stab likewise timidly and thus extract too little blood, or orient the fingertip in a less than optimal position and thus collect likewise little blood, or too much. Observing both expert and novice helps distinguish the differences and thus determine what grooming the novice requires.

People who perform habitual activities oftentimes take difficulty articulating the stride-by-step procedure and fifty-fifty come to think of that process as cocky-evident.

The Campylobacter report provides additional examples: Interview or focus group participants might fail to mention the many points of contact between children and birds either because they knew the intervention was meant to separate the two (courtesy bias) or because the types of contact were and so commonplace every bit to seem unworthy of mention. Observing children play with birds, feed and h2o them, collect eggs, and make clean corrals provides tangible evidence that those designing public health interventions should take into account both homo nature (children like to play with animals) and economic and cultural practices (even a very young child may exist assigned household chores; parents may view learning to raise animals every bit a key life skill). Cumulative findings from these observations contributed to a conclusion that the intervention was unlikely to succeed, a conclusion confirmed by subsequent research demonstrating that corralling, instead of decreasing risk of Campylobacter-associated diarrhea in children, really doubled it.³⁸

The bed net study besides provides examples: Absent ascertainment, as noted in a higher place, public health practitioners might not take thought to ask about bed design. Conversely, mentioning bed design—an attribute of daily existence so routine every bit to laissez passer almost unperceived—might never have occurred to a fellow member of the at-risk population. Had interviewers thought to ask, cyberspace occupants might besides accept mentioned that they enter and exit their nets more once per night, but information technology is unlikely that they could have reported very precisely the number of entries and exits, the amount of time the internet was lifted, or the amount of fourth dimension dissimilar occupants spend outside the net. Observation made information technology possible to quantify this phenomenon much more systematically.⁴³

Later validating the method, Gittelsohn used structured mealtime observations to estimate differences in caloric and micronutrient intake between men, women, and children in lowland south-central Nepal.^{64 – 66} Information technology is unlikely that parents would have been able to provide such detailed information virtually intra-household nutrient allocation. Bentley et al. used structured observation during determinative enquiry to certificate child feeding practices prior to a nutritional intervention to improve infant growth and development in Andhra Pradesh, Bharat.^x Brummell used observation to discover tacit knowledge related to the prognosis of patients suffering cardiac arrest and whether to attempt resuscitation in two Great britain hospital emergency departments.⁶⁷ Huot and Laliberte Rudman, who used participant observation to acquire about the daily routines of refugees in Canada, explain why observation can be then important for understanding habitual phenomena⁶⁸:

The tacit nature of daily occupation can brand the details involved in participation hard to verbalize because respondents may not have reflected upon their occupational engagement in such detail, or may assume that such "minutia" may not be relevant for research.

This statement could exist extended to many areas of health at individual, household, community, and facility levels. Oftentimes observation, used together with more common methods similar interviews or focus groups, is the but way to make such tacit knowledge explicit.

Triangulating Observation Information With Information From Other Methods

In both the case studies described here and many of the examples cited, researchers used observation together with other methods to achieve a more consummate film of a setting, do, or intervention. Using observation to triangulate data gathered from interviews or focus group discussions can bring to light differences betwixt what people say they do (reported beliefs) and what people actually practice (observed beliefs). In some cases, this may reveal social desirability bias: People over- or under-study a detail beliefs considering it violates what they perceive to be social norms. Hygiene studies, for example, have often found that people over-report handwashing at critical times; ascertainment shows much lower levels.^{69 , seventy}

Using observation to triangulate data from interviews or focus group discussions can bring to light differences betwixt what people say they do and what they actually do.

There is no Peruvian data on reported ITN utilize that we tin can compare to the case study #2 observation. But there is at to the lowest degree a plausible ground for comparison in Ghana: Dark observation of net utilize in Northern and Upper W Regions found that but 17% of the population used a cyberspace at whatsoever time during the night.⁷¹ In a malaria indicator survey of the same 2 districts, 51% and 54% of the population reported sleeping under a cyberspace.⁷² The numbers are not directly comparable for many reasons, so these differences should be interpreted with caution. The observation study is based on a small purposive sample, the survey on a population-based representative sample; the data were collected in unlike years and at different times of year. Only the broad gap suggests a considerable difference betwixt reported and actual net apply. Also, for the observation sample, we know when each individual entered and exited his or her net and how long individuals spent protected versus unprotected. All we know from the survey is that the individual reported sleeping under the net at some signal during the dark—we have no idea for how long.

