CHAPTER 4: PHASE 2 IDENTIFICATION OF STRATEGIES RESEARCH METHODOLOY, DATA PRESENTATION, INTERPRETATION AND LITERATURE CONTROL
Chapter 4 presents Phase 2, the process according to the Systems Model of the study (refer to Figure 1.1 and Section 1.8). The aim of Phase 2 was to identify strategies to form the basis for the development of the strategic action plan to enhance accessibility to health care in rural areas of Zimbabwe (refer objective 5, Study Phase 2). This discussion portrays all the processes involved in Phase 2; the methodology, the data collection process, data presentation, analysis, interpretation, and the literature control are discussed.
Qualitative research focuses on getting profound and important information from small groups which fulfill a certain standard set out by the researcher (Polit & Beck 2012:342). It involves interactive, inductive and flexible ways of data collection and analysis (Onwuegbuzie & Combs 2010:3; Polit & Beck 2012:342). During Phase 2, the researcher used the nominal group technique (NGT), which is a qualitative data collection method.
The qualitative approach was used to collect data from the national health directors as essential stakeholders to produce outputs according to the Systems Model. The quantitative data gathered in Phase 1 (inputs), informed and supported the qualitative data gathering process of Phase 2 (outputs).
The population for Phase 2 was the national health directors in the MoHCC. There were 15 national health directors (Departmental Directors) in the MoHCC head office.
Convenient sampling was done to recruit all the national health directors (15) for inclusion in the study. All available national health directors were invited to participate in the nominal group session.
PROCESS/UNIT OF ANALYSIS
The gatekeeper (Principal Director for Planning, Policy, Monitoring and Evaluation), on behalf of the Permanent Secretary for Health, invited all 15 national health directors for the NGT using information letters (Annexure N). The gatekeeper agreed with the participants and the researcher on the date, time and venue of the meeting, 3 months before the actual date for the nominal group session. The initial date for the nominal group session was 26 November 2015. The researcher invited an experienced facilitator to enhance the credibility of the study as discussed under sections 4.7.1 and 4.8.1 in this chapter. The researcher booked and paid for the facilitator’s plane ticket, as well as the facilitator’s hotel accommodation. A conference room was reserved for the NGT data collection process. Four days before the 26th November 2015, the gatekeeper realised that the date was clashing with another MoHCC planning meeting. The researcher was advised to postpone the nominal group session. The researcher had to postpone the plane ticket, cancel the hotel booking and venue reservation that was already made. The date, time and venue were followed up with the gatekeeper several times, and it was finally agreed that the nominal group will be facilitated on 6 April 2016.
On 5 April 2016, the gatekeeper confirmed the attendance of 15 national health directors and the arrangements were made accordingly. On 6 April 2016, despite confirmation of the gatekeeper that all national health directors were willing to participate, at 10.00 am, the time arranged for the NGT session, only 2 members arrived. The researcher contacted the gatekeeper to confirm the attendance of the other members and to inform him that more participants were required for the NGT session. The facilitator invited the 2 participants for tea while waiting for other participants. The facilitator and the researcher had to be patient to avoid postponing the session again.
One of the participants in attendance then contacted her colleagues as she assured the researcher of the importance of the research and their willingness to participate. At 11.30 am, another 3 national health directors arrived, and the facilitator, researcher and present participants agreed to start with the nominal group session.
Five national health directors were enough to conduct a NGT as 5-15 participants could still allow for the quality and diversity of ideas (Delp, Thesen, Motiwalla & Seshardi 1977:15 cited in Harvey & Holmes 2012:190; Fournier, Escourrou, Dupouy, Bismuth, BIrebent, Simmons, Poutrain & Oustic 2014:3).
DATA COLLECTION INSTRUMENT: THE NOMINAL GROUP TECHNIQUE
A NGT is a group process for gathering opinions, aggregating judgments, and reaching consensus to increase rationality and creativity when resolving complex problems such as accessibility to health care in rural areas (Delbecq, Van de Ven & Gustafson 1975 cited in Harvey & Holmes 2012:190; Fournier et al 2014:2; McMillan, Kelly, Sav, King, Whitty & Wheeler 2014:2). According to the application of the Systems Model, the NGT was the process used to develop outputs, that is, the strategies for the strategic action plan to enhance accessibility to health care in rural areas of Zimbabwe. The nominal group process permitted in-depth exploration of and eliciting information from the stakeholders during the development of the strategies for the strategic action plan that might enhance accessibility to health care in rural areas of Zimbabwe.
