- Email: [email protected]
Population health research: Linking theory and methods
274
Book Reviews
cervical, immune, and hereditary factors leading to infertility. In this chapter the author pinpoints the lagging behind in Egyptian biogynecological subspecialization. In addition, factors affecting the delivery of quality health service process, which were described by other researchers in the Middle East [2,3], are presented such as lack of standardization of diagnostic procedures, not being sensitive to the socio-cultural background of women and poor doctor-patient communication process. In Chap. 9 the author describes the main features of the quest for biogynecological therapy in upper Egypt mainly: spending and selling where the majority of infertile women buy their health care (public and private) in cash supported by their husbands and selling their possessions when they have 'down spent' their existing cash; doctor shopping; ambivalence towards physicians; drugs and delirium, the technological obsessions; the biopower and technopatriarchy; and the old reproductive technologies. Chapter 10 describes the new reproductive technologies and the painful invasive procedures that women still undergo and the moral burden placed on them as a result of these new technologies. Chapter 11 describes women's concerns of "babies of the tubes" (IVF) and discusses its relationship to the variability in the provision of proper information about this procedure. The book concludes its presentation in Chap. 12 by welt thought out comprehensive recommendations that may help prevent infertility and may ensure the receipt of appropriate diagnostic and treatment services.
The book is a very good source of information for medical schools, community medicine, family medicine and public health students and will enable them to understand the roots of ill health and to formulate a comprehensive approach in understanding and dealing with health issues. It will also be a good resource book for continuing education programs aimed at social and health sciences graduates. The stories presented in this book can be used as effective illustrations of the comprehensive problems of women's health as addressed to program managers and policy makers.
Polmlafion Heath Research: ~ " l ~ r y and Methods, edited by Kathryn Dean. Sage, London, 1993. 246 pp., $23.95.
for the argument in favour of complex theory rather than for the model it presents. The framework does not really cope with much complexity and is restricted to the ageing process rather than health more generally. The next chapter 0Voliusky) makes a cogent and clear argument for differentiating between age, period and cohort analysis of health-related behaviour. The following three chapter (Nesselroade and Hershberger, McQueen and Kreiner) examine methodologically tricky aspects to survey research. They may make depressing reading to those wanting to use surveys because they stress the complexities of the method that are so often overlooked in the field. Chapter 4 describes the importance of"intra individual variability'--that is that we may not give the same to answer to a survey on Monday as we did on Friday. It argues that we can not assume stability in peoples' psychological or other traits and should try to build this knowledge in to the design of survey research. McQueen provides an excellent chapter on the complexities of survey research. He (Chap. 5) maintains that many critical methodological discussions in the social sciences have not reached many population health researchers. He points out that the concepts at the heart of population health research (such as "coping", "social support" and "empowerment') are dynamic rather than static. This makes the task of the researcher more challenging. McQueen argues for the rather dauntingly named continuous data stream as a means of obtaining health-related opinions, attitudes and behaviours that are more dynamic than one-off survey designs. His comment on quasi-experimental design is one that I know I will be quoting often: "In principle it is a rigorous and strong design; in practice it is problematic" (p. 111). Chapter 6 stresses the importance of statistical procedures for validating scales. It warns the reader never to rely completely on previously reported validation of a given scales.
