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Hughes, I. (2006). Action research in healthcare: what is the evidence?

ALAR
Journal, 11(1), 29-39.

Action research in healthcare: What is the evidence?


Ian Hughes
Systematic reviews of action research in healthcare have been conducted; one in the United
Kingdom and the USA. The UK Health Technology Assessment review studied action
research in a variety of settings including hospitals and nursing homes, providing a definition
of action research in health, and a list of 20 questions judged to be useful in evaluating the
quality of action research proposals and reports. In the USA, the Agency for Healthcare
Research and Quality commissioned an assessment of community-based participatory
research in health. This rigorous review found that while a significant number of studies
achieved high ratings for one of research rigour or community participation or health
outcomes, few achieved high ratings for the quality of research and participation and health
outcomes.

This paper will combine information from these systematic reviews and other sources, to
invite discussion of the quality of action research reported in the health related literature, and
the criteria used to judge the quality of action research in healthcare settings.

If we want more evidence-based practice, we need more practice-based evidence.


(L.W. Green http://www.lgreen.net/)

Participatory and action research is increasingly used in various healthcare settings.


Action researchers in health work close to biomedical researchers. While attention is
starting to shift away from paradigm wars towards sorting out the strengths and
weaknesses of different research approaches for different research tasks, it is too early
to report that peace has been declared between quantitative, qualitative and
participative approaches in healthcare research.

Since the 1990’s health care new systems known as evidence based practice, evidence
based medicine and evidence-based healthcare have been developed to support health
professionals in providing the best available care.

Evidence based medicine has been defined as ‘the conscientious, explicit, judicious
use of current best evidence in making decisions about the care of individual patients’
(Sackett, et al, 1996). From medicine, these principles have expanded into the care of
patients or clients by other health professions as evidence based practice (EBP) and
more recently, to include service development and management in evidence based
health care . Evidence based practice asserts that making clinical decisions based on
best evidence, either from the research literature or clinical expertise, improves the
quality of care and the patient's quality of life. In this framework, clinicians may
utilizing the best evidence available from the same sources, may still apply this
knowledge differently, and outcomes may vary depending upon the patients' values,
preferences, concerns, or expectations.
Most texts on evidence based practice present a set of identified levels or hierarchies
of evidence which were established initially within evidence based medicine. (see, for
example, . Although wording may differ slightly, the constructions are similar to the
following table:

Hierarchy of levels of evidence in evidence based practice


Level Description
1 Evidence obtained from systematic reviews of relevant and multiple
randomised controlled trials (RCTs) and meta analyses of RCTs (see
Ovretveit, 1998: 95-97)
2 Evidence obtained from at least one well designed RCT
3 Evidence obtained from well designed non-randomised controlled trials,
single group pre-post, cohort, time series or matched experimental studies
4 Evidence obtained from well designed non-experimental research
5 Opinion of respected authorities based on clinical experience, descriptive
studies or reports of expert committees

This hierarchy of levels of evidence clearly prefers ‘multiple well-designed


randomised controlled trials’ over other forms of evidence such as ‘non-experimental
research’, ‘clinical evidence’ or ‘descriptive studies’. Participatory action research
approaches would be included under ‘non-experimental research’ or ‘descriptive
studies’, ranked as inferior in the quality of knowledge they produce to the ‘gold
standard’ randomised controlled trials.

Action researchers in health are responding to this challenge in a number of ways.


One is to organise randomised controlled trials of action research. Amanda Hampshire
and her colleagues in UK conducted a randomised control trial of the use of action
research in primary health care {Hampshire, 1999 #69}. Twenty-eight general
practices were randomly allocated to two groups. Action research to improve pre-
school child health services was facilitated in 14 clinics, by facilitating practice
meetings and providing written feedback. The other 14 practices received written
feedback alone. In summary, health professionals reported improvements in all 14
action research practices, and none of the others, but formal measures did not show
any statistically significant changes. The authors conclude that action research is a
successful method of promoting change in primary health care, but measuring the
impact is difficult.

The work of Hampshire and her colleagues demonstrates that it is possible to apply
the randomised controlled trials to action research. Some would ask whether this is
appropriate, and whether we should buy into the idea that randomised controlled trials
are a ‘gold standard’ of healthcare knowledge, but that is outside the scope of this
paper. The difficulties of making statistical measures of the effectiveness of
interventions to improve the quality of care is well recognised, and by no means
limited to action research. This work illustrates one way of generalising action
research findings, but combing the results of several case studies.

Elizabeth Hart and Meg Bond {Hart, 1995 #77} identify four types of action research
in healthcare. They call these ‘experimental, organisational, professionalising and
empowering action research, and arrange them on a continuum from top-down control
to bottom-up participation in decision making. This typology includes research
approaches which are designed and controlled by the researcher, with the dual aims of
increasing knowledge and contributing to improved practice, as well as others which
could be described as a ‘participatory, democratic process concerned with developing
practical knowing in the pursuit of worthwhile human purposes, grounded in a
participatory worldview’, which is the definition of action research proposed by
Reason and Bradbury {Reason, 2001 #73, p. 1}.

