Methodologic challenges in health services research in the pediatric population

The relationship between characteristics of context and research utilization in a pediatric setting

Background

Research utilization investigators have called for more focused examination of the influence of context on research utilization behaviors. Yet, up until recently, lack of instrumentation to identify and quantify aspects of organizational context that are integral to research use has significantly hampered these efforts. The Alberta Context Tool (ACT) was developed to assess the relationships between organizational factors and research utilization by a variety of healthcare professional groups. The purpose of this paper is to present findings from a pilot study using the ACT to elicit pediatric and neonatal healthcare professionals' perceptions of the organizational context in which they work and their use of research to inform practice. Specifically, we report on the relationship between dimensions of context, founded on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and self-reported research use behavior.

Methods

A cross-sectional survey approach was employed using a version of the ACT, modified specifically for pediatric settings. The survey was administered to nurses working in three pediatric units in Alberta, Canada. Scores for three dimensions of context (culture, leadership and evaluation) were used to categorize respondent data into one of four context groups (high, moderately high, moderately low and low). We then examined the relationships between nurses' self-reported research use and their perceived context.

Results

A 69% response rate was achieved. Statistically significant differences in nurses' perceptions of culture, leadership and evaluation, and self-reported conceptual research use were found across the three units. Differences in instrumental research use across the three groups of nurses by unit were not significant. Higher self-reported instrumental and conceptual research use by all nurses in the sample was associated with more positive perceptions of their context.

Conclusions

Overall, the results of this study lend support to the view that more positive contexts are associated with higher reports of research use in practice. These findings have implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of organizational context that are influential in shaping research use behavior.

Lay evaluation of services for childhood asthma

Users' views on health services are increasingly valued, but insufficient attention has been given to evaluations of childhood services. Asthma, the most common chronic childhood disease, is an significant condition around which to explore views of childhood services, especially since most care is provided in the community rather than in hospital. The aim of the present study was to investigate the views of children, young people and their parents on primary care services for childhood asthma, to explain how they should be characterised as evaluators of health services, and to identify the dimensions of care which they see as important. The authors conducted semi-structured interviews with 20 families recruited from responders to a respiratory symptoms questionnaire and from two general practices. Data were analysed using the constant comparative method. Children and young people identified outcomes of care, quality of care, communication and the professional-patient relationship, and organisation and access to healthcare as the key dimensions of their experiences of health services. They were active and critical, judging the performance and delivery of health services against standards which drew on lay knowledge and experience. Parents also emphasised outcomes, quality, organisation and access to healthcare as important, and drew attention to the complex and challenging nature of the professional-parent relationship. Parents had several roles, seeing themselves as carers and advocates as well as users of health services. They also drew on lay standards to evaluate care. Children and young people are willing and able to give active and critical views on health services. Parents' views should also be sought in their own right.

The importance of outcomes research in pediatric emergency medicine

Applying the methods and tools of outcomes research, "evaluation of the impact of health care on the health outcomes or 'end results' of patients and populations," to the clinical domain of emergency services for children offers an important strategic opportunity for addressing the questions that confront all health care services: What works? For which patients? At what cost? From whose perspective? Although the important questions to address are extensive, much of the intersection between emergency services and outcomes research remains unexplored. Important challenges for researchers intrigued by the opportunities at this intersection of fields include: 1) clear definition of the scope of emergency services; 2) consideration of the appropriate end-point of emergency services-the entire episode of illness and/or services provided within the emergency setting; 3) selection and development of measures that incorporate children's and families' perspectives; and 4) a clear focus on linking research findings with strategies for improving outcomes and informed decision making. This essay will provide an overview of accomplishments and challenges from the field of outcomes research, suggest important opportunities for applying existing methods to emergency medical services for children, and identify potential career paths for current and future investigators.