CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY
This chapter presents the research design and methodology used in this study and describes how the study was conducted including the population, sampling procedures, data collection, data analysis and ethical considerations.
PURPOSE OF THE STUDY
The purpose of this study was to evaluate the ART program in the PHC settings of Lesotho and develop a tool that can be used to assess the ART program in the PHC settings of Lesotho.
The objectives of this study were:
For the quantitative strand to;
describe ART services offered in PHC settings of Lesotho.
determine if staffing patterns had an association with
onumber of days ART services were offered
onumber of days PMTCT services were offered
onumber of patients seen
otime spent by patients seeking ART services at the facility
otime taken by a patient to consult a registered nurse midwife/clinician For the qualitative strand to;
explore and describe experiences and views of registered nurse midwives/clinicians on the ART program in the PHC settings of Lesotho.
explore and describe experiences and views of patients on the ART program in the PHC settings of Lesotho.
For the whole study to;
develop an evaluation tool that can be used to assess the ART program in PHC settings of Lesotho.
The study was envisaged to be conducted in all 10 districts of Lesotho, however, data were collected in only 6 districts. This was due to either failure to obtain permission to collect data from the District Health Management Team (DHMT) or the district was not easily accessible due to the geographical terrain of the country. Figure 2.2 shows a map depicting the districts and the health facilities of Lesotho. Each district has at least one hospital and several health centre facilities which are disproportionately distributed. Data was collected from health facilities offering ART services in PHC settings and they included outpatients departments of district hospitals and health centre facilities. The registered nurses were recruited to participate in the study during their PHC planning meetings at the district hospitals. The patients were recruited to participate in the study at selected clinics on days on which they sought ART services.
According to Polit and Beck (2012:740) the research design is a strategy for addressing the research question including specifications for enhancing the study’s integrity or as described by de Vos et al (2011:142-143), the research design is a process of directing the researcher`s viewpoints for the purposes of a particular study. It is a strategic framework for action that serves as a bridge between research questions and the execution or implementation of the research and distinguishes research from other forms of research (Terre Blanche et al 2006: 34).
This study conducted evaluation research which is defined by Polit and Beck (2012:726) as research which assesses how well a program, practice or policy is working. Evaluation research tracks the progress of social programs and is aimed at educational or social development (Terre Blanche et al 2006: 410). de Vos et al (2011:452) further explained the purpose of evaluation research to be the ‘intended use of the evaluation activity, namely gathering information for improving the design, development, formation and implementation of a program (formative evaluation); describing the process of a program as it is being developed (process evaluation); or assessing the impact, outcome or worth of a program (summative evaluation). Terre Blanche et al (2006: 411) reiterated the purpose of social research to be a focus on theories of change implicit in social programs and to analyze ways in which those involved in social programs go about their work, the issues they deal with and the manner in which they confront those issues.
In this study process evaluation of the ART program in PHC settings of Lesotho was conducted. Polit and Beck (2012:261) explained that ‘process analysis involves an in-depth examination of the program involving a collection of both qualitative and quantitative data’. Process evaluations are aimed at understanding internal dynamics of how a program, organization or relationship operates and requires sensitivity to both qualitative and quantitative changes in programs throughout their development and further investigate informal patterns and unanticipated interactions (Patton 2002: 160). In undertaking the process evaluation of the ART program in PHC settings of Lesotho the researcher used mixed methods research in which both qualitative and quantitative data were collected.