The NGT is a highly structured method which facilitates the generation and discussion of participant ideas, thereby eliciting and comparing opinions and reaching consensus on priorities (O’Connor, Cerin, Hughes, Robles, Thompson, Baranowski, Lee, Nicklas & Shewchuk 2013:2) identified by national health directors, since they were from different departments.
When comparing the NGT with other group processes, such as the Delphi (Delbecq et al 1975 cited in Harvey & Holmes 2012:190), focus groups and brainstorming, the NGT has many advantages over other group processes (Fournier et al 2014:4). This served as the motivation for using the nominal group to develop the strategies.
One of the advantages is that one participant in the group cannot dominate the discussion and it constrains the group leader to have less influence (and therefore less potential bias), as may occur in traditional focus groups (O’Connor et al 2013:2; Fournier et al 2014:4). In this study, the researcher instructed the participants to individually write down strategies that can be used to enhance accessibility to health care in rural areas of Zimbabwe during the NGT. The fact that every individual participant had an opportunity to respond in an orderly manner showed no influence of dominant participants. The subsequent contributions ended with voting, providing all the participants equal opportunity to fairly contribute and provide independent opinions. Since qualitative methods are used to explore people’s ideas, the reasons why problems occur, and what people see as possible solutions and constraints, surfaces. This allowed the researcher and participants to conduct an in-depth inquiry into solutions to enhance accessibility to health care in rural areas of Zimbabwe, from the national health directors’ perspectives.
Another advantage is that the NGT allows for the quick development of a list of consensual and ranked answers to a precise question. In this study, it took 5 participants 90 minutes to reach consensus (Fournier et al 2014:5). This method has been used extensively for a wide range of general practice related purposes, including the exploration of emergent concepts or identification of educational needs. Thus, the researcher felt that it would be appropriate to use it to elicit strategies from the national health directors (Fournier et al 2014:2). The focus instruction of the group meeting was exploratory as it probed participants to set strategies from the findings, and was clear to the participants. This facilitated the participants to make a meaningful contribution.
Participants were directly involved in both data collection and analysis and therefore researcher-bias was minimised. The process followed facilitated task completion and the immediate dissemination of the consensus strategies to the group, which fostered participation satisfaction (Hiligsmann, Salas, Hughes, Manias, Gwadry-Sridhar, Linck & Cowell 2013:134).
The disadvantage of a NGT is that some participants feel the process is perfunctory (Fournier et al 2014:5). This was avoided to some extent as the experienced facilitator allowed detailed discussions during the process while ensuring that the procedures of nominal group processes were adhered to.
A NGT can also be challenging to implement effectively with many participants, unless it is planned very carefully beforehand. In this study, the group was planned in advance and was conducted with 5 national health directors. The participants were selected based on their expertise on health care issues, they were representative of their profession (nurses, pharmacists, environmental health specialists and doctors), and they had the power to implement the findings since they were national health directors.
DATA COLLECTION (NOMINAL GROUP) PROCESS
After ethical approval (Annexure A) and informed consent (Annexure R) was obtained from all the participants, data were gathered through the NGT and the steps followed were those described by Delbecq et al (1975:41 cited in Harvey & Holmes 2012). An experienced facilitator facilitated the process.
The researcher used a facilitator who is an expert in nominal group facilitation and therefore was familiar and comfortable with the group meeting process, providing quality leadership during the process. The facilitator had extensive experience in facilitating nominal groups at both national and international levels. She had a PhD degree, a nursing degree, and was trained in communication and counselling skills. She, therefore, was the ideal person to facilitate the nominal group with stakeholders in a health-related field.
A Holiday Inn hotel in Zimbabwe, close to the offices of the MoHCC head office, the workplace of all stakeholders, was selected and agreed on by the participants as the ideal venue for the NGT session. A spacious room with the capacity to host 17 people was selected.
