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Journal of Advanced Nursing, 1997, 25, 753–759



Methodological issues in the evaluation of the
quality of public health nursing: a case study of
the maternal and child health centres in
Hong Kong
Dr Sheila Twinn PhD BA PGCEA RN RSCN RHV
Senior Lecturer, Department of Nursing, Faculty of Medicine, The Chinese University of
Hong Kong, Shatin, Hong Kong




Accepted for publication 19 April 1996



                                         TWI NN S. (1997)   Journal of Advanced Nursing 25, 753–759
                                         Methodological issues in the evaluation of the quality of public health nursing:
                                         a case study of the maternal and child health centres in Hong Kong.
                                         The demand for the evaluation of the quality of patient and client care has
                                         increased in public health nursing as in all disciplines of nursing. In Hong Kong
                                         this demand led to the development of a collaborative study with the
                                         Department of Health to evaluate the quality of public health nursing in the
                                         maternal and child health centres. A multiple case study design was developed
                                         to undertake the research using both qualitative and quantitative methods of
                                         data collection. The findings from the study demonstrated not only implications
                                         for clinical practice which have been reported elsewhere, but also
                                         methodological issues for the evaluation of care. These findings indicate three
                                         major issues for consideration. The first issue is that of the cultural context of
                                         care which includes perceptions of care such as demands on the service and
                                         expectations of care. The second issue is the use of health data, including both
                                         the methods of recording as well as the sources of data. The final issue is that of
                                         the method of data collection, in particular the implications of the use of
                                         language in data collection tools. The findings suggest that both the use of
                                         professional language and the need for translation have implications for data
                                         collection methods. Indeed in the author’s view the development of
                                         methodologies for the evaluation of care must address culturally specific issues,
                                         particularly where English is not the first language of subjects in the study. In
                                         addition the use the use of language in the method of data collection highlights
                                         more general issues raised by the use of translation in the collection and
                                         analysis of qualitative data.


                                                                     level include the growth of consumerism and increasing
I NTRODUCTI ON
                                                                     expectations amongst patients and clients. The legislation
The demand for the evaluation of health care has arisen              of individual countries such as the National Health Service
at both an international and local level in response to a            and Community Care Act 1990 in the United Kingdom
range of different factors. These factors include policy             (UK) has also contributed to this demand since the
documents from organisations such as the World Health                legislation requires providers to measure the quality of
Organisation (WHO), in which health care providers of                care.
member states are required to evaluate the quality of care              Although authors such as Griffiths (1995) argue the slow
(Roemer & Montoya-Aguilar 1988). Factors at a more local             development of outcome measurement in the evaluation

© 1997 Blackwell Science Ltd                                                                                                753
S. Twinn

of nursing care, the extent to which outcomes have been         developmental screening programs, health advice and
developed within the process of quality assurance varies        counselling and more general advice about child rearing
amongst the different disciplines of nursing. Generally         practice and family health.
nursing in the community is less well developed than the           The centres are extremely well used with #92% of fam-
acute sector. Some authors (Zlotnick 1992, Barriball &          ilies with young children accessing the service (DoH 1994).
Mackenzie 1993) attribute this phenomenon to the diffi-         Indeed an average attendance at a clinic session is around
culties of measuring the quality of nursing care in the com-    200 children. Evidence such as this highlights once more
munity. In particular these difficulties relate to defining      the cultural dichotomy present in the provision of health
standards in practice and the role played by factors outside    care. It was from this background that a study was devel-
the domain of nursing in determining the quality of care.       oped collaboratively with the public health nursing div-
                                                                ision of the Department of Health in Hong Kong. The aim
                                                                of the study was to evaluate the effectiveness of care pro-
Public health nursing
                                                                vided by the maternal and child health centres in meeting
The situation in public health nursing, a discipline of nurs-   the needs of families with young children.
ing in the community, is perhaps more complex, with
difficulties in identifying appropriate outcome measures
                                                                THE STUDY
being clearly acknowledged (Zlotnick & Gould 1993,
Goodwin 1994). Despite these complexities the demand            Three objectives were identified to meet this aim. The first
for quality care measures in public health nursing remains      was to establish the extent to which the centres met the
and Hong Kong is no exception in demanding high quality         health needs of women, infants and young children, the
service provision from public health nursing. However,          second to identify practitioners’ and clients’ perceptions
the implications of the evaluation process for different cul-   of care provided by the centre and lastly to develop a set
tural groups within this discipline of nursing provides an      of tools to measure the effectiveness of nursing care in the
important focus for consideration.                              centres. In order to achieve these objectives a case study
                                                                design was developed using the interpretation of the meth-
                                                                odology proposed by Yin (1994). Yin differentiates
BACKGROUND TO THE STUDY
                                                                between the use of a single and multiple case study
Although Hong Kong has been a British colony since 1842,        approach and for this particular study it was decided that
#98% of the 6·5 million population are Chinese and con-         a multiple study was most appropriate, using both
tinue to retain traditional Chinese cultural values (Lau &      quantitative and qualitative methods of data collection.
Kuan 1988). However, the influence of the British colonial          The use of a multiple case study design requires the
system is witnessed in the structure of health care pro-        researcher to identify an appropriate number of cases for
vision where the legitimised system is that of a western        the study. In this study, because of its collaborative nature,
model. Alongside this approach to care the use of tra-          the number of cases were determined jointly with the
ditional Chinese medicine continues, with individuals fre-      Department of Health. Subsequently, following consider-
quently accessing both forms of care (Lee & Cheung 1989,        ations of service provision, one maternal and child health
Hedley et al. 1990), perhaps reflecting a dichotomy of cul-      centre from each of the four health regions of the Territory
tural values in the Territory. This situation is likely to be   was selected as a case study. In each of the case studies
exacerbated when Hong Kong returns to Chinese sover-            the unit of analysis consisted of four different groups of
eignty in 1997. An indication of the outcome of this            individuals: clients, nurses, doctors and administrative
approach to care is, however, reflected by the health indi-      personnel. Because of resource implications and the inter-
ces of the Territory which for example has an Infant            ests of the researchers the study focused on clients’ and
Mortality Rate (IMR) of 4·7 per 1000 live births in 1993        nursing staff ’s perception of the service.
(DoH 1994).
   Nursing practice presents a similar pattern adopting a
                                                                Data collection
western philosophy and approach to care in both the acute
sector and nursing in the community. Public health nurs-        The data collection consisted of four stages within each of
ing, the most well established nursing service in the com-      the case studies. However, prior to data collection a
munity sector, was initially modelled directly on the           briefing visit was carried out to each of the study centres
health visiting service provided in the UK (DoH 1992).          in order to explain the study and provide the opportunity
   Public health nurses participate in a range of nursing       for staff to ask questions. The researchers considered this
practice, of which the maternal and child health centres        process important for two reasons. Firstly generally little
provide an important focus. These centres provide free          research had been undertaken in nursing in Hong Kong,
heath care to antenatal women and children up to the age        and secondly because of the possible concerns respon-
of five. The provision of care includes immunisation and         dents associate with the purpose of evaluation research