This book starts from the viewpoint that quantitative research methods could be of more use to population health researchers if they were better able to explain the complexities of the many variables that contribute to health. The book contains numerous examples of the problems that arise from a theoretical research and from the failure to fit theory with methods suited to any particular research problem. The collection of chapters were originally presented and discussed in a working meeting held at the European Office of the World Health Organisation in Copenhagen. The contributors are population health researchers, psychologists, mathematicians and statisticians. Kathryn Dean (editor) provides a very useful introduction and conclusion which are excellent pleas for quantitative researchers to adapt traditional experimental designs so that research can cope with the myriad factors that affect any health outcome you care to think of. Complexity is a central theme of the book and it is refreshing to see quantitative researchers grappling with this. In recent years it seems to have been researchers from the qualitative side of the fence who have engaged in soul searching about the adequacy of their methods. The introduction also provides a useful guide to the changing concepts of science. This serves to set the debates in the volume within a historical context. Chapter 2 (Riley) sets out to provide a theoretical framework for research on the multiple influences affecting health in populations. It points out the limitation of studies which focus solely on individual behaviours and argues for theories which involve factors ranging from genetic make up and family background to life-experienee and the changing social environment. The chapter is most useful
Reproductive Health Team and Child Family Health Group Amman Jordan
Raeda AI-Qutob
REFERENCES 1. Zurayak H., Younis Nabil and Khattab H. Rethinking family planning policy in light of reproductive health research. The Policy Series in Reproductive Health, No. 1. The Population Council, 1994. 2. AI-Qutob R. and Mawajdeh S. Assessment of the quality of prenatal care: the transmission of information to pregnant women in maternal and child health centers in Jordan. Int. Q. Commun. Hlth Educ. 13, 47, 1992-1993. 3. Mawajdeh S. and AI-Qutob R. Assessment of the managerial functions in primary health care settings. J. Hlth Admin. Edue. 11, 609, Fall, 1993.
Book Reviews
275
Chapters 7-10 are very teclmical. They deal with various aspects of statistical modelling. Most of the mathematics on which they arc based was beyond the understanding of the reviewer. These chapters would have benefited from more commentary and interpretation directed at the vast majority of health researchers who do not have the sophisticated understanding of mathematics these chapters demand. It was refreshing to find a book firmly fixed within a quantitative approach which was so reflective about the type of method used and the ways in which theory and method are related. A number of the authors also acknowledged that qualitative methodologies have much to offer population health research. The tone of the book was of
methodological catholicism rather than exclusiveness. I would recommend the book for Masters of Public Health and other health sciences graduate courses. It is not a book for those learning research methods for the first time. For experienced researchers, however, who are keen to question their own methods and practices this collection raises important issues and provides much food for thought.
Child Growth and Nutrition in Developing Countries: PrinrRl~ for Action, edited by Per Pinstrup-Anderson, David Pelletier and Harold Alderman. Cornell University Press, Ithaca, 1995. 447 pp.
In Chap. 8, the authors assess whether child survival interventions have led to improved nutrition in young children. While programs that have increased the incidence and length of breast-feeding and improved child feeding during weaning have led to better child nutrition, other child survival strategies such as oral rehydration therapy, measles vaccination and programs to reduce mortality from acute respiratory infections have not had measurable impact on child growth. The effects of clean water and sanitation on child nutrition is the subject of Chap. 9. While both improve child health and nutrition, there is still much to learn to maximize their potential impact and five areas of needed research are outlined. Family planning is the subject of a separate chapter (Chap. 10). Demographic data show strong correlations between birth intervals and child survival and growth, and also show that younger and older mothers have poorer birth outcomes and higher infant mortality. But showing that family planning programs cause the desired changes in demographics (lower fertility, increased birth intervals, and improved ages of mothers) is more problematic. The complexity of the issue is exemplified by the mixed results on birth spacing where breast-feeding duration and associated postpartum infecundity have apparently offset the effect of increased use of contraceptives. Chapters 11 and 12 shift focus to the food supply variable and explore the issues of feeding programs, food-related income transfers and agriculture. The first two have proven to be effective in reducing malnutrition in some settings but not in others. The most effective programs target those most in need, cover the most vulnerable (pregnant women and children under two years of age), reduce participation barriers and match the program to the causes of malnutrition. Changes in agriculture practices and policies are controversial and their effects on malnutrition not well understood. Converting from subsistence