Health Action Research

HEALTH ACTION RESEARCH

Health Action Research – ROJoson’s Exceptional Achievements and Excellent Contribution to Society in the Local, National and International Level

How ROJoson Got Involved in Health Action Research

ROJoson has been doing medical researches as early as when he was just a first-year surgical resident in the Department of Surgery of the Philippine General Hospital. During his 5-year residency years (1976 – 1981), he completed 12 research papers with 9 published (5 during residency years and an additional 4 after residency) and with 5 research awards.

After residency, he continued to do medical researches. As of 2019, he has a total of 50 published papers (4 - international; 47 – local; 29 – with ROJOSON as primary author). He has a total of at least 16 research awards (1976 – October, 2006).

Most of his research papers from 1976 up to present (2019) are of the action research types. However, it was only when he formulated the innovative problem–based and community–based medical curriculum of the Zamboanga Medical School Foundation / Ateneo de Zamboanga University School of Medicine (ZMSF/ADZU-SOM) in 1994 and when became Chairman of the Department of Surgery of Ospital ng Maynila Medical Center (OMMC-Surgery) that he gave preference for health action researches rather than on the traditional medical researches as action researches focus on solving problems. In ZMSF/ADZU-SOM, the emphasis had been to do action researches for health problems in the community the medical students were assigned to. In OMMC-Surgery, the emphasis had been to do action researches to improve patient care in the Department through improved governance, service and training.

ROJoson had extensive experiences in doing and teaching residents do health action researches in OMMC-Surgery. There were a lot of action research papers that he did with the residents of the Department of Surgery of Ospital ng Maynila Medical Center from 2001 to 2009 when he was Chairperson of the said Department. Unfortunately, most were not published because of the preference of the available local medical journals for traditional medical researches. However, the results of the completed action researches were used to improve patient care and also governance, service, and training of the OMMC-Surgery.

Traditional medical researches are more focused on hypothesis testing rather than on solving health problems. For one reason or another, probably, because of lack of relevance and practicality, the utility of traditional medical researches usually ends after being presented in scientific meetings and after being published in journals. Furthermore, traditional clinical medical researches, which usually come in the form of experimental and randomized controlled clinical trials, are more technically difficult to conduct that physicians usually frown upon them.

Action research as defined by Cohen and Manion is a "small scale intervention in the functioning of the real world and a close examination of the effects of such intervention." [Cohen L, Manion L: Research Methods in Education. London, Croom Helm, 1980.]

Action research is situational; it is concerned with diagnosing a problem in a specific context and attempting to solve it in that context.

While experimental research is concerned mainly with establishing relationships and testing theories, action research has as a focus a specific problem in a specific setting. It makes no attempt to identify one particular factor and study it in isolation divorced from the context giving it meaning.

As Margules points out, "in combining action processes (planning, implementation, and evaluation) with research processes (problem identification, hypothesis formation, and testing), the result is a sequence of steps and activities that identify the relevant events that must happen in the initiation and implementation of change." [Marguiles N: Managing change in health care organization. Medical Care 15:693-704, 1977.]

The essential steps in action research are the following:

· Analysis of the problems

· Research designs on how to solve the problems

· Implementation of action plan

· Evaluation of results of implementation

Above is the story behind ROJoson’s endeavor in health action research.

ROJoson’s Achievements and Contributions to Society in the Local and National Level

ROJoson advocated action researches in the community health management courses in the curriculum of Zamboanga Medical School Foundation / Ateneo de Zamboanga University School of Medicine (ZMSF/ADZU-SOM) for which he was the primary designer and developer. The medical students have been producing researches that involved solving specific health problems in the specific setting of the community they have been assigned to (from 1994 to 2019). The action researches qualify the students of ZMSF/ADZU-SOM to get an MD-MPH degree.

The innovative medical curriculum of ZMSF/ADZU-SOM was adopted by Bicol Christian College of Medicine from 1995 to 2003 and Southwestern University College of Medicine in Cebu from 1995 to 2000. Thus, the medical students in these two medical schools had also tried to produce researches that involved solving specific health problems in the specific setting of the community they were assigned to.

Samples of action research outputs from Community Health Management Courses of Medical Schools Helped by ROJoson Circa 1994 – 2005:

From ZMSF/ADZU-SOM

Links: http://som.adzu.edu.ph/; http://som.adzu.edu.ph/research/index.php?pageNum_search=20; http://som.adzu.edu.ph/research/index.php?pageNum_search=21]

From Bicol Christian College of Medicine [https://rojosonmedicaleducation.wordpress.com/2013/03/04/outputs-from-community-health-management-courses-rojoson-circa-1994-2005/]

Community Health Management on Cardiopulmonary Diseases [Link: http://rjoson.tripod.com/bccmcomhmgt/cardiopulmo.htm]

Community Health Management on Cancer[Link: http://rjoson.tripod.com/bccmcomhmgt/cancer.htm]

ROJoson advocated health action researches (Health Action Research Project) in the Department of Surgery of Ospital ng Maynila Medical Center from 2001 to 2009 when he was Chairperson of the said Department.