754                                                    © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759
Public health nursing in Hong Kong

(Tones & Tilford 1994). This second reason was                    included Cantonese as a first language, being the parent of
particularly important since the informal feedback given          the child, the child having no known abnormality and the
to one of the researchers during the early stages of              parent having attended the centre and been interviewed
the study clearly demonstrated some concern amongst               by the nursing staff on at least four occasions. Using these
practitioners as to the purpose of the study.                     criteria 8 clients were interviewed from each of the four
                                                                  centres providing a sample of 32 informants, two of whom
Epidemiological survey                                            were fathers. The interviews, carried out in Cantonese,
The first stage of data collection involved an epidemiological     were translated into English and transcribed. Although a
survey of women and children living within the catchment          small sample, the informants came from a range of socioe-
area of the study centres. This proved very time consuming        conomic groups and provided a range of different percep-
as no readily accessible data sources were maintained. Data       tions of the service. Interestingly only one client refused
such as immunisation rates are collected on a Territory wide      to participate in the study, stating that she had insufficient
basis and only include those children attending the maternal      time to be interviewed.
and child health centres. Child protection data is collected         The criteria used for selecting the purposive sample of
from the perspective of the perpetrator rather than the           nurses included factors such as professional qualifications,
abused child, contributing to the difficulty of identifying the   perceptions of service provision, years of professional
location of children at risk of being abused.                     experience and perceived attitudes to practice. The coded
   Although the nursing staff collect other health data which     questionnaires were used to select participants meeting
are entered into the child’s record, there was no computeriz-     these criteria. In each of the four centres, four nurses were
ation of records nor systematic method of maintaining con-        selected for interview and all agreed to participate, giving
sistency of the type of data entered onto the records. This       a total of 16 informants. Although informants were given
situation demanded a manual search of the records and due         the choice of being interviewed in Cantonese or English,
to the high attendance rates at the centres a systematic sam-     all but three of the sample elected to be interviewed in
pling method was used with every tenth record being               Cantonese. The interviews were transcribed and translated
sampled. This method of sampling provided data on socioe-         into English where necessary.
conomic factors, including housing, and some crude data
on health factors such as health during pregnancy, father’s
                                                                  Analysis
health and the perinatal health of the baby.
                                                                  Data analysis consisted of two stages consistent with the
                                                                  methodology suggested by Yin (1994). The first stage
Questionnaire
                                                                  focused on the data collected in the individual case study,
The second stage of the study involved a coded confiden-           using descriptive statistics to analyse the quantitative data
tial questionnaire consisting of closed and open questions        and content analysis to analyse the qualitative data obtained
administered to a total population sample of 42 qualified          from the interviews and questionnaires. The second stage
nursing staff within each of the study centres, including         involved a cross case analysis of these data to enable pattern
midwives, enrolled nurses, registered nurses and nursing          matching and the development of policy implications. The
officers. 41 of these nurses completed the questionnaire          findings from the data analysis demonstrated the signifi-
giving an overall response rate of 97%. The question-             cance of issues such as the nurses’ perceived role in clinical
naire included demographic data, including professional           practice, staffing levels, resources, the organisation of the
qualifications and experience, as well as questions about          centre and the requirement for a health needs data base in
the nursing staff’s perception of the health needs of clients,    evaluating the outcome of nursing care.
the organisation of the service and professional support.            These findings not only have implications for clinical
The next stage of the study involved a structured telephone       practice, but also for the methodology used to evaluate the
interview with a systematic sample of non-attenders from          quality of care. The implications of the findings for clinical
each study centre. It was interesting to observe that of those    practice have been reported elsewhere (Twinn 1994). This
21 (64%) families who responded to the interview, of the          paper therefore focuses on the methodological issues
18 (86%) who had children living in Hong Kong, all were           which emerged from the study within the context of the
accessing child health care at either a private clinic or         evaluation of the quality of nursing care.
another government centre.

                                                                  METHODOLOGICAL ISSUES IN THE
Interviews                                                        EVALUATION OF THE QUALI TY OF
                                                                  NURSING CARE
The final stage of the study involved a semi structured
interview with a purposive sample of nurses and clients.          From undertaking this case study three particular issues
The criteria used for selection of the client sample              emerged which in my opinion have implications for the

© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759                                                     755
S. Twinn

methodology used in evaluating the quality of nursing           tions about the appropriateness of selecting waiting times
care. The first of these issues can be described as the cul-     as a measure of the quality of service provision. This is
tural context of the evaluation of nursing care. The second     particularly so where people with health problems have
issue relates to the use of health data and the third issue     been raised in a tradition of queueing for several hours to
the methods of data collection, in particular the use of        ensure being seen by a doctor in the government run
language. Although the first two of these issues have par-       General Outpatient Clinics (GOPC).
ticular relevance in developing methodologies for the              Issues such as this demonstrate the importance of sel-
evaluation of care, the third issue raises more general ques-   ecting culturally appropriate criteria in measuring the
tions about methodology, in research as well as evaluation,     quality of care. In addition the findings demonstrated the
and consequently provides the final focus of the                 informants reluctance to make demands on the nursing
discussion.                                                     staff. A major theme to emerge from the content analysis
                                                                demonstrated parents’ concern that nurses had little time
                                                                available to answer their questions. Parents also stated they
The cultural context of the evaluation of nursing
                                                                felt unable to ask questions because of the queues of
care
                                                                parents waiting to see the nurse.
The cultural context of evaluation studies has implications
                                                                Lack of expectations The second factor identified within
not only for research undertaken outside the UK, but also
                                                                the context of perceptions of care is that of lack of expec-
for research undertaken with ethnic minority groups
                                                                tations in relation to health care. A third of the parent
within the UK, particularly where English is not the first
                                                                sample, when asked to describe methods of improving the
language of those individuals. Indeed Nelson et al (1994)
                                                                service defined it as ‘good enough’ and could not identify
suggest that there is a tendency for researchers ‘to exclude
                                                                areas for change. Other studies have demonstrated similar
subjects who do not fit neatly into the prevailing culture’.
                                                                findings with different levels of expectations about service
   Leininger (1991) develops this idea further in her debate
                                                                provision amongst different cultural groups (Kelley &
about the significance of culture to caring and the impli-
                                                                Alexander 1991). It is perhaps also significant for the
cations of culture in defining and determining care. Indeed
                                                                development of evaluation methodologies that respon-
she argues that the influence of culture on the perceptions
                                                                dents expressed surprise at being asked this question, sug-
of care is fundamental to identifying the process of care
                                                                gesting that generally they did not expect to participate in
and therefore the evaluation process. Although within this
                                                                the planning of health care. It is, however, important to
study the cultural context of the evaluation of care focuses
                                                                acknowledge that similar findings have emerged in
predominantly on perceptions of care, more general factors
                                                                research with other cultural groups, where evidence indi-
such as the privacy during the provision of care and par-
                                                                cates that consumers of health care demonstrate ambiv-
ticipation in research studies were also considered as
                                                                alence about their participation and involvement in the
implications for the development of the methodology for
                                                                planning of care (Waterworth & Luker 1990)
the evaluation of care.
                                                                Attitude of nursing staff The third factor in determining
                                                                perceptions of care related to the attitude of nursing staff.
Perceptions of care
                                                                Of those 18 (56%) clients who identified need for change
The perceptions of care identified in the findings from this      in service provision, five identified the need for change in
study highlight three factors which the author suggests         the attitude of nursing staff to clients. Although a small
require consideration in the context of the development of      number, this finding was common to three of the four case
evaluation studies in nursing care.                             study centres, highlighting the importance of the inter-
                                                                action between clients and nurses. The importance of
Demands on the service The first of these factors is             client–nurse interaction was illustrated particularly when
described as demands on the service. Although topics such       parents were asked to describe their most satisfactory and
as waiting times and demands on practitioners’ time,            least satisfactory experience in the centre. In each category
included within this category, are not unique to this par-      half of the described experiences related to their inter-
ticular cultural context (Gribben 1992, Piper 1989), the        action with nursing staff. Their descriptions included
responses of the informants in the study reflect the norms       examples of nurses being very caring, as well as descrip-
of this cultural group.                                         tions of nurses being dismissive and uncaring to parents’
   Indeed despite clients differing in their perception of      concerns.
acceptable waiting times, the majority considered waiting          It is interesting that, although parents justified their criti-
for as much as 90 min to see the nurse as acceptable; a         cisms of the nurses’ behaviour once more within the con-
very different finding from the studies cited above.             text of demands on the service, the importance of nurse–
Although this response may in part reflect the value placed      client interaction in determining patient satisfaction with
by parents on the health of their child, it also raises ques-   services is reflected in other research studies (Megivern

756                                                   © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759
Public health nursing in Hong Kong

et al. 1992). Indeed although evidence such as this suggests      amongst the client sample who were generally willing and
the significance of the nurse–client interaction in                enthusiastic to offer their opinions of the service.
determining quality of care, the apparent reluctance of par-
ents in this study to express criticism of this important
                                                                  The use of health data
component of care, highlights the implications of this
phenomenon in both the collection and interpretation of           The second major methodological issue in the evaluation
data within different cultural contexts.                          of the quality of care to emerge from the study was that of
                                                                  the use of health data. Within this category two particular
Privacy More general issues to emerge within the cultural
                                                                  issues require addressing. The first of these relates to the
context of the evaluation of care included factors such as
                                                                  method of recording data and the second to accessing
the degree of privacy provided during consultations with
                                                                  sources of data. The manual search of the records demon-
the nurse. Because of the demands on the service, nurse
                                                                  strated a wide range of quality in recording health data.
informants described the lack of privacy they were able to
                                                                  Although this finding is not unique to this study (Aaronson
provide during their consultations with parents as a major
                                                                  & Burman 1994), the practice of health data being entered
factor influencing the quality of the provision of care.
                                                                  by a range of different professionals using a mixture of
Indeed the lack of privacy emerged as a repeated resource
                                                                  English and Chinese, raises questions about interpret-
issue throughout the data analysis. However, clients were
                                                                  ation and translation as well as accuracy of the data.
much less concerned about this issue stating that they were
                                                                  Indeed both these issues highlight the difficulty of
only discussing ‘baby matters’ and privacy was not
                                                                  interpreting the data obtained from the health records as
important to them in this context.
                                                                  a measure in the evaluation process.
   Although it is possible to argue that parents accessing
the service are used to small crowded living accommo-
                                                                  Sources of data The source of data raises further questions
dation with little privacy in their life, it is important to
                                                                  for consideration, since although data are collected manu-
note that one women stated that if privacy was available
                                                                  ally on a number of health indicators, currently there is
parents may be prepared to discuss more sensitive health
                                                                  no method of readily accessing this information. In
issues. This is a particularly important observation within
                                                                  addition some data are collected on a territory wide basis,
a culture where the uptake of cervical cytology is low and
                                                                  and therefore not available for nurses to use to determine
breast cancer is a major cause of death amongst women
                                                                  health needs of the population of the catchment area of
(Pei et al. 1991, FPAHK 1993, DoH 1994). This finding not
                                                                  the centre. In addition at present there is no systematic
only highlights the implications of the cultural context in
                                                                  data base from which to identify morbidity and mortality
the development of evaluation tools, but also the different
                                                                  rates, highlighting once again the difficulty of targetting
perceptions of nurses and clients in the evaluation of
                                                                  health needs and measuring the effectiveness of the
care.
                                                                  outcome of nursing interventions.
Research participants The final issue for consideration               In addition it is perhaps important to add that both
within the context of cultural issues, once again is more         researchers and practitioners have experienced difficulty
general and relates to the participation of informants in         in accessing data held by the Department of Health.
research. As in any research informed consent was                 Although this situation in part results from the lack of a
obtained from all the participants as part of the ethical         computersied data base, the situation was complicated at
procedures of the study. However, informal feedback               the time of the study by difficulties generally in accessing
obtained at the briefing sessions of the nursing staff, sug-       potentially sensitive information in the Territory. Despite
gested that despite concern about the participating in the        some of these issues being resolved by the implementation
study, in reality they considered they had little choice but      of a system of computerized records currently being devel-
to participate in the study, since the research was being         oped, the philosophy of open access to health data remains
undertaken with the collaboration of the nursing division         a more complex issue. However, the recent introduction
of the Department of Health. They also initially expressed        of legislation on access to information may help to address
their distrust and concern as to why their centre had been        this issue.
selected for the study.
    Although the earlier discussion suggests that concerns
                                                                  Methods of data collection: the use of language.
such as this may be equally relevant to all cultural groups
where evaluation research is undertaken, the continuing           The final methodological issue to be considered in this
presence of a hierarchical nursing structure in Hong Kong         paper relates to the implications of the use of language in
raises questions about the voluntary nature of participants       the methods of data collection. Although this issue has
in the study; a phenomenon which may indeed have impli-           much wider implications than merely studies in the evalu-
cations for the interpretation of data. It is interesting, how-   ation of care, three particularly relevant areas were ident-
ever, this reluctance to participate was not observed             ified from the findings of this study. The first of these

© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759                                                    757
S. Twinn

relates to the use of professional language, particularly in   study demonstrated the complexity of the processes
the development of the interview guide. The use of the         involved in translation.
term ‘weighing’ in the parent interview guide provides a          A lack of understanding by the English researcher about
useful illustration from the study. From the author’s pro-     one of the responses in an interview with one of the nurse
fessional background in health visiting practice in the UK,    informants led to three different bilingual nurses translat-
the term weighing is generally interpreted as having the       ing that particular section of the interview. As shown in
baby weighed and may or may not include receiving              the brief extract of one interviewer–informant interaction
professional advice.                                           (Figure 1) all three translators provide a different interpret-
  However, in practice in Hong Kong, the term is used to       ation of the Cantonese data. Although this finding may
describe the process of bringing the baby to the centre for    have more relevance for the implications of the translation
advice, not merely to the physical activity of weighing.       process in the analysis of qualitative data (Twinn 1995),
Although the researchers had considerable discussion           in the author’s opinion this finding raises questions about
about professional practice prior to and during the devel-     the validity and reliability of findings generated from
opment of the interview schedule, this particular issue had    evaluation studies which have involved the use of
not arisen. In the author’s opinion the use of professional    translation in the collection and analysis of data.
language not only has implications for the development of
the tools for evaluation, but also the interpretation of the
                                                               CONCLUSI ONS
data.
                                                               Obviously the findings of this case study cannot be gen-
Methods of data collection The development of the inter-       eralized to other cultural groups. However, the issues
view guide also highlighted the complexity of developing       raised in this paper, not only highlight some of the com-
methods of data collection for use in evaluation studies in    plexities of evaluating care in public health nursing, but
a different cultural setting, particularly where translation   also more importantly the significance of addressing cul-
of the tool is required. In this study the researchers used    turally specific issues when developing the methodology
both the literature review and local expert opinion to         for the evaluation of care.
identify topics for inclusion within the semi-structured
interview guide used with both the parents and nurses.
                                                               Translator I
The guides were then developed in English and translated
into Cantonese. One particular problem encountered was         In27 Have you seen the bruising on children’s body that alarm
that for some words and concepts such as privacy and                you for more attention or some marks of physical
health needs there was no obvious Cantonese equivalent              punishment?
and the Cantonese speaking researcher had to use               R28 No, I haven’t seen that. But I’ve seen some burning marks
appropriate phrases to convey the meaning to informants.            of the candle. But it is quite common for the boat people to
   In this study only one interviewer was used which                use these, burning on newborn’s body for they always cry.
allowed for consistency of interpretation of concepts such
as privacy. Although authors such as Nelson et al (1994)       Translator II
argue that, due to the nature of interviewing, this approach
                                                               In27 Have you seen any bruises that caused concern?
is appropriate when using qualitative methods of data col-
                                                               R28 No I haven’t … but I have seen some burn marks from
lection, inevitably the interviewer elaborated on the points
                                                                    resulting from Joss sticks. the new born babies of fisherman
for discussion in different ways during the interviews with         got pairs of burn marks on their trunk if they cry a lot.
clients and nurses. This process raises questions about
how translation and the use of language influence the data      Translator III
collection, particularly in relation to the validity and
reliability of concepts within the interview schedule.         In27 Have you ever seen some bruise marks or ‘bamboo stick’
                                                                    marks that will warrant you to do something about it?
Implications of translation Indeed these questions raise       R28 No I have never seen one. but I did see babies burned with
the final issue for consideration within the context of the          joss stick. the new born babies like to cry and when they
                                                                    cry, the boat people like to use joss sticks to burn their
use of language in association with the methods of data
                                                                    babies on their nipples. They usually make the marks with
collection which is that of the implications of translation
                                                                    the joss sticks and make several holes.
for the interpretation of data. As described earlier, the
interviews were carried out in Cantonese and then trans-       (These transcripts represent a verbatim translation of the Chinese
lated and transcribed in English. Although there is little     data which is why it may seem grammatically incorrect)
reference in the literature to the influence of translation
on issues of validity and reliability in qualitative data      Figure 1 Three different translations of the same interviewers
analysis, an incident in the analysis of the data in this      question (IN27) and the response (R28)