farming to cash crop production, improved technologies and government pricing and marketing policies are all discussed. Community participation is seen by many as the key to successful nutrition programs. The scarcity of examples to support this theory is evident after reading Chap. 13. The author of this section discusses the definition and objectives of community participation and provides an analytical framework for measuring it. A few case studies are presented and the conclusion is reached that community participation is both possible and beneficial in food and nutrition programs. Chapter 14 discusses the efforts to use multisectoral approaches to nutrition planning that were popular in the 1970s and that subsequently failed to live up to expectations. This chapter provides a text book example of what happens when an attractive theory runs into hard reality. The problems encountered included lack of
This book utilizes the expertise of 19 authors to explore the current state of knowledge regarding childhood undernutrition and what can be done about it. The editors have organized the 17 chapters into 5 categories: household behavior, interventions influencing behavior, interventions influencing health, interventions influencing access to food, and organization, information and action. The purpose of each chapter is to look at the interaction betwecn multiple variables and their effects on childhood nutrition from both an academic and practical perspective. The authors ask: What do we know?. What has been shown to work? and, What research is needed to provide answers that will assist programs to work better? The editors assume that readers are familiar with the magnitude of the worldwide problem of malnutrition and growth faltering and its effect on personal and national development. This topic is covered only superficially in the first two chapters. Chapters 3-7 cover household behavior and interventions to modify this behavior. Questions addressed in these chapters include: Who makes better use of nutrition information, more educated or uneducated women? Do community-level public health interventions such as sanitation and the provision of clean drinking water provide more benefit than increasing household resources? How does nutrition information and resources change household behavior? Some findings reinforce conventional beliefs (maternal education is positively associated with child health and nutrition); others do not (increased income does not directly correlate to better nutrition). In addition to reviewing recent studies and successful programs, methodological and programmatic errors of unsuccessful programs are discussed. It appears that multiple component interventions are more successful than single-component ones, especially if they include strong political support, infrastructure, and training and supervision of field personnel. Chapter 5 covers growth monitoring, an often-used strategy in nutrition education projects. The frequent lack of success of this intervention appears due to a lack of clarity of goals (surveillance vs education), poor implementation and ineffective use of education. Chapter 6 summarizes behavioral issues related to nutrition and points out that many variables need to be considered including the frequency of feeding, mother's time devoted to other activities, and beliefs about feeding children. The impact of women's nutrition on that of children is the subject of Chap. 7.
Department of Public Health Flinders University of South Australia GPO Box 2100 Adelaide South Australia 5001 Australia
Frances Baron
Book Reviews
cervical, immune, and hereditary factors leading to infertility. In this chapter the author pinpoints the lagging behind in Egyptian biogynecological subspecialization. In addition, factors affecting the delivery of quality health service process, which were described by other researchers in the Middle East [2,3], are presented such as lack of standardization of diagnostic procedures, not being sensitive to the socio-cultural background of women and poor doctor-patient communication process. In Chap. 9 the author describes the main features of the quest for biogynecological therapy in upper Egypt mainly: spending and selling where the majority of infertile women buy their health care (public and private) in cash supported by their husbands and selling their possessions when they have 'down spent' their existing cash; doctor shopping; ambivalence towards physicians; drugs and delirium, the technological obsessions; the biopower and technopatriarchy; and the old reproductive technologies. Chapter 10 describes the new reproductive technologies and the painful invasive procedures that women still undergo and the moral burden placed on them as a result of these new technologies. Chapter 11 describes women's concerns of "babies of the tubes" (IVF) and discusses its relationship to the variability in the provision of proper information about this procedure. The book concludes its presentation in Chap. 12 by welt thought out comprehensive recommendations that may help prevent infertility and may ensure the receipt of appropriate diagnostic and treatment services.
The book is a very good source of information for medical schools, community medicine, family medicine and public health students and will enable them to understand the roots of ill health and to formulate a comprehensive approach in understanding and dealing with health issues. It will also be a good resource book for continuing education programs aimed at social and health sciences graduates. The stories presented in this book can be used as effective illustrations of the comprehensive problems of women's health as addressed to program managers and policy makers.