Mixed methods research is described by various authors in terms of philosophy or methods used. Polit and Beck (2012:734) define mixed methods research as ‘research in which both qualitative and quantitative data are collected and analysed to address different but related questions’. de Vos et al (2011:435) concurred with a definition of mixed methods research provided by Creswell and Plano-Clark (2011:5) which describes it as ‘a philosophical assumption as well as methods of inquiry which involves philosophical assumptions that guide the direction of the collection and analysis and the mixture of qualitative and quantitative data in a single study or series of studies. Johnson et al (2007:120) described mixed methods as research where the researcher mixes or combines quantitative and qualitative research techniques, methods, approaches, concepts or language into a single study or set of related studies. According to Creswell and Plano Clark (2011:5), mixed methods is a research design with philosophical assumptions as well as methods of inquiry that guide the direction of the collections and analysis and the mixture of qualitative and quantitative approaches in many phases of the research process. de Vos et al (2011:435-436) and Creswell and Plano Clark (2011:12-13) further give the value or advantages of mixed methods research as:
Enabling the simultaneous address of a range of confirmatory and exploratory questions and this therefore allowed the researcher to use both the qualitative and quantitative approaches.
Providing strengths that offset weaknesses of and has potential for better inferences in either quantitative or qualitative research. The researcher was able to get an in-depth understanding of the ART program using focus group interviews which are not possible the quantitative data collection method.
Giving comprehensive evidence for studying a research problem than either quantitative or qualitative research alone. The researcher merged both data sets to get a comprehensive understanding of the implementation processes of the ART program.
Encouraging researchers to collaborate across both quantitative and qualitative methods giving greater confidence in findings than either approach alone. In this study the researcher gave an integrated description of the ART program from the merged data sets.
Encouraging the use of multiple worldviews or paradigms rather than the typical association of quantitative or qualitative paradigms alone. Pragmatism in which both qualitative and qualitative worldviews of the ART program were used.
Giving a greater opportunity for assortment of divergent views and perspectives and makes researchers alert to the possibility that issues are multifaceted than they may be originally. The researcher collected data from both registered nurses and patients to bring a better understanding of the ART program.
Practical in allowing researchers to be free to use all methods possible to address a research problem as well as the fact that they make a combination of inductive and deductive reasoning processes. This allowed the researcher to collect the data using either qualitative or quantitative methods allowing the ART program to be critically analysed.
Eliminating different kinds of bias hence explaining the true nature of phenomenon under investigation and improves various forms of validity or quality criteria. In this study the researcher employed rigor processes of both qualitative and quantitative research techniques.
Mixed methods research was chosen as the researcher envisaged collecting both qualitative and quantitative data to answer two separate but related study questions. The researcher viewed this type of research to be able to bring a more comprehensive evaluation of the ART program in PHC settings.
The mixed methods convergent parallel research design was used to address pertinent questions of this study. As explained by Creswell and Plano Clark (2011:78) the Convergent Parallel Research Design is one in which both quantitative and qualitative data are collected simultaneously but separately and have equal importance in addressing the study questions. The authors further explain that this study design is strong in that it makes intuitive sense, is efficient as both types of data are collected during one phase of the research at about the same time and that data analysis is independent for each data set using techniques traditionally associated with each data type (Creswell & Plano Clark 2011:78). The purpose of this type of study is to obtain different but complementary data on the same topic to best understand the research topic and bring together differing strengths and non-overlapping weaknesses of quantitative methods with those of qualitative methods and is used when the researcher has the intention to triangulate the methods by directly comparing and contrasting quantitative statistical results with qualitative findings for justification and validation purposes (Creswell & Plano Clark 2011:77). The researcher achieved triangulation by collecting both qualitative data through focus group discussions and quantitative data through a cross sectional survey. Data were also collected from different samples and they included registered nurses involved in the provision of ART services and patients who were HIV positive and sought ART services.
The study population is described as a large group of many cases from which the researcher draws a sample and can be stated in theoretical terms (Neuman 2003: 541). It is also referred to as the target population which is, according to Polit and Beck (2012:744), is the whole population in which the researcher is interested and to which he or she would like to generalize the study results. However, researchers do not have access to the whole population and therefore make use of the accessible population which is described Polit and Beck (2012:719) as that population which is available for the study and is often a non-random subset of the target population. The researcher also set eligibility or inclusion criteria which, according to Polit and Beck (2012:726), are criteria designating specific attributes for inclusion into the target population.