The venue was prepared for 15 participants, the facilitator and the researcher. The seating arrangement was a U-shape pattern to ensure that all the participants could see the flip chart, the overhead projector, and one another. The seating arrangements allowed enough space behind chairs for participants to freely move around. The room was well lit and conducive to open discussion. Participants indicated that they were comfortable in the venue.
The facilitator and researcher ensured that every seating place had a pen, notepad, and 5 index cards. Flipcharts and markers, a laptop and a screen were placed at the open end of the seating arrangement (Delbecq et al 1975:41 cited in Harvey & Holmes 2012).
The nominal group was conducted in two separate sessions to ensure that all participants (stakeholders) were well informed about the data gathered during Phase 1 of the study. They were, therefore, able to take note of the voice of the health care users as well as the professional nurses in developing the strategies.
Session 1 – Presentation of findings of Phase 1 to nominal group participants
The researcher welcomed all the participants and the facilitator. He explained the purpose of having the nominal group in two sessions, as well as the importance of both sessions.
A PowerPoint presentation with a summary of the key findings from Phase 1 was presented by the researcher. The purpose of the presentation was to enlighten the participants about the challenges and opportunities experienced by professional nurses and health care users in the field as they are the important stakeholders. This information was necessary to ensure that participants develop relevant strategies based on the evidence from the field. The findings presented were based on the Systems Model, which purports that a successful health care system requires inputs that include physical resources, material resources, human resources, financial resources, and managerial resources (refer to Section 1.8). After the presentation, the group shared a coffee break before the NGT commenced as session 2 .
Session 2: Nominal group technique (NGT) data gathering process
The facilitator gave the participants the information leaflet that explained the purpose of the research, for them to read and to make sure it was understood (refer Annexure N). Participants were asked to read the information and sign the consent form if they agreed to participate in the study. If they wished to withdraw from the study, there was no penalty. All 5 participants were willing to participate and signed the consent form.
The facilitator summarised the researchers’ presentation of the findings of Phase 1 to set the scene for the development of the strategies. The facilitator re-emphasised the reasons for including the national health directors as important stakeholders in the study that focused on developing strategies for the strategic action plan to enhance accessibility to health care in rural areas of Zimbabwe. The process, as well as the advantages of abiding to the NGT steps, was explained by the facilitator to ensure that the participants were familiar with the rules that apply and the structure of the process. One of the participants asked whether they can simply discuss the topic rather than having a formal nominal group discussion. The facilitator explained the difference between the NGT and focus group discussions, in that the NGT is used for decision-making by consensus. Each participant had a chance to freely contribute to decision-making without interference from other participants, unlike in formal group discussions where it is not a systematic discussion. The participants were satisfied and agreed to commence with the NGT. Participants indicated after the NGT that this was a very positive experience and can be used to gather information or discuss any topic where consensus needs to be reached at governmental level.
After the process of the NGT was clearly explained to the participants, the facilitator read the instructions to the participants in simple and clear terms for their clarity and understanding. Every participant also received the typed instructions:
Please write down the strategies you think can enhance accessibility to health care in rural areas of Zimbabwe?
Please provide a numeric number in front of every strategy that you propose.
The facilitator repeated the instructions 3 times to ensure the participants understood what was expected of them. The participants were requested to silently generate the strategies as individuals in Step 1.