Evidence based practice is informed by research findings. It is not realistic to expect


individual practitioners to undertake reviews of published research before designing
each intervention. I know of three systematic reviews of action research.

The largest and most systematic review was prepared by the RTI Evidence-based
Practice Center at University of North Carolina for the US Agency for Healthcare
Research and Quality. Their full report is available on the open Web. They defined
Community-Based Participatory Research (CBPR) as ‘a collaborative research
approach is designed to ensure and establish structures for participation by
communities affected by the issue being studies, representatives of organizations, and
researchers in all aspects of the research process to improve health and well-being
through taking action, including social change’. They identified 1408 published
articles which satisfied at least one of their inclusion criteria, and after systematically
applying exclusion criteria, reviewed 185. Several reports claiming to be Community-
Based Participatory Research did not fit their systematic definition, reflecting well
known difficulties in defining action research.

The systematic literature search illustrates the increase in the number of CBPR
studies, especially after 1996. The identified a total of 11 studies in all years prior to
1996, and 24 in the three years from 2001 to 2003 {Viswanathan, 2004 #66, p. 59}.

Viswanathan and her colleagues asked two key questions that relate to the quality of
action research and health. They systematically reviewed each article with regard to
the quality of research method and the quality of community involvement. They also
asked whether CBPR projects achieved their intended to outcomes.
Table 1: Publication dates of CBPR articles

35

30
Number of Studies

25

20
15

10

0
Before 1980-1985 1986-1990 1991-1995 1996-2000 2001-2005
1980
Year (2003-2005 projected)

(Source: based on {Viswanathan, 2004 #66} p. 59)

To assess the equality of research methods, Viswanathan and her colleagues reviewed
four randomized controlled trials, four quasi experimental studies, two single group
pretest and posttests and one non- experimental design, all of which were considered
CBPR. There is an inherent difficulty in systematic the judgment of the quality of
CBPR. Whereas we might consider a randomized trial in which studies were allocated
between a CBPR approach and traditional research methods, because CBPR requires
that the community identify the health problem to be addressed, and be involved in
designing and conducting the research, the two approaches would almost certainly
yield very different interventions and recruitment strategies, leaving little for
comparison other than the final outcome measure.

The review rated the quality of reported research elements on a scale from 1 to 3, with
higher scores representing higher values. The researchers did not establish a cut-off
score for acceptable quality. On this 3-point scale, 50% of CBPR studies score more
than 2.5, 17% were between 2 and 2.5, 33% were between 1.5 and 2, and none were
rated below the half-way mark {Viswanathan, 2004 #66}. The reviewers commented
that some CBPR achieve high scores for research quality, but they found very few
complete and fully evaluated CBPR interventions, partly because page length
limitations in journals lead to incomplete documentation.

Of the same studies, only one third achieved quality ratings for participation higher
than 2.5. A quarter was between 2 and 2.5, 42% were between 1.5 and 2 and none
rated below the half-way mark for participation {Viswanathan, 2004 #66}. Studies
which rated high for research quality did not achieve such high scores for
participation, and from other data in the reviewers found evidence that high-quality
scores in community collaboration are associated with low-quality scores for research.
Despite this trend, the review uncovered several examples of outstanding research
combined withy collaborative community participation throughout the research
process {Webb, 2004 #89}. My conclusion is not that high levels of participation
produce poor quality research, but that more attention to quality of both research and
participation, and adequate resources are needed.

Some research benefits of community involvement include greater participation rates


in research, increased external validity, decreased loss on follow-up and increased
individual and community capacity.

Overall, stronger or more consistent positive health outcomes were found in the better
quality research designs. CBPR can also lead to unintended positive health outcomes,
and positive outcomes not directly related to the measured intervention.

Now I turn to two systematic reviews of action research from Britain.

The review by Meyer is an example of the confusion of types and approaches


sometime found in the action research literature. Mayer, Spilsbury and Prieto take a
definition of action research from a critical theory approach to educational action
research {Carr, 1986 #90}, claiming that this is a rejection of both ‘positivist and
interpretative (sic) views of science’ {Meyer, 1999 #65, p. 38}, they incorrectly place
this within the ‘new paradigm research’ emerging from a ‘participatory worldview’
{Reason, 2001 #73}. They then engage in a discussion of generalization of findings,
within the positivist paradigm, and go on to report a systematic review grounded in
the same positivist tradition. This kind of epistemological confusion makes it difficult
to engage in clear analysis and critique of action research.

As Reason and Bradbury point out in their Introduction to the Handbook of Action
Research, ‘action research has been … promiscuous in its sources of theoretical
inspiration’ {Reason, 2001 #73, p. 3}. The Handbook includes chapters that draw on
pragmatic philosophy (Levin and Greenwood, Chapter 9), critical thinking (Kemmis,
Chapter 8), the practice of democracy (Gustavsen, Chapter 1), liberationist thought
(Fals Borda, Chapter 2), humanistic and transpersonal psychology (Rowan, Chapter
10; Heron and Reason, Chapter 16); constructionist theory (Lincoln, Chapter 11;
Ludema, Cooperrider and Barrett, Chapter 17), systems thinking (Flood, Chapter 12;
Pasmore Chapter 3) and complexity theory. While it is a mistake to claim that there is
one theoretical approach to action research, it is confusing and misleading to mix
models from different professional settings, paradigms and theoretical frameworks in
a single study, and Meyer and her colleagues do.