The population included health care professionals working in Lesotho; and all individuals who sought health care in the PHC settings of Lesotho.
The target population included registered nurses/midwives/clinicians providing ART services in PHC settings in Lesotho; and all individuals who were HIV positive and sought ART services in PHC settings in Lesotho.
The accessible population included registered nurses/midwives/clinicians providing ART services in PHC settings of Lesotho who were available at the time of the study and all individuals who were HIV/AIDS positive and sought ART services in PHC settings of Lesotho and were available at the time of the study.
Inclusion criteria were registered nurses employed in the health clinics providing primary health care services and available at the time of the study were included in the study. Adults aged 18 years and older who were HIV/AIDS positive, can speak either Sesotho and/or English and were able to give consent and available at the time of the study were included in this study.
Burns and Grove (2003:495) explain that a sample is a subset of the population selected to take part in a study whilst Neuman (2003: 543) describes a sample as a smaller set of cases a researcher selects from a larger pool and generalizes to the population. The researcher describes the following sampling processes that were used to select participants to take part in the study.
The sampling frame is described as the list of every member of the population from which the sample is drawn by Burns and Grove (2003:496) and Polit and Beck (2012:742). In this study the quantitative sampling frame included human resource registers of registered nurses working at PHC settings in Lesotho. The qualitative sampling frame included ART patient registers for HIV positive patients on ART and sought their treatment from PHC facilities.
Quota sampling was used in the quantitative strand of the study. de Vos et al (2011:232-233) explain that the main purpose of quota sampling is to draw a sample that has exactly the same proportions and characteristics as the target population and the sampling procedures rely on a convenience choice. Due to the mountainous nature of the terrain of Lesotho, the researcher included all 10 districts to give room to get input from the nurses found in each district. In total there are one hundred and sixty (160) health centres distributed across the country. With an average of three registered nurses (including midwives and clinicians) the target population was four hundred and eighty (480) nurses. The researcher used the Raosoft sample size calculator to estimate the total number of participants needed for the quantitative strand of the study and it was two hundred and fourteen participants (214).
Convenience sampling was used to select registered nurses/midwives/clinicians working in PHC settings to participate in the study. Polit and Beck (2012:724) define convenience sampling as selection of the available individuals as participants in a study and it is also referred to as accidental sampling. Burns and Grove (2003:248) explain that convenience samples are generally inexpensive, accessible and less time consuming although they are considered a poor approach as they provide little control for the control of bias as subject are included in the study because they happened to be in the right place at the right time. The researcher chose this sampling approach owing to the location of the facilities in regard to the topography of the country (see figure 2.1). Some of the health centres are only accessible by air whilst others are inaccessible due to poor road networks. Hence the researcher decided to meet with them during their district monthly planning meetings. Registered nurses working in the PHC settings were introduced to the researcher and study and asked to participate in the study during their monthly PHC planning meetings (hence the reason for convenience sampling method as it was most suitable).
Purposive sampling was used to recruit registered nurses who took part in the focus group discussions. Purposive sampling, also referred to as judgemental, theoretical or selective sampling, includes the conscious selection of participants for the study (Burns & Grove 2003:255; Polit & Beck 2012:517). Burns and Grove (2003:287) explain that when targeting professional groups, the participants can be known to each other and in such cases purposive sampling is used to recruit the participants. The researcher did not use the same registered nurses involved in the completion of the questionnaires. Two (2) focus group discussions were done for the registered nurses/midwives/nurse clinicians rendering ART services. The researcher invited five (5) registered nurses from two (2) health centre facilities found in two (2) adjacent districts (Maseru and Mafeteng districts) to participate in the first focus group discussions when they came for their statistical reporting meeting at a hospital responsible for the supervision of both clinics. The second focus group discussion involved three (3) registered nurses from another health facility in Maseru district. The interviews were conducted in English, as some of the participants were foreign nationals. Participants were asked to provide written consent to ensure confidentiality of information discussed in the focus groups.