Triangulation may as well reveal that a word, phrase, or concept means something different to participants than to the researcher. The possibility, in the Campylobacter study, that participants who reported keeping their birds in the corral "all the fourth dimension," really meant "all the time except for sure specific seemingly obvious times" is ane example. Had we employed only interviews in that report, we would likely take concluded—incorrectly—that birds were never loose. Had we employed only observation, we would likely have concluded that birds were loose 20% of the fourth dimension—more accurate, but not the whole story. Just the combination revealed the differences in meaning and their conflicting unspoken assumptions.

Observation and Reactivity

A cardinal objection to observation is that it leads to reactivity: Those under observation may alter their beliefs because they know they are being observed. Nevertheless, this trouble is non unique to ascertainment: People as well change their behavior when they are being studied in other ways. Survey and interview respondents may reply questions based on what they think society (social desirability bias) or the interviewer (courtesy bias) look of them. Observer expectancy effect refers to how an observer tin shape behavior—deliberately or subconsciously—past providing subtle nonverbal cues such equally slight changes in facial expression. The Hawthorne upshot was named for a study in which factory workers from both intervention and control groups became more productive because they knew that researchers were testing possible interventions (such equally better lighting) to improve productivity. More detailed definitions are beyond the scope of this article but can exist found in many social scientific discipline references.^{73 – 76}

In one instance of reactivity, P.V. Ram and colleagues found testify of a 35% increase in handwashing when an observer was present compared with when there was no observer and handwashing was detected by a motion sensor hidden within a bar of lather.7⁷⁷ Simply while reactivity often does occur, researchers tin measure and adjust for information technology.¹⁷ Reactivity too diminishes with time: The longer amount of time or the greater number of times people are observed, the less probable they are to react to an observer'southward presence.^{78 – 80} Ram's study concluded that their findings "call into question the validity of structured ascertainment details because it appears that a bulk of participating caregivers substantially altered their behavior in the presence of an observer." Merely the report included but 1 observation per household. Had Ram'southward team observed each household multiple times and waited until household members became accustomed to the observer'south presence, their results might accept been different.

Ram and her colleagues have a point that in some cases a less invasive technological method might exist preferable to observation. For example, studies exploring household use of cleaner cookstoves to reduce indoor air pollution often use temperature sensors (called stove use monitors or SUMs) to track which stove is being used when and for how long.^{81 , 82} At least one recent study reports that combining observation and SUMs data provides a more accurate picture than SUMs data solitary.⁸³

Moreover, reactivity is often unrelated to the focus behavior. In the bed cyberspace study, we identified 339 instances of reactivity across 60 observations using the broadest possible definition: whatsoever interaction whatsoever between the observer and whatsoever member of the observed household. Of these 339 instances, just 2 were directly related to the behavior of interest: protecting against mosquito bites.¹⁷ In a like way, John Schnelle and colleagues plant that observations did not change provider treatment of nursing abode residents in the United Kingdom.⁸⁴

Another way to control reactivity is through unannounced spot checks similar to those we used in case study #1. Nazmul Chaudhury and colleagues used this method to relate the degree of health worker and teacher absence in wellness facilities and primary schools in Bangladesh, Republic of ecuador, Bharat, Indonesia, Peru, and Uganda.⁸⁵ In his classic article well-nigh nighttime observations among the Samukundi Abelam, Richard Scaglion describes how he used spot checks to document time allotment inside this Papua New Guinea ethnic group.⁸⁶ Scaglion admits, however, that he was not e'er able to maintain the element of spontaneity that spot check observations are meant to provide:

… it is not easy for an anthropologist in the field to come upon an Abelam unawares. Since I did not want to record "greeting anthropologist" as a frequent action when people were first observed, I often had to reconstruct what they were doing immediately before I arrived.

Conclusion

In sum, ascertainment can be an essential tool in formative research. As a stand up-alone method, information technology can measure phenomena not measurable by any other method. In combination with interviews or focus groups, it can propose questions to exist posed through these other methods. Information technology can too triangulate findings from other methods, reveal potential differences between reported and observed behavior, and thus help assess social desirability bias. Given these benefits, observation—either lone or in combination with other methods—is something both investigators and program managers should consider when undertaking formative research.