758                                                   © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759
Public health nursing in Hong Kong

   Indeed the importance of culturally specific issues such           Lee R.P. & Cheung Y.W. (1989) Receptivity to traditional Chinese
as those of the perception of care and the use of health               and modern medicine among Chinese adolescents in Hong
data in evaluating the outcome of care are particularly                Kong. In The Triumph of Practicality (Quah S.R. ed) Institute
                                                                       of Southeast Asian Studies, Singapore.
important in developing and establishing tools to measure
                                                                     Leininger M. (1991) Ethnonursing: A Research Method with
the effectiveness of care.
                                                                       Enablers to Study the Theory of Culture Care. National League
In addition the findings highlight the significance of trans-
                                                                       for Nursing Publication 15(2402), 73–117.
lation to both the evaluation of care and qualitative                  Megivern K., Halm M., Jones G. (1992) Measuring patient satis-
research methods; an issue of particular importance when               faction as an outcome of nursing care. Journal of Nursing Care
evaluating the care provided to populations where English              Quality 6(4) 9–24.
is not their first language.                                          Nelson McDermott M.A. & Palchanes K. (1994) A Literature
                                                                       review of the Critical Elements in Translation theory. IMAGE:
                                                                       Journal of Nursing Scholarship 26(2), 113–117.
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Hedley A.J., Cheng K.K., Pei G., Fielding R., Lo A. & Pang S.F.      Yin R.K. (1994) Case study Research: Design and Method. Sage,
  (1990) Surveys on health and medical care in Hong Kong II:           Newbury Park, California.
  general population. Department of Community Medicine               Zlotnick C. (1992) A Public Health Quality Assurance System
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Kelley M.A. & Alexander C.S. (1991) Maternal satisfaction with       Zlotnick C. & Gould P. (1993) Prenatal quality of life outcomes
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Lau S.K. & Kuan H.C. (1988) The ethos of the Hong Kong Chinese.
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© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759                                                              759

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Methodology issue in the evaluation of the quality