Purposive sampling was also used to identify HIV/AIDS positive individuals who could participate in focus group discussions at the chosen health centre facilities. Again two rounds of focus group discussions were conducted. The first group had seven (7) participants and the second group had four (4) participants from Maseru and Mafeteng districts. As they came in for their regular ART services participants were introduced to the researcher and the study and asked to participate in the study.
For the quantitative strand of the study, the researcher used the Raosoft calculator to determine the sample size. There were a total of 160 health centre facilities and 40% (n=64) participated in the study. Convenient selection of the health centre was done according to accessibility within the district. With a total of one hundred and sixty (160) health centre facilities within Lesotho and an average of three registered nursing personnel working at each facility, in total there were four hundred and eighty (480) registered nursing staff serving the health centre facilities. With reference to the Raosoft calculator, using a confidence level of 95%, allowing a 5% error margin and a 50% response rate, a sample size of two hundred and fourteen (214) was found appropriate to adequately represent the population under study (www.raosoft.com/samplesize.html).
For the qualitative strand of the study, focus group discussions were conducted. According to Burns and Grove (2003:286), studies using focus group interviews usually include between one (1) and fifty (50) groups. According to Dickinson, Leech and Zoran (2009:[3-4]), the number of times a focus group meets can vary from a single meeting to multiple meetings. Onwuegbuzie et al (2009:[3-4]) ) explained that using multiple focus groups permits the researcher to assess the extent to which saturation was reached and the groups can be formed by pre-existing groups or newly formed groups. Onwuegbuzie et al (2009:[3-4])) suggested that three to six different focus groups are adequate to reach data saturation and/or theoretical saturation with each group meeting once or multiple times. In this study four (4) focus group discussions were conducted.
Burns and Grove (2003:287) stated that each focus group should have six (6) to ten (10) participants. Onwuegbuzie et al (2009:[3-4])) endorsed the use of very small focus groups which he referred to as ‘mini-focus groups’ which include 3 or 4 participants when participants have specialized knowledge and/or experiences to discuss in a group and further suggested over-recruiting by at least 20% to 50% of the total number of participants. In this study the smallest focus group had three (3) participants and the largest had seven (7) participants and a 43 % over recruitment rate.
TABLE OF CONTENTS
CHAPTER 1 ORIENTATION TO THE STUDY
1.3 RESEARCH PROBLEM
1.4 PURPOSE OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 DEFINITION OF TERMS
1.7 THEORETICAL FOUNDATIONS OF THE STUDY
1.8 RESEARCH DESIGN AND METHOD
1.9 ETHICAL CONSIDERATIONS
1.10 SCOPE AND LIMITATIONS
CHAPTER 2 LITERATURE REVIEW
2.2 THE KINGDOM OF LESOTHO
2.3 ART PROGRAM IN LESOTHO
CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY
3.2 PURPOSE OF THE STUDY
3.3 STUDY OBJECTIVES
3.4 STUDY SETTING
3.5 RESEARCH DESIGN
3.8 DATA COLLECTION INSTRUMENTS
3.9 DATA COLLECTION PROCESS
3.11 ETHICAL CONSIDERATIONS
3.12 DATA ANALYSIS
CHAPTER 4 ANALYSIS, PRESENTATION AND DESCRIPTION OF THE RESEARCH FINDINGS
4.2 QUANTITATIVE RESULTS
4.3 QUALITATIVE ANALYSIS
4.4 DATA INTEGRATION
4.5 OUTCOME OF THE STUDY: DESIGN AND VALIDATION OF THE TOOL
CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS
5.2 RESEARCH DESIGN AND METHOD
5.3 SUMMARY AND INTERPRETATION OF RESEARCH FINDINGS
5.5 CONCEPTUAL FRAMEWORK INTEGRATION
5.7 CONTRIBUTIONS OF THE STUDY
5.8 LIMITATIONS OF THE STUDY
5.9 CONCLUDING REMARKS
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