Purpose: The purpose of this presentation is to help prepare and support nurse investigators who take on challenge and reward of conducting global health research by describing research cycle and author’s experience in conducting a research in LMIC, Nepal.
Methods: Case study methodology, a reflexive account of transactions and processes, is used to describe the research process and experience (Yin, 2017). The unit of analysis was the preparation and conduct of research in Nepal. Though we present the research experience in Nepal, similarities in social, cultural, political and economic characteristics make Nepal a representative country for other LMICs, especially in South Asian countries.
Brief introduction of the research study-The aims of the research study was to translate and culturally validate the Self-Care of Heart Failure Index into the Nepali language, examine the context of HF self-care, factors influencing HF self-care, and the relationship with health-related quality of life among patients living with HF in Nepal. The study collected data from three leading hospitals providing cardiovascular services in Kathmandu, Nepal: Shahid Gangalal National Heart Center, Manmohan Cardiothoracic Vascular and Transplant Center, and Norvic International Hospital.
Results:
Literature review- The search of the literature on HF in Nepal generated a handful of studies. Those studies were limited to the clinical profiles of the patients and medication use (Dubey, Sharma, & Chaurasia, 2012; Regmi, Maskey, & Dubey, 2017; Shrestha et al., 2015). There is a need for a big push on HF research in Nepal to help generate needed evidence on disease burden, help identify, develop, and tailor appropriate management strategies and improve health outcomes of patients living with HF.
Key stakeholder engagement- The study involved key contact and gatekeepers from Nepal early in the planning phase. Key contacts include a professor, former dean, and senior/renowned cardiac doctor who helped researchers identify gatekeepers. The gatekeepers were assumed in several roles: key informants and facilitators to access the hospitals, to obtain the host country’s ethical approval and inform timing, to assist in questionnaire translation and validation and participant recruitment process, to identify research assistants and to help navigate through the unfamiliar system, hierarchy, and culture. To reach key contact and gatekeepers, at first researcher tried to explain about self and research interest using formal emails. With no responses for weeks, the researcher opted to use informal, online social networking sites common in the community (for e.g. Facebook and Viber); this played a profound effect in hearing back.
Translation of instruments- Combination of recommended methods for cross-cultural validation studies such as translation, back translation, synthesis of back translation, and experts (Nepali cardiologists and cardiovascular nurses) review were conducted to develop Nepali version of SCHFI (Beaton, Bombardier, Guillemin, & Ferraz, 2000; Bowden & Fox-Rushby, 2003; Deek et al., 2016). Translation of the instrument has demonstrated face and content validity. Access to reliable, valid and culturally appropriate instruments is critical in describing the state of the problem as well as developing tailored and targeted interventions.
Data collection- Ethical approval for the study was received from the institutional review board of sponsoring country (US), data collection sites and Nepal Health Research Council (a central body under the Ministry of Health, with the regulating authority of all the health research activities in Nepal). Once the ethical approval received, the researcher met with hospital directors for the final clearance and requested collaboration to start participant recruitment and data collection. Data collection then began with the help of research assistants. Collaboration with hospital nurse in-charge and supervisors from the hospitals helped identify research assistants, qualified staff to assist in research; the duties of those staffs were arranged to facilitate training and data collection activities. A total of 221 patients living with heart failure were recruited for the study.
Discussion/Conclusion: The conduct of global nursing research in LMICs is challenging, especially for the novice researcher. It is not uncommon to find perplexities in resource-limited settings considering geopolitical stability and regulatory process which may result in a significant delay in recognition of the regulatory requirements and expectations. Despite the challenges, there are meaningful opportunities for education, research policy, and practice which is crucial because the global demographics of disease burden continue to shift and impact poorest and vulnerable population. Lessons learned during the cycle of the study include the importance of preplanning, engaging key stakeholders from an early phase of the study, being flexible, establishing a good rapport, and respectful relationships with collaborators, appreciating individual and cultural differences, having a backup plan(s) and sharing findings.
Acknowledgment
The research study was supported by 2018 NLN Foundation for Nursing Education Scholarship Award, Southern Nursing Research Society 2018 Dissertation Award, Sigma Theta Tau Nu Beta 2018 Nursing Research Award, Scholl Foundation, and Deans travel fund.