KILLED BIRTH ATTENDANCE AND MATERNAL AND NEONATAL HEALTH OUTCOMES

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CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY

INTRODUCTION

The research design and methodology employed to conduct the study “developing strategies to improve the utilisation of skilled birth attendance in West Gojjam zone, Ethiopia” is stated. The chapter reasserts the foundation of the research, explains the study design, study population, sampling and sampling designs, research tools, data collection procedures and data analysis. Trustworthiness and ethical considerations relevant to the study are also presented.

RESEARCH DESIGN

The research design used in a particular research largely determines the reliability of the research results and this comprises of the firm foundation of the entire structure of the research work. It is imperative to have a well thought out blueprint of the research plan for the smooth implementation of research operations as this would make the research as efficient as possible, yielding ample information with minimal expenditure of resources (Kothari 2009:32).
Kothari (2009:31) states that a research design is a conceptual structure within which a research is carried out and consists of the blueprint for data collection, measurement and analysis. Research designs are logical blueprints that link the research question, the data to be collected and strategies for data analysis with the ultimate goal of addressing the intended research questions (Yin 2010:75-76). Saunders et al (2009:136) also define a research design as an overall general plan of how the researcher will proceed to answer the research questions.
According to Creswell (2009:3), research designs are plans and procedures for research that range from broader assumptions to finer methods of data collection and analysis. The plan involves decision on which research design to be used to address a particular study topic. The selection of a research design depends on the nature of the research problem or issues being addressed, personal experiences of the researcher and the audience for the study.
The qualitative paradigm is concerned with describing and understanding human experiences of a particular phenomenon from the perspectives of the people who had or having the experience (Ellis 2010:10). Creswell (2009:4) also indicates that qualitative research is a means for exploring and understanding the meanings that individuals or groups ascribe to social or human problems. Therefore, a qualitative research paradigm was employed in this study to describe, understand and explore individuals and community perceptions and experiences regarding the utilisation of skilled birth attendance services and reasons for not utilising skilled birth attendance services. The following section presents the various aspects of the research design.

Qualitative aspect of design

According to Saldaña (2011:3-4), qualitative research is a broad term for a wide range of approaches and methods applied to study natural social life. Primarily, the nature of information or the data collected and analysed is non-numeric and comprises of textual materials such as interview transcripts, field notes, documents, visual materials, and these account for human experiences in social life. Qualitative research explores in-depth opinions from study participants’ attitudes, behaviours and experiences using interviews, focus group discussions and observations (Dawson 2007:15). Green and Thorogood (2004:5) contend that it makes sense to characterise qualitative research by the overall aims of the research not by the type of data collected and/or method employed to generate the data. The most basic features of qualitative research is that the aims are intended to address the ‘why’,’ how’ or ‘what’ of the phenomenon being investigated rather than research questions about the ‘how many’ or ‘how much’ (Green & Thorogood 2004:5; Pope & Mays 2006:3). Therefore, it was reasonable and appropriate to employ qualitative research in the current study as this research aimed at exploring and describing the perceptions and experiences of the individual and the community in the utilisation of skilled birth attendance service.
According to Pope and Mays (2006:4), qualitative research has different distinguishing features. The first distinguishing feature is its interpretative nature; the meaning the people give to their experiences in the social world and how they understand and interpret the social phenomena. The other characteristics are that qualitative studies are invariably conducted in the people’s natural settings and employ different qualitative research methods to study important questions about social phenomena. Yin (2010:8-9) also describes the five basic features of qualitative research as follows:
• It deals with researching the meanings of people’s lives in real life settings;
• It captures the views and perspectives of the study participants but not the values;
• Preconceptions and meanings held by the investigator;
• It covers the contextual issues in which the study participants actually reside;
• It helps to contribute new insights into the extant or emerging concepts; and
• It employs multiple sources of data.
Furthermore, qualitative research is best suited as a stand-alone design for research questions that cannot be addressed or are unfolded by quantitative research (Bowling & Ebrahim 2005:216; Pope & Mays 2006:5-6).
In this study, the qualitative aspect of the research design was used to explore and describe the individual and community perceptions and experiences of the utilisation of skilled birth attendance. Understanding the perceptions and experiences of the community on the utilisation of skilled birth attendance and reasons for not utilising skilled birth attendance was used to develop strategies to improve the utilisation of skilled birth attendance.

Descriptive aspect of the design

According to Polit and Beck (2010:21-22), the most important purpose of quantitative and qualitative research is the description of phenomena. The main purpose of descriptive studies is to « describe, observe, and document aspects of a situation » (Polit & Beck 2010:236). Descriptive research studies are studies concerned with portraying accurately, the characteristics of an individual or, of a group (Kothari 2009:37). Ruane (2005:12) also submits that descriptive research confers a detailed picture or account of some social phenomena, setting, experience, and group.
The purpose of social research may be categorised into three groups based on what the researcher is striving to accomplish and these include exploratory, descriptive and explanatory. Many social researches are descriptive in nature. Descriptive research depicts a picture of the specific details of a situation, social setting, or relationship; it focuses on how and who questions such as How did it happen? Who is involved? (Neuman 2007:16). Punch (2000:38) also states that to describe is to draw a picture of what happened, or of how things are proceeding, or of what a situation or person or event is (or was) like, or means, or of how things are related to each other. A descriptive study is designed to collect data, organise, analyse and present information about the issues being researched. It is also concerned with disentangling complicated issues into easily understandable and summarising of information into pragmatic generalisations or summarising details of situations.
Hence, in the current study, the descriptive aspect of the design was utilised by the researcher with respect to:
• individual and community perceptions of the utilisation of skilled birth attendance;
• individual and community experiences of the utilisation of skilled birth attendance;
• the experiences of offering skilled birth attendance by the health system; and
• the strategies formulated in this study to improve the utilisation of skilled birth attendance.