  • 1. Journal of Advanced Nursing, 1997, 25, 753–759 Methodological issues in the evaluation of the quality of public health nursing: a case study of the maternal and child health centres in Hong Kong Dr Sheila Twinn PhD BA PGCEA RN RSCN RHV Senior Lecturer, Department of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Accepted for publication 19 April 1996 TWI NN S. (1997) Journal of Advanced Nursing 25, 753–759 Methodological issues in the evaluation of the quality of public health nursing: a case study of the maternal and child health centres in Hong Kong. The demand for the evaluation of the quality of patient and client care has increased in public health nursing as in all disciplines of nursing. In Hong Kong this demand led to the development of a collaborative study with the Department of Health to evaluate the quality of public health nursing in the maternal and child health centres. A multiple case study design was developed to undertake the research using both qualitative and quantitative methods of data collection. The findings from the study demonstrated not only implications for clinical practice which have been reported elsewhere, but also methodological issues for the evaluation of care. These findings indicate three major issues for consideration. The first issue is that of the cultural context of care which includes perceptions of care such as demands on the service and expectations of care. The second issue is the use of health data, including both the methods of recording as well as the sources of data. The final issue is that of the method of data collection, in particular the implications of the use of language in data collection tools. The findings suggest that both the use of professional language and the need for translation have implications for data collection methods. Indeed in the author’s view the development of methodologies for the evaluation of care must address culturally specific issues, particularly where English is not the first language of subjects in the study. In addition the use the use of language in the method of data collection highlights more general issues raised by the use of translation in the collection and analysis of qualitative data. level include the growth of consumerism and increasing I NTRODUCTI ON expectations amongst patients and clients. The legislation The demand for the evaluation of health care has arisen of individual countries such as the National Health Service at both an international and local level in response to a and Community Care Act 1990 in the United Kingdom range of different factors. These factors include policy (UK) has also contributed to this demand since the documents from organisations such as the World Health legislation requires providers to measure the quality of Organisation (WHO), in which health care providers of care. member states are required to evaluate the quality of care Although authors such as Griffiths (1995) argue the slow (Roemer & Montoya-Aguilar 1988). Factors at a more local development of outcome measurement in the evaluation © 1997 Blackwell Science Ltd 753
  • 2. S. Twinn of nursing care, the extent to which outcomes have been developmental screening programs, health advice and developed within the process of quality assurance varies counselling and more general advice about child rearing amongst the different disciplines of nursing. Generally practice and family health. nursing in the community is less well developed than the The centres are extremely well used with #92% of fam- acute sector. Some authors (Zlotnick 1992, Barriball & ilies with young children accessing the service (DoH 1994). Mackenzie 1993) attribute this phenomenon to the diffi- Indeed an average attendance at a clinic session is around culties of measuring the quality of nursing care in the com- 200 children. Evidence such as this highlights once more munity. In particular these difficulties relate to defining the cultural dichotomy present in the provision of health standards in practice and the role played by factors outside care. It was from this background that a study was devel- the domain of nursing in determining the quality of care. oped collaboratively with the public health nursing div- ision of the Department of Health in Hong Kong. The aim of the study was to evaluate the effectiveness of care pro- Public health nursing vided by the maternal and child health centres in meeting The situation in public health nursing, a discipline of nurs- the needs of families with young children. ing in the community, is perhaps more complex, with difficulties in identifying appropriate outcome measures THE STUDY being clearly acknowledged (Zlotnick & Gould 1993, Goodwin 1994). Despite these complexities the demand Three objectives were identified to meet this aim. The first for quality care measures in public health nursing remains was to establish the extent to which the centres met the and Hong Kong is no exception in demanding high quality health needs of women, infants and young children, the service provision from public health nursing. However, second to identify practitioners’ and clients’ perceptions the implications of the evaluation process for different cul- of care provided by the centre and lastly to develop a set tural groups within this discipline of nursing provides an of tools to measure the effectiveness of nursing care in the important focus for consideration. centres. In order to achieve these objectives a case study design was developed using the interpretation of the meth- odology proposed by Yin (1994). Yin differentiates BACKGROUND TO THE STUDY between the use of a single and multiple case study Although Hong Kong has been a British colony since 1842, approach and for this particular study it was decided that #98% of the 6·5 million population are Chinese and con- a multiple study was most appropriate, using both tinue to retain traditional Chinese cultural values (Lau & quantitative and qualitative methods of data collection. Kuan 1988). However, the influence of the British colonial The use of a multiple case study design requires the system is witnessed in the structure of health care pro- researcher to identify an appropriate number of cases for vision where the legitimised system is that of a western the study. In this study, because of its collaborative nature, model. Alongside this approach to care the use of tra- the number of cases were determined jointly with the ditional Chinese medicine continues, with individuals fre- Department of Health. Subsequently, following consider- quently accessing both forms of care (Lee & Cheung 1989, ations of service provision, one maternal and child health Hedley et al. 1990), perhaps reflecting a dichotomy of cul- centre from each of the four health regions of the Territory tural values in the Territory. This situation is likely to be was selected as a case study. In each of the case studies exacerbated when Hong Kong returns to Chinese sover- the unit of analysis consisted of four different groups of eignty in 1997. An indication of the outcome of this individuals: clients, nurses, doctors and administrative approach to care is, however, reflected by the health indi- personnel. Because of resource implications and the inter- ces of the Territory which for example has an Infant ests of the researchers the study focused on clients’ and Mortality Rate (IMR) of 4·7 per 1000 live births in 1993 nursing staff ’s perception of the service. (DoH 1994). Nursing practice presents a similar pattern adopting a Data collection western philosophy and approach to care in both the acute sector and nursing in the community. Public health nurs- The data collection consisted of four stages within each of ing, the most well established nursing service in the com- the case studies. However, prior to data collection a munity sector, was initially modelled directly on the briefing visit was carried out to each of the study centres health visiting service provided in the UK (DoH 1992). in order to explain the study and provide the opportunity Public health nurses participate in a range of nursing for staff to ask questions. The researchers considered this practice, of which the maternal and child health centres process important for two reasons. Firstly generally little provide an important focus. These centres provide free research had been undertaken in nursing in Hong Kong, heath care to antenatal women and children up to the age and secondly because of the possible concerns respon- of five. The provision of care includes immunisation and dents associate with the purpose of evaluation research 754 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759
  • 3. Public health nursing in Hong Kong (Tones & Tilford 1994). This second reason was included Cantonese as a first language, being the parent of particularly important since the informal feedback given the child, the child having no known abnormality and the to one of the researchers during the early stages of parent having attended the centre and been interviewed the study clearly demonstrated some concern amongst by the nursing staff on at least four occasions. Using these practitioners as to the purpose of the study. criteria 8 clients were interviewed from each of the four centres providing a sample of 32 informants, two of whom Epidemiological survey were fathers. The interviews, carried out in Cantonese, The first stage of data collection involved an epidemiological were translated into English and transcribed. Although a survey of women and children living within the catchment small sample, the informants came from a range of socioe- area of the study centres. This proved very time consuming conomic groups and provided a range of different percep- as no readily accessible data sources were maintained. Data tions of the service. Interestingly only one client refused such as immunisation rates are collected on a Territory wide to participate in the study, stating that she had insufficient basis and only include those children attending the maternal time to be interviewed. and child health centres. Child protection data is collected The criteria used for selecting the purposive sample of from the perspective of the perpetrator rather than the nurses included factors such as professional qualifications, abused child, contributing to the difficulty of identifying