Links: http://omsurg_research.tripod.com/; http://reynaldojoson.tripod.com/researches_unpublished03_04.htm

The Health Action Research Project was part of OMMC Surgery Social Responsibility Program which satisfied the WHO framework of values, namely, relevance, quality, cost-effectiveness, and equity.

Relevance – Solving situational health problems in the Department through research contributes to relevance of the project. With relevance, the output of the project benefits the patient-clients of the Department in terms of provision of improved health care. With relevance too, the project makes the surgical residents more motivated to do such kind of clinical medical researches and it facilitates formation of effective and efficient surgeon-researchers. The same reasonings and justifications for relevance go for the Multi-center Cooperative and Collaborative Action Research Study (MCCCARS) project of OMMC Surgery.

Quality - The Health Action Research Project improves patient care. Thus, quality service is being promoted. It also improves the teaching method on research to surgical residents. Thus, quality training in research is being promoted.

Cost-effectiveness – The Health Action Research Project promotes cost-effectiveness in patient care. It also promotes cost-effectiveness in teaching research to surgical residents, in terms of more research outputs and meaningful and useful at that in consideration of logistical constraints, compared to when traditional clinical medical researches will be emphasized.

Equity –Action researches, being situational, solve the health problems of the underprivileged and indigent patient-clients of the Department in the most effective and efficient way possible thereby still producing quality health care. They also solve the health educational problems of a scarcely funded health institution and still produce effective educational methods of research.

A paper entitled “Development of an Action Research Program in a Department of Surgery in the Philippines” was presented in the 4^th Asia-Pacific Conference on Problem-based Learning in Health Sciences in 2004 with the following abstract:

Abstract

In the Philippines, action research is practically unheard of in the field of clinical medicine. This paper reports on the development of an action research program in the Department of Surgery of Ospital ng Maynila Medical Center. With the guidance of the Chairman of the Department and a research grant from the North Texas Association of Philippine Physicians, 4 action research papers were produced in 2003 by 16 residents and 16 papers by 16 residents in the following year. The action research program has produced tangible changes in patient care such as 1) use of selective preoperative screening leading to reduction of unnecessary laboratory examinations, reduction of average number of preoperative patient visits from 6 to 2 and preoperative medical expenses by 50%; 2) reduction of discrepancy in clinical and pathological tumor and nodal evaluation in breast cancer patients thereby improving accuracy of the pretreatment cancer staging; 3) reduction of incidence of sudden cancellation in elective operations from 10% to 5% thereby avoiding patient anxiety; 4) reduction of unnecessary appendectomy from 10% to less than 5%; 5) reduction of unnecessary fibrocystic breast excisions in young women from 35% to 7%; and 6) reduction of incidence of surgical wound infections in appendiceal and colorectal surgery. With the residents doing one small scale action research per year and with the motivating effect of relevance and tangible outcome of such kind of research, the authors are confident that the residents will imbibe the habit of doing high impact medical researches.

https://rojosonommcsurgeryfilesandnotes.wordpress.com/2018/03/29/development-of-an-action-research-program-in-a-department-of-surgery-in-the-philippines-2/

Below is a sample of action researches made by the OMMC Surgery:

All researches have impact on improving patient care, governance system, and educational and training system of OMMC Surgery.

Below is a list of some titles of completed action research papers from which the types of improvement can be appreciated:

ROJoson established the Multi-center Cooperative and Collaborative Action Research Study (MCCCARS) among surgeons in different parts of the country in 2004. [Link: http://mcccars.tripod.com]

A 2004 report on MCCCAR shows the following:

As of October, 2002, 17 surgeons subscribed to the e-group of the MCCCARS and these surgeons were affiliated with 8 different centers distributed over Metro Manila, other parts of Luzon, the Visayas, and Mindanao (Ospital ng Maynila Medical Center; Philippine General Hospital; Manila Doctors Hospital; Zamboanga City Medical Center; Davao Regional Hospital; Visayas Community Medical Center, Batangas Regional Hospital; Region 1 Medical Center)

As of December, 2003, about 70 surgeons are now subscribed to the egroup of the MCCCARS

An e-group (mcccars@yahoogroups.com) and a website (http://mcccars.tripod.com) were set-up to facilitate communication among members of MCCCARS.

The multi-center cooperative and collaborative action research studies have been producing the following impact:

1. Utility (problem-solving and improvement in patient care) not only in one institution but also in multiple institutions and simultaneous at that

2. Learning of research methodology by participants in the process of cooperating and collaborating

3. Motivation to do research in the process of cooperating and collaborating

How do the Health Action Research Project contribute to the Social Responsibility Program of the Department of Surgery of Ospital ng Maynila Medical Center?