Meyer et al Although they claim to undertake a systematic review

In their systematic review of 75 action research reports Meyer and her colleagues
Through an action research approach, what factors are identified as influencing
change in health care practice?'
Table 2: Systematic reviews
Reference No. articles Study design Aim or question
reviewed
{Viswanathan, 185 articles Community (1) What defined CBPR? (2) How has CBPR
2004 #66} (from 1408 based been implemented to date with regard to the
articles participatory quality of research methodology and
identified) research community involvement? (3) What is the
evidence that CBPR efforts have resulted in
the intended outcomes? (4) What criteria and
processes should be used for review of CBPR
in grant proposals?
{Meyer, 1999 75 articles Action Through an action research approach, what
#65} (from 333 research factors are identified as influencing change in
articles health care practice?'
identified)
{Waterman, 59 articles Action To examine the role of action research in UK
2001 #67} (from 285 research healthcare settings and to provide guidance for
articles funding agencies, policy makers, ethics
identified) committees, users and researchers for
assessing action research proposals and
reports

Handbook No No. Claimed Method Aim/Question


Cahpter artic articles systemtatic described?
IH.enl les review
iden ed
tifie
d
{Hampshir ( (35 Controlled Y Action discuss the benefits and
e, 1999 N=1 referen clinical trial research difficulties of using action
#69} 4 ces) research in primary health care
case
s,
cont
rols
=
14)
{Viswanath 1 185 Systematic Y Community (1) What defined CBPR? (2) How
an, 2004 408 Review e based has CBPR been implemented to
#66} s participator date with regard to the quality of
y research research methodology and
community involvement? (3)
What is the evidence that CBPR
efforts have resulted in the
intended outcomes? (4) What
criteria and processes should be
used for review of CBPR in grant
proposals?
{Meyer, 333 75 Systematic Y Action Through an action research
1999 #65} Review e research approach, what factors are
s idenbtified as influencing chaqnge
in health care practice?' (:9)
{Waterman, 285 59 Systematic Y Action To examine the role of action
2001 #67} Review e research research in UK healthcare settings
s and to provide guidance for
funding agencies, policy makers,
ethics committees, users and
researchers for assessing action
research proposals and reports
{Green, not (31 Review Y Particpatory Guidelines intended for use by
2005 #87} state referen e research grant application reviewers to
d ces) s appraise whether proposals for
funding as participatory research
meet participatory research criteria
{O'Fallon, not (50 Meeting N Community To promote the use of and support
2000 #84} state referen report o based for CBPR by institutions by
d ces) participator presenting them with sucessful
y research models of CBPR
{Healy, not (40 Critical N Participator Critical appraisal of the promise of
2001 #85} state referen appraisal o y action PAR for social workers
d ces) research
{White not (108 Review N Participator … defines PAR, parovides an
2004, #71} state referen o y action overview of the charicteristics of
d ces) research this approach, and discusses 4
elements for syswtematic
incorporation of the PAR approach
into the research process.
{Karim, not (25 Review N Action … examines some of the evidence
2001 #64) state referen o research for and against a research
d ces) methodology that may be
unfamiliar to many nurses
{Khanlou, not (36 Discussion N Participator This paper addresses the
2005 #88} state referen o y action distinctive nature of participatory
d ces) research action research (PAR) in relation
to ethical review requirments

Background
Action research is employed in many healthcare settings in the UK but its scope and
role in this context is not clear. It is practised under a variety of names and has been
applied in many settings since Kurt Lewin coined the phrase in 1947. Its particular
strength lies in the coupling of participation and research to action and change.

Action research is a period of inquiry that describes, interprets and explains social
situations while executing a change intervention aimed at improvement and
involvement. It is problem- focused, context-specific and future-oriented. Action
research is a group activity with an explicit critical value basis and is founded on a
partnership between action researchers and participants, all of whom are involved in
the change process. The participatory process is educative and empowering, involving
a dynamic approach in which problem identification, planning, action and evaluation
are interlinked. Knowledge may be advanced through reflection and research, and
qualitative and quantitative research methods may be employed to collect data.
Different types of knowledge, including practical and prepositional, may be produced
by action research. Theory may be generated and refined, and its general application
explored through the cycles of the action research process.

has the potential to be useful in areas such as developing innovation, improving


healthcare, developing knowledge and understanding in practitioners, and
involvement in users and staff.

Their findings indicate that action research is suited to developing innovative


practices and services over a wide range of healthcare situations. The review
demonstrates how the action research process can assist in the establishment of an
environment that promotes generation and development of creative ideas and
implementation of changes in practice.

Caldwell, C. H., Zimmerman, M. A., & Isichei, P. (2001). Collaborative


partnerships to enhance family health: An assessment of strengths &
challenges in doing community-based research. Journal of Public Health
Management Practices, 7, 1-9.

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