the perceptions of service provision, years of professional location of children at risk of being abused. experience and perceived attitudes to practice. The coded Although the nursing staff collect other health data which questionnaires were used to select participants meeting are entered into the child’s record, there was no computeriz- these criteria. In each of the four centres, four nurses were ation of records nor systematic method of maintaining con- selected for interview and all agreed to participate, giving sistency of the type of data entered onto the records. This a total of 16 informants. Although informants were given situation demanded a manual search of the records and due the choice of being interviewed in Cantonese or English, to the high attendance rates at the centres a systematic sam- all but three of the sample elected to be interviewed in pling method was used with every tenth record being Cantonese. The interviews were transcribed and translated sampled. This method of sampling provided data on socioe- into English where necessary. conomic factors, including housing, and some crude data on health factors such as health during pregnancy, father’s Analysis health and the perinatal health of the baby. Data analysis consisted of two stages consistent with the methodology suggested by Yin (1994). The first stage Questionnaire focused on the data collected in the individual case study, The second stage of the study involved a coded confiden- using descriptive statistics to analyse the quantitative data tial questionnaire consisting of closed and open questions and content analysis to analyse the qualitative data obtained administered to a total population sample of 42 qualified from the interviews and questionnaires. The second stage nursing staff within each of the study centres, including involved a cross case analysis of these data to enable pattern midwives, enrolled nurses, registered nurses and nursing matching and the development of policy implications. The officers. 41 of these nurses completed the questionnaire findings from the data analysis demonstrated the signifi- giving an overall response rate of 97%. The question- cance of issues such as the nurses’ perceived role in clinical naire included demographic data, including professional practice, staffing levels, resources, the organisation of the qualifications and experience, as well as questions about centre and the requirement for a health needs data base in the nursing staff’s perception of the health needs of clients, evaluating the outcome of nursing care. the organisation of the service and professional support. These findings not only have implications for clinical The next stage of the study involved a structured telephone practice, but also for the methodology used to evaluate the interview with a systematic sample of non-attenders from quality of care. The implications of the findings for clinical each study centre. It was interesting to observe that of those practice have been reported elsewhere (Twinn 1994). This 21 (64%) families who responded to the interview, of the paper therefore focuses on the methodological issues 18 (86%) who had children living in Hong Kong, all were which emerged from the study within the context of the accessing child health care at either a private clinic or evaluation of the quality of nursing care. another government centre. METHODOLOGICAL ISSUES IN THE Interviews EVALUATION OF THE QUALI TY OF NURSING CARE The final stage of the study involved a semi structured interview with a purposive sample of nurses and clients. From undertaking this case study three particular issues The criteria used for selection of the client sample emerged which in my opinion have implications for the © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759 755
  • 4. S. Twinn methodology used in evaluating the quality of nursing tions about the appropriateness of selecting waiting times care. The first of these issues can be described as the cul- as a measure of the quality of service provision. This is tural context of the evaluation of nursing care. The second particularly so where people with health problems have issue relates to the use of health data and the third issue been raised in a tradition of queueing for several hours to the methods of data collection, in particular the use of ensure being seen by a doctor in the government run language. Although the first two of these issues have par- General Outpatient Clinics (GOPC). ticular relevance in developing methodologies for the Issues such as this demonstrate the importance of sel- evaluation of care, the third issue raises more general ques- ecting culturally appropriate criteria in measuring the tions about methodology, in research as well as evaluation, quality of care. In addition the findings demonstrated the and consequently provides the final focus of the informants reluctance to make demands on the nursing discussion. staff. A major theme to emerge from the content analysis demonstrated parents’ concern that nurses had little time available to answer their questions. Parents also stated they The cultural context of the evaluation of nursing felt unable to ask questions because of the queues of care parents waiting to see the nurse. The cultural context of evaluation studies has implications Lack of expectations The second factor identified within not only for research undertaken outside the UK, but also the context of perceptions of care is that of lack of expec- for research undertaken with ethnic minority groups tations in relation to health care. A third of the parent within the UK, particularly where English is not the first sample, when asked to describe methods of improving the language of those individuals. Indeed Nelson et al (1994) service defined it as ‘good enough’ and could not identify suggest that there is a tendency for researchers ‘to exclude areas for change. Other studies have demonstrated similar subjects who do not fit neatly into the prevailing culture’. findings with different levels of expectations about service Leininger (1991) develops this idea further in her debate provision amongst different cultural groups (Kelley & about the significance of culture to caring and the impli- Alexander 1991). It is perhaps also significant for the cations of culture in defining and determining care. Indeed development of evaluation methodologies that respon- she argues that the influence of culture on the perceptions dents expressed surprise at being asked this question, sug- of care is fundamental to identifying the process of care gesting that generally they did not expect to participate in and therefore the evaluation process. Although within this the planning of health care. It is, however, important to study the cultural context of the evaluation of care focuses acknowledge that similar findings have emerged in predominantly on perceptions of care, more general factors research with other cultural groups, where evidence indi- such as the privacy during the provision of care and par- cates that consumers of health care demonstrate ambiv- ticipation in research studies were also considered as alence about their participation and involvement in the implications for the development of the methodology for planning of care (Waterworth & Luker 1990) the evaluation of care. Attitude of nursing staff The third factor in determining perceptions of care related to the attitude of nursing staff. Perceptions of care Of those 18 (56%) clients who identified need for change The perceptions of care identified in the findings from this in service provision, five identified the need for change in study highlight three factors which the author suggests the attitude of nursing staff to clients. Although a small require consideration in the context of the development of number, this finding was common to three of the four case evaluation studies in nursing care. study centres, highlighting the importance of the inter- action between clients and nurses. The importance of Demands on the service The first of these factors is client–nurse interaction was illustrated particularly when described as demands on the service. Although topics such parents were asked to describe their most satisfactory and as waiting times and demands on practitioners’ time, least satisfactory experience in the centre. In each category included within this category, are not unique to this par- half of the described experiences related to their inter- ticular cultural context (Gribben 1992, Piper 1989), the action with nursing staff. Their descriptions included responses of the informants in the study reflect the norms examples of nurses being very caring, as well as descrip- of this cultural group. tions of nurses being dismissive and uncaring to parents’ Indeed despite clients differing in their perception of concerns. acceptable waiting times, the majority considered waiting It is interesting that, although parents justified their criti- for as much as 90 min to see the nurse as acceptable; a cisms of the nurses’ behaviour once more within the con- very different finding from the studies cited above. text of demands on the service, the importance of nurse– Although this response may in part reflect the value placed client interaction in determining patient satisfaction with by parents on the health of their child, it also raises ques- services is reflected in other research studies (Megivern 756 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759