Acknowledgments

I am grateful to Marianne Henry for her help with literature review and manuscript preparation. I wish to thank the editor and editorial staff of GHSP as well equally the three anonymous reviewers, all of whose comments considerably strengthened this manuscript. I also wish to thank the many participants in the 4 studies described hither for their time, patience, and willingness to participate. Finally, I am grateful for the comments and suggestions of the many students with whom I take discussed these concepts in formative research classes over nearly a decade and to Drs. Elli Leontsini and Peter Winch for inviting me to exercise so.

Notes

Peer Reviewed

Competing Interests: None alleged.

Funding: Funding for case study #1 was provided by the Thrasher Research Fund (honor 02813-1). Funding for instance study #two was provided by the US Bureau for International Evolution (USAID) nether Grant Number 527G001000070. Case written report #3 was supported by the Quality Assurance Project under contracts number HRN-C-00-96-90013 and GPH-C-00-02-00004-00 with the Us Agency for International Development (USAID). Funding for example study #iv was provided past the Australian Bureau for International Development (AusAID), the WHO Special Program for Research and Training in Tropical Diseases (TDR), and the United States Agency for International Evolution (USAID) under the Quality Assurance and Workforce Development Projection at Academy Research Co., LLC (contract number GPH-C-00-02-00004-00). Conclusions and opinions are the sole responsibility of the writer and exercise non necessarily reflect the views or policies of the funders.

Outset Published Online: May 23, 2018

Cite this article equally: Harvey SA. Observe before you leap: why observation provides critical insights for determinative research and intervention design that you'll never get from focus groups, Interviews, or KAP Surveys. Glob Wellness Sci Pract. 2018;half dozen(two):299-316. https://doi.org/10.9745/GHSP-D-17-00328

• Received: 2017 Aug 19.
• Accepted: 2018 Feb 6.
• Published: 2018 Jun 27.

• © Harvey.

This is an open up-admission commodity distributed under the terms of the Creative Commons Attribution iv.0 International License (CC By four.0), which permits unrestricted utilize, distribution, and reproduction in whatsoever medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the post-obit permanent link: https://doi.org/10.9745/GHSP-D-17-00328

REFERENCES

1. 1.↵
2. ii.
3. 3.
4. 4.↵

   Institute of Medicine. Who Will Go on the Public Salubrious? Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Printing; 2003. doi:10.17226/10542

5. v.↵

   Neonatal Mortality Formative Inquiry Working Group. Developing community-based intervention strategies to save newborn lives: lessons learned from formative research in five countries. J Perinatol. 2008;28(suppl two):S2–S8. doi:10.1038/jp.2008.166 . pmid:19057564

6. 6.
7. 7.
8. 8.
9. 9.
10. 10.↵
11. xi.
12. 12.
13. 13.
14. 14.↵
15. xv.↵
16. xvi.↵
17. 17.↵
18. 18.↵
19. nineteen.↵
20. 20.
21. 21.↵
22. 22.↵
23. 23.↵
24. 24.↵
25. 25.↵
26. 26.
27. 27.↵
28. 28.↵
29. 29.↵
30. 30.
31. 31.↵
32. 32.↵
33. 33.
34. 34.
35. 35.
36. 36.↵
37. 37.↵
38. 38.↵
39. 39.↵
40. 40.↵
41. 41.↵
42. 42.↵
43. 43.↵
44. 44.↵
45. 45.↵
46. 46.↵

    World Wellness Arrangement (WHO); International Confederation of Midwives (ICM); International Federation of Gynecology and Obstetrics (FIGO). Making Pregnancy Safer: The Critical Role of the Skilled Bellboy. A Joint Statement past WHO, ICM and FIGO. Geneva: WHO; 2004. . Accessed Apr 5, 2018.

47. 47.↵
48. 48.↵
49. 49.↵
50. 50.↵
51. 51.↵
52. 52.↵
53. 53.↵
54. 54.↵
55. 55.↵
56. 56.
57. 57.
58. 58.↵
59. 59.↵
60. 60.↵
61. 61.
62. 62.
63. 63.↵
64. 64.↵
65. 65.
66. 66.↵
67. 67.↵
68. 68.↵
69. 69.↵
70. 70.↵
71. 71.↵
72. 72.↵
73. 73.↵
74. 74.
75. 75.
76. 76.↵
77. 77.↵
78. 78.↵
79. 79.
80. 80.↵
81. 81.↵
82. 82.↵
83. 83.↵
84. 84.↵
85. 85.↵
86. 86.↵

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Source: https://www.ghspjournal.org/content/6/2/299

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