The use of direct clinician observation and vignettes for health services quality evaluation in developing countries
Social Science and Medicine
University of Maryland, Department of Agricultural and Resource Economics, United States; Centre for Educational Development in Health Arusha, Tanzania
This paper reports the results of a comparison between two different methods of examining quality in outpatient services in a developing country. Data from rural and urban Tanzania are used to compare the measures of quality collected by direct clinician observation (DCO) (where clinicians are observed in the course of their normal consultations) and vignettes (unblind case studies with an actor). The vignettes are shown to exhibit a strong connection between the inputs provided during consultation (rational history taking, physical examination and health education) and the ability of the clinician to properly diagnose the presented illness. However, the inputs provided in vignettes are not well correlated with the inputs provided in DCO, suggesting that the inputs provided in the vignette are not well correlated with the inputs that would be provided in an actual consultation. We conclude that since vignettes do not appear to be measuring what would be provided in an actual consultation they are not a good measure of quality. Instead, we suggest that vignettes and DCO be used simultaneously. We show how the scores obtained using vignettes in conjunction with DCO can be used to improve the reliability of DCO and therefore our estimates of actual clinician quality. © 2005 Elsevier Ltd. All rights reserved.
developing world; health services; monitoring; quality control; service provision; anamnesis; article; clinical observation; comparative study; consultation; controlled study; correlation analysis; developing country; general practitioner; health care quality; health education; health service; human; intermethod comparison; measurement; normal human; outpatient care; physical examination; qualitative analysis; rural area; Tanzania; urban area; Clinical Competence; Developing Countries; Health Care Surveys; Humans; Medical Audit; Medical History Taking; Nursing Audit; Observation; Outcome and Process Assessment (Health Care); Patient Education; Patient Simulation; Physical Examination; Referral and Consultation; Tanzania; Africa; East Africa; Eastern Hemisphere; Sub-Saharan Africa; Tanzania; World