Polmlafion Heath Research: ~ " l ~ r y and Methods, edited by Kathryn Dean. Sage, London, 1993. 246 pp., $23.95.
for the argument in favour of complex theory rather than for the model it presents. The framework does not really cope with much complexity and is restricted to the ageing process rather than health more generally. The next chapter 0Voliusky) makes a cogent and clear argument for differentiating between age, period and cohort analysis of health-related behaviour. The following three chapter (Nesselroade and Hershberger, McQueen and Kreiner) examine methodologically tricky aspects to survey research. They may make depressing reading to those wanting to use surveys because they stress the complexities of the method that are so often overlooked in the field. Chapter 4 describes the importance of"intra individual variability'--that is that we may not give the same to answer to a survey on Monday as we did on Friday. It argues that we can not assume stability in peoples' psychological or other traits and should try to build this knowledge in to the design of survey research. McQueen provides an excellent chapter on the complexities of survey research. He (Chap. 5) maintains that many critical methodological discussions in the social sciences have not reached many population health researchers. He points out that the concepts at the heart of population health research (such as "coping", "social support" and "empowerment') are dynamic rather than static. This makes the task of the researcher more challenging. McQueen argues for the rather dauntingly named continuous data stream as a means of obtaining health-related opinions, attitudes and behaviours that are more dynamic than one-off survey designs. His comment on quasi-experimental design is one that I know I will be quoting often: "In principle it is a rigorous and strong design; in practice it is problematic" (p. 111). Chapter 6 stresses the importance of statistical procedures for validating scales. It warns the reader never to rely completely on previously reported validation of a given scales.
This book starts from the viewpoint that quantitative research methods could be of more use to population health researchers if they were better able to explain the complexities of the many variables that contribute to health. The book contains numerous examples of the problems that arise from a theoretical research and from the failure to fit theory with methods suited to any particular research problem. The collection of chapters were originally presented and discussed in a working meeting held at the European Office of the World Health Organisation in Copenhagen. The contributors are population health researchers, psychologists, mathematicians and statisticians. Kathryn Dean (editor) provides a very useful introduction and conclusion which are excellent pleas for quantitative researchers to adapt traditional experimental designs so that research can cope with the myriad factors that affect any health outcome you care to think of. Complexity is a central theme of the book and it is refreshing to see quantitative researchers grappling with this. In recent years it seems to have been researchers from the qualitative side of the fence who have engaged in soul searching about the adequacy of their methods. The introduction also provides a useful guide to the changing concepts of science. This serves to set the debates in the volume within a historical context. Chapter 2 (Riley) sets out to provide a theoretical framework for research on the multiple influences affecting health in populations. It points out the limitation of studies which focus solely on individual behaviours and argues for theories which involve factors ranging from genetic make up and family background to life-experienee and the changing social environment. The chapter is most useful
Reproductive Health Team and Child Family Health Group Amman Jordan
Raeda AI-Qutob
REFERENCES 1. Zurayak H., Younis Nabil and Khattab H. Rethinking family planning policy in light of reproductive health research. The Policy Series in Reproductive Health, No. 1. The Population Council, 1994. 2. AI-Qutob R. and Mawajdeh S. Assessment of the quality of prenatal care: the transmission of information to pregnant women in maternal and child health centers in Jordan. Int. Q. Commun. Hlth Educ. 13, 47, 1992-1993. 3. Mawajdeh S. and AI-Qutob R. Assessment of the managerial functions in primary health care settings. J. Hlth Admin. Edue. 11, 609, Fall, 1993.
Book Reviews
275
Chapters 7-10 are very teclmical. They deal with various aspects of statistical modelling. Most of the mathematics on which they arc based was beyond the understanding of the reviewer. These chapters would have benefited from more commentary and interpretation directed at the vast majority of health researchers who do not have the sophisticated understanding of mathematics these chapters demand. It was refreshing to find a book firmly fixed within a quantitative approach which was so reflective about the type of method used and the ways in which theory and method are related. A number of the authors also acknowledged that qualitative methodologies have much to offer population health research. The tone of the book was of
methodological catholicism rather than exclusiveness. I would recommend the book for Masters of Public Health and other health sciences graduate courses. It is not a book for those learning research methods for the first time. For experienced researchers, however, who are keen to question their own methods and practices this collection raises important issues and provides much food for thought.
Child Growth and Nutrition in Developing Countries: PrinrRl~ for Action, edited by Per Pinstrup-Anderson, David Pelletier and Harold Alderman. Cornell University Press, Ithaca, 1995. 447 pp.