TABLE OF CONTENTS
CHAPTER 1: ORIENTATION TO THE STUDY
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 THE PURPOSE OF THE STUDY
1.5 RESEARCH OBJECTIVES
1.6 THE SIGNIFICANCE OF THE STUDY
1.7 DEFINITIONS OF KEY TERMS
1.8 OPERATIONAL DEFINITIONS
1.9 META-THEORETICAL/THEORETICAL GROUNDING
1.10 RESEARCH DESIGN
1.11 ETHICAL CONSIDERATION
1.12 SCOPE OF THE STUDY
1.13 STRUCTURE OF THE DISSERTATION
CHAPTER 2: LITERATURE REVIEW ON ACCESSIBILITY TO HEALTH CARE AND THE SYSTEMS MODEL
2.2 THE SYSTEMS MODEL
2.3 HEALTH CARE SERVICES
2.4 ACCESSIBILITY TO HEALTH CARE
2.5 FACTORS ASSOCIATED WITH ACCESSIBILITY TO HEALTH CARE (INPUTS)
2.9 SUMMARY .
CHAPTER 3: PHASE 1 RESEARCH METHODOLOGY, DATA ANALYSIS, PRESENTATION AND INTERPRETATION
3.2 RESEARCH DESIGN
3.3 QUANTITATIVE RESEARCH (Phase 1)
3.6 DATA COLLECTION INSTRUMENTS
3.7 PRE-TESTING OF THE DATA COLLECTION INSTRUMENTS
3.8 RELIABILITY AND VALIDITY OF DATA GATHERING INSTRUMENTS
3.9 ETHICAL CONSIDERATIONS
3.10 DATA COLLECTION PROCESS
3.11 DATA ENTRY AND ANALYSIS
3.12 DATA PRESENTATION ANALYSIS AND INTERPRETATION
3.13 PHYSICAL RESOURCES (SYSTEMS MODEL INPUT)
3.14 MATERIAL RESOURCES INPUTS – ACCESSIBILITY TO MEDICAL SUPPLIERS
3.15 HUMAN RESOURCES (Systems Model input)
3.16 SERVICES AVAILABLE AND ACCESSIBLE AT THE RURAL HEALTH FACILITIES
3.17 WAITING TIME AT THE HEALTH FACILITY
3.18 HEALTH CARE USER FEES
3.19 TRADITIONAL HEALTH CARE SERVICES
3.20 ACCESSIBILITY TO THE REFERRAL HEALTH FACILITIES
3.21 MANAGEMENT SUPPORT TO PROFESSIONAL NURSES (Management Resources input)
3.22 IMPORTANT FACTORS FACILITATING ACCESSIBILITY TO HEALTH CARE SERVICES AS INDICATED BY HEALTH CARE USERS
CHAPTER 4: PHASE 2 IDENTIFICATION OF STRATEGIES RESEARCH METHODOLOY, DATA PRESENTATION, INTERPRETATION AND LITERATURE CONTROL
4.2 QUALITATIVE RESEARCH
4.5 PROCESS/UNIT OF ANALYSIS
4.6 DATA COLLECTION INSTRUMENT: THE NOMINAL GROUP TECHNIQUE
4.7 DATA COLLECTION (NOMINAL GROUP) PROCESS
4.9 DISCUSSION OF THE FINDINGS AND LITERATURE CONTROL .
CHAPTER 5: THE DEVELOPMENT OF THE DRAFT STRATEGIC ACTION PLAN
5.2 THE STRATEGIC ACTION PLAN
5.3 FORMULATING THE STRATEGIC ACTION PLAN
CHAPTER 6: PHASE 4: THE VALIDATION PROCESS METHODOLOGY AND VALIDATION OF THE STRATEGIC ACTION PLAN
6.2 POPULATION AND UNIT OF ANALYSIS
6.3 DATA COLLECTION PROCESS (validation process)
6.4 THE VALIDATION PROCESS
6.5 STEP 4: REVIEW OF ALL COMMENTS AND DEVELOPMENT OF THE SECOND DRAFT STRATEGIC ACTION PLAN
6.6 STEP 5: VALIDATION OF THE STRATEGIC ACTION PLAN THROUGH VIRTUAL MEETING
6.7 TRUSTWORTHINESS IN THE DEVELOPMENT OF THE STRATEGIC ACTION PLAN
6.8 STRENGTHS AND LIMITATIONS OF THE STRATEGIC ACTION PLAN
6.9 SUMMARY ..
CHAPTER 7: CONCLUSIONS AND RECOMMENDATIONS
7.1 INTRODUCTION .
7.3 RECOMMENDATIONS FOR IMPLEMENTATION AND SHARING OF THE STRATEGIC ACTION PLAN
7.4 CONTRIBUTIONS OF THE STUDY
7.5 RECOMMENDATIONS FOR FUTURE STUDIES
7.6 LIMITATIONS OF THE STUDY
7.7 CONCLUDING REMARKS
LIST OF REFERENCES
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STRATEGIES TO ENHANCE ACCESSIBILITY TO HEALTH CARE IN RURAL AREAS OF ZIMBABWE