The health action researches promote and facilitate the development of useful surgeon-researchers through the motivating effect of their relevance and utility. The impact of this output consists of formation of more surgeon-researchers contributing to the health development not only in the Department of Surgery but also outside the Department and OMMC, in the communities where the graduates will be practicing and in the communities where the members of the MCCCARS (Multi-center Cooperative Collaborative Action Study) are practicing.

The health action researches improve patient care in the Department through improved governance, service, and training.

Thus, the Health Action Research Project of OMMC Surgery not only addresses the needs of its internal clients, the surgical residents, but also its external clients, the patients and the Filipino citizenry.

ROJoson’s Action Researches in OMMC Surgery won three awards (national and international):

· Winner, 2004 Asian Hospital Management Awards, Knowledge Management System of the Department of Surgery of Ospital ng Maynila Medical Center (October 7, 2004)

· Winner, 2005 Anvil Award, Wholistic Corporate Social Responsibility Program of Department of Surgery, Ospital ng Maynila Medical Center , February, 2005

· Runner-up, 2005 Asian Corporate Social Responsibility Awards, Conducive Practice Program of the Department of Surgery, Ospital ng Maynila Medical Center (September 9, 2005)

ROJoson’s Action Research in Zamboanga Sibugay Provincial Hospital won an international award in 2015: Winner – AHMA – 2015 – Community Hospital Improvement:

An Online Collaborative and Interactive Learning to Create a Structured, Comprehensive and Sustainable Design and Development Plan on Maternal Death Control Management System in Zamboanga Sibugay Provincial Hospital

ROJoson used action researches for his 3 theses:

MHA – Improving the Medical Staffing of the Emergency Room of the Manila Doctors Hospital

MHPEd - Evaluation and Improvement of the Training Program for Rotating Year Level V Medical Students in a General Surgery Division in the Philippine General Hospital and University of the Philippines College of Medicine

MSc Surg – Development and Evaluation of Distance Education in General Surgery in Zamboanga City Medical Center

ROJoson participated in the 4^th Asia-Pacific Conference on Problem-based Learning in Health Sciences in 2004 with 19 action research papers in health education:

Link: https://rojosonommcsurgeryfilesandnotes.wordpress.com/2018/03/29/ommc-surgery-participation-in-4th-asia-pacific-conference-on-problem-based-learning-in-health-sciences-in-2004-papers/

ROJoson used action researches in the formulation of health-process-evidence-based clinical practice guidelines for relevance, quality, cost-effectiveness, and equity. The following paper was presented in the 4^th Asia-Pacific Conference on Problem-based Learning in Health Sciences in 2004 with the following abstract:

DEVELOPMENT OF A HEALTH-PROCESS-EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES MODEL IN A CLINICAL DEPARTMENT IN THE PHILIPPINES

https://rojosonommcsurgeryfilesandnotes.wordpress.com/2015/08/24/development-of-a-health-process-evidence-based-clinical-practice-guidelines-model-in-a-clinical-department-in-the-philippines/

When formulating conventional evidence-based clinical practice guidelines in medicine, there are two problems commonly encountered in developing countries such as the Philippines. One problem is the insufficiency of data-evidences, particularly those from the community. The other problem is the non-applicability of existing evidence-based guidelines in the literature primarily because of cost and availability reasons. This paper reports on the development of a health-process-evidence-based clinical practice guidelines (HPE-CPG) model in the Department of Surgery of Ospital ng Maynila Medical Center which was primarily designed to facilitate formulation and utility of the guidelines. The basic methodology of generating evidence-based guidelines was used – clinical question formulation, literature search for evidence, analysis of evidences, formulation of answers to questions posed, group deliberation, testing, refinement, and institutionalization. This was the basis for the tag of “evidence-based”. In the formulation of answers and deliberation phase, the World Health Organization concept of health and primary health care approach (basis for the “health-based”) and the conventional patient management processes (basis for the “process-based”) were utilized, one, to help make decisions where there were no existing evidences or just soft evidences and two, to ensure utility of the guidelines. The formulated guidelines were evaluated using effectiveness, efficiency and utility as general parameters and standards set by the Department as specific parameters. The Department has formulated HPE-CPGs on thyroid disorders, breast disorders, appendicitis, hernias, and other clinical conditions since 2002. The outcome has been facilitation of patient management by resident staff and achievement of department targets for improved patient care.

ROJoson uses action researches for medical, surgical, hospital administration, educational researches and community health problems from 1976 to 2019.

IMPACT

ROJoson’s use of action researches in medical, surgical, hospital administration, educational researches and community health problems from 1976 to 2019 has promoted problem-solving and continual improvement of existing management systems. The use of action researches have promoted relevance, quality, cost-effectiveness, and equity in the research outputs.

ROJoson has taught his students how to use action researches.

ROJ@19sept28