In Chap. 8, the authors assess whether child survival interventions have led to improved nutrition in young children. While programs that have increased the incidence and length of breast-feeding and improved child feeding during weaning have led to better child nutrition, other child survival strategies such as oral rehydration therapy, measles vaccination and programs to reduce mortality from acute respiratory infections have not had measurable impact on child growth. The effects of clean water and sanitation on child nutrition is the subject of Chap. 9. While both improve child health and nutrition, there is still much to learn to maximize their potential impact and five areas of needed research are outlined. Family planning is the subject of a separate chapter (Chap. 10). Demographic data show strong correlations between birth intervals and child survival and growth, and also show that younger and older mothers have poorer birth outcomes and higher infant mortality. But showing that family planning programs cause the desired changes in demographics (lower fertility, increased birth intervals, and improved ages of mothers) is more problematic. The complexity of the issue is exemplified by the mixed results on birth spacing where breast-feeding duration and associated postpartum infecundity have apparently offset the effect of increased use of contraceptives. Chapters 11 and 12 shift focus to the food supply variable and explore the issues of feeding programs, food-related income transfers and agriculture. The first two have proven to be effective in reducing malnutrition in some settings but not in others. The most effective programs target those most in need, cover the most vulnerable (pregnant women and children under two years of age), reduce participation barriers and match the program to the causes of malnutrition. Changes in agriculture practices and policies are controversial and their effects on malnutrition not well understood. Converting from subsistence farming to cash crop production, improved technologies and government pricing and marketing policies are all discussed. Community participation is seen by many as the key to successful nutrition programs. The scarcity of examples to support this theory is evident after reading Chap. 13. The author of this section discusses the definition and objectives of community participation and provides an analytical framework for measuring it. A few case studies are presented and the conclusion is reached that community participation is both possible and beneficial in food and nutrition programs. Chapter 14 discusses the efforts to use multisectoral approaches to nutrition planning that were popular in the 1970s and that subsequently failed to live up to expectations. This chapter provides a text book example of what happens when an attractive theory runs into hard reality. The problems encountered included lack of
This book utilizes the expertise of 19 authors to explore the current state of knowledge regarding childhood undernutrition and what can be done about it. The editors have organized the 17 chapters into 5 categories: household behavior, interventions influencing behavior, interventions influencing health, interventions influencing access to food, and organization, information and action. The purpose of each chapter is to look at the interaction betwecn multiple variables and their effects on childhood nutrition from both an academic and practical perspective. The authors ask: What do we know?. What has been shown to work? and, What research is needed to provide answers that will assist programs to work better? The editors assume that readers are familiar with the magnitude of the worldwide problem of malnutrition and growth faltering and its effect on personal and national development. This topic is covered only superficially in the first two chapters. Chapters 3-7 cover household behavior and interventions to modify this behavior. Questions addressed in these chapters include: Who makes better use of nutrition information, more educated or uneducated women? Do community-level public health interventions such as sanitation and the provision of clean drinking water provide more benefit than increasing household resources? How does nutrition information and resources change household behavior? Some findings reinforce conventional beliefs (maternal education is positively associated with child health and nutrition); others do not (increased income does not directly correlate to better nutrition). In addition to reviewing recent studies and successful programs, methodological and programmatic errors of unsuccessful programs are discussed. It appears that multiple component interventions are more successful than single-component ones, especially if they include strong political support, infrastructure, and training and supervision of field personnel. Chapter 5 covers growth monitoring, an often-used strategy in nutrition education projects. The frequent lack of success of this intervention appears due to a lack of clarity of goals (surveillance vs education), poor implementation and ineffective use of education. Chapter 6 summarizes behavioral issues related to nutrition and points out that many variables need to be considered including the frequency of feeding, mother's time devoted to other activities, and beliefs about feeding children. The impact of women's nutrition on that of children is the subject of Chap. 7.
Department of Public Health Flinders University of South Australia GPO Box 2100 Adelaide South Australia 5001 Australia
Frances Baron