  • 5. Public health nursing in Hong Kong et al. 1992). Indeed although evidence such as this suggests amongst the client sample who were generally willing and the significance of the nurse–client interaction in enthusiastic to offer their opinions of the service. determining quality of care, the apparent reluctance of par- ents in this study to express criticism of this important The use of health data component of care, highlights the implications of this phenomenon in both the collection and interpretation of The second major methodological issue in the evaluation data within different cultural contexts. of the quality of care to emerge from the study was that of the use of health data. Within this category two particular Privacy More general issues to emerge within the cultural issues require addressing. The first of these relates to the context of the evaluation of care included factors such as method of recording data and the second to accessing the degree of privacy provided during consultations with sources of data. The manual search of the records demon- the nurse. Because of the demands on the service, nurse strated a wide range of quality in recording health data. informants described the lack of privacy they were able to Although this finding is not unique to this study (Aaronson provide during their consultations with parents as a major & Burman 1994), the practice of health data being entered factor influencing the quality of the provision of care. by a range of different professionals using a mixture of Indeed the lack of privacy emerged as a repeated resource English and Chinese, raises questions about interpret- issue throughout the data analysis. However, clients were ation and translation as well as accuracy of the data. much less concerned about this issue stating that they were Indeed both these issues highlight the difficulty of only discussing ‘baby matters’ and privacy was not interpreting the data obtained from the health records as important to them in this context. a measure in the evaluation process. Although it is possible to argue that parents accessing the service are used to small crowded living accommo- Sources of data The source of data raises further questions dation with little privacy in their life, it is important to for consideration, since although data are collected manu- note that one women stated that if privacy was available ally on a number of health indicators, currently there is parents may be prepared to discuss more sensitive health no method of readily accessing this information. In issues. This is a particularly important observation within addition some data are collected on a territory wide basis, a culture where the uptake of cervical cytology is low and and therefore not available for nurses to use to determine breast cancer is a major cause of death amongst women health needs of the population of the catchment area of (Pei et al. 1991, FPAHK 1993, DoH 1994). This finding not the centre. In addition at present there is no systematic only highlights the implications of the cultural context in data base from which to identify morbidity and mortality the development of evaluation tools, but also the different rates, highlighting once again the difficulty of targetting perceptions of nurses and clients in the evaluation of health needs and measuring the effectiveness of the care. outcome of nursing interventions. Research participants The final issue for consideration In addition it is perhaps important to add that both within the context of cultural issues, once again is more researchers and practitioners have experienced difficulty general and relates to the participation of informants in in accessing data held by the Department of Health. research. As in any research informed consent was Although this situation in part results from the lack of a obtained from all the participants as part of the ethical computersied data base, the situation was complicated at procedures of the study. However, informal feedback the time of the study by difficulties generally in accessing obtained at the briefing sessions of the nursing staff, sug- potentially sensitive information in the Territory. Despite gested that despite concern about the participating in the some of these issues being resolved by the implementation study, in reality they considered they had little choice but of a system of computerized records currently being devel- to participate in the study, since the research was being oped, the philosophy of open access to health data remains undertaken with the collaboration of the nursing division a more complex issue. However, the recent introduction of the Department of Health. They also initially expressed of legislation on access to information may help to address their distrust and concern as to why their centre had been this issue. selected for the study. Although the earlier discussion suggests that concerns Methods of data collection: the use of language. such as this may be equally relevant to all cultural groups where evaluation research is undertaken, the continuing The final methodological issue to be considered in this presence of a hierarchical nursing structure in Hong Kong paper relates to the implications of the use of language in raises questions about the voluntary nature of participants the methods of data collection. Although this issue has in the study; a phenomenon which may indeed have impli- much wider implications than merely studies in the evalu- cations for the interpretation of data. It is interesting, how- ation of care, three particularly relevant areas were ident- ever, this reluctance to participate was not observed ified from the findings of this study. The first of these © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759 757
  • 6. S. Twinn relates to the use of professional language, particularly in study demonstrated the complexity of the processes the development of the interview guide. The use of the involved in translation. term ‘weighing’ in the parent interview guide provides a A lack of understanding by the English researcher about useful illustration from the study. From the author’s pro- one of the responses in an interview with one of the nurse fessional background in health visiting practice in the UK, informants led to three different bilingual nurses translat- the term weighing is generally interpreted as having the ing that particular section of the interview. As shown in baby weighed and may or may not include receiving the brief extract of one interviewer–informant interaction professional advice. (Figure 1) all three translators provide a different interpret- However, in practice in Hong Kong, the term is used to ation of the Cantonese data. Although this finding may describe the process of bringing the baby to the centre for have more relevance for the implications of the translation advice, not merely to the physical activity of weighing. process in the analysis of qualitative data (Twinn 1995), Although the researchers had considerable discussion in the author’s opinion this finding raises questions about about professional practice prior to and during the devel- the validity and reliability of findings generated from opment of the interview schedule, this particular issue had evaluation studies which have involved the use of not arisen. In the author’s opinion the use of professional translation in the collection and analysis of data. language not only has implications for the development of the tools for evaluation, but also the interpretation of the CONCLUSI ONS data. Obviously the findings of this case study cannot be gen- Methods of data collection The development of the inter- eralized to other cultural groups. However, the issues view guide also highlighted the complexity of developing raised in this paper, not only highlight some of the com- methods of data collection for use in evaluation studies in plexities of evaluating care in public health nursing, but a different cultural setting, particularly where translation also more importantly the significance of addressing cul- of the tool is required. In this study the researchers used turally specific issues when developing the methodology both the literature review and local expert opinion to for the evaluation of care. identify topics for inclusion within the semi-structured interview guide used with both the parents and nurses. Translator I The guides were then developed in English and translated into Cantonese. One particular problem encountered was In27 Have you seen the bruising on children’s body that alarm that for some words and concepts such as privacy and you for more attention or some marks of physical health needs there was no obvious Cantonese equivalent punishment? and the Cantonese speaking researcher had to use R28 No, I haven’t seen that. But I’ve seen some burning marks appropriate phrases to convey the meaning to informants. of the candle. But it is quite common for the boat people to In this study only one interviewer was used which use these, burning on newborn’s body for they always cry. allowed for consistency of interpretation of concepts such as privacy. Although authors such as Nelson et al (1994) Translator II argue that, due to the nature of interviewing, this approach In27 Have you seen any bruises that caused concern? is appropriate when using qualitative methods of data col- R28 No I haven’t … but I have seen some burn marks from lection, inevitably the interviewer elaborated on the points resulting from Joss sticks. the new born babies of fisherman for discussion in different ways during the interviews with got pairs of burn marks on their trunk if they cry a lot. clients and nurses. This process raises questions about how translation and the use of language influence the data Translator III collection, particularly in relation to the validity and reliability of concepts within the interview schedule. In27 Have you ever seen some bruise marks or ‘bamboo stick’ marks that will warrant you to do something about it? Implications of translation Indeed these questions raise R28 No I have never seen one. but I did see babies burned with the final issue for consideration within the context of the joss stick. the new born babies like to cry and when they cry, the boat people like to use joss sticks to burn their use of language in association with the methods of data babies on their nipples. They usually make the marks with collection which is that of the implications of translation the joss sticks and make several holes. for the interpretation of data. As described earlier, the interviews were carried out in Cantonese and then trans- (These transcripts represent a verbatim translation of the Chinese lated and transcribed in English. Although there is little data which is why it may seem grammatically incorrect) reference in the literature to the influence of translation on issues of validity and reliability in qualitative data Figure 1 Three different translations of the same interviewers analysis, an incident in the analysis of the data in this question (IN27) and the response (R28) 758 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 753–759
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