Explorative aspect of the design

Exploratory research instigates with the phenomenon of interest and studies the in-depth nature of the phenomenon, including its manifestation and other factors associated with it. Qualitative methods are well suited for investigating the full nature of little studied or known phenomena. Exploratory qualitative research is useful to explore the manner in which a phenomenon is manifested and the underlying processes (Polit & Beck 2010:22; Wood & Ross-Kerr 2011:121). Kothari (2009:2) indicates that a researcher conducts exploratory studies in order to be familiar with the phenomenon and get new insights of it. Exploratory research is carried out with the intention of getting insights with the research topic, or to be familiar with a phenomenon and for in-depth exploration of new or little studied matters. Exploratory research virtually generates data of a qualitative nature (Ruane 2005:12).
According to Saunders et al (2009:139-140), an exploratory study is an avenue to discern what is happening; to seek new insights; to ask questions and to asses phenomena in a new light. It is very helpful to understand the detailed nature of a problem. The flexibility and adaptability to change features of exploratory research makes researchers to change direction when new results emerge and new insights appear to the researcher (Wood & Ross-Kerr 2011:121). Saunders et al (2009:140) also pointed out three principal mechanisms of conducting exploratory studies which are conducting a literature review, expertise interviewing and focus group discussions.
In the current study, individual interviews and focus group discussions were employed to explore the individual and community experiences of the utilisation of skilled birth attendance, experience of offering skilled birth attendance by the health system and reasons for not utilising skilled birth attendance. A thorough exploration of these phenomena helped the researcher in the development of strategies to improve the utilisation of skilled birth attendance.

THE RESEARCH METHOD

According to Dawson (2009:37), Dawson (2007:28) and Ellis (2010:13), research methods are tools used to collect data for the inquiry. The research method to be used in the study is guided by the choice of research paradigm and subsequent research methodology. Greener (2008:10) also defines research methods as specific activities devised to generate data.
Dawson (2009:34-35) indicates that the budget, time and human resources as well as the purpose of the research need to be taken into account to determine the research method(s) to use in the research. In this study, the methods used to explore and describe personal and community perceptions and experiences of the utilisation of skilled birth attendance, and to explore reasons for not utilising skilled birth attendance are discussed in detail below, starting with the population for the study.
The research was done in two phases, which are interdependent. The phases were planned and conducted for compilation of evidence in preparation for and development of strategies.

PHASE 1

Phase 1 was collection, analysis and interpretation of empirical data for this study. The purpose of this phase was to explore and describe the individual and community perceptions and experiences of the utilisation of skilled delivery care in order to develop strategies to improve the utilisation of skilled birth attendance.

Population and sampling

Population

According to Treiman (2009:3), a population is any definable collection of things with common characteristics. The study population refers to all individuals on whom the study is going to be conducted (Smith, Francis & Schafheutle 2008:83). Gray, Williamson, Karp and Dalphin (2007:103) also indicate that a population encompasses all the possible cases of the research interest. The population of interest is dependent on the purpose of the research. Prior to formulating the sampling strategy, it is critical to agree on the definition of the study population, including the details of the inclusion and exclusion criteria as this is helpful for the researchers to assess the validity and reliability with which eligible study participants will be identified by any sampling strategy (Smith et al 2008:83). In this study, the study population were pregnant women, women who gave birth within one year, health extension workers, primary health care unit directors, midwives working on labour and delivery units, traditional birth attendants, district maternal health and youth reproductive health officers and heads of district health offices.
The target population is all the elements, individuals or members that meet certain criteria for inclusion in the study (Polit & Beck 2010:569). As stated earlier, the target population consisted of:
• women who were pregnant at the time and had previously given birth at least once;
• women who gave birth within one year;
• health extension workers who were working in health posts at the time and have at least two years of experience;
• director of the selected primary health care units;
• district health office maternal and youth reproductive health technical officers of the selected districts;
• heads of district health office; and
• traditional birth attendants who were functioning or had functioned as traditional birth attendants.

Sample and sampling technique

A sample is a specified number of study participants selected from the study population. A sample is studied to make a valid inference about the entire population without studying every element in that population. The main reason for selecting a sample rather than studying the entire population is to make an accurate conclusion about the whole study population in a more cost-effective and efficient way (Lyons & Doueck 2010:111; Maltby, Williams, McGarry & Day 2010:126; Polit & Beck 2010:307). A sample was selected from a large population of pregnant women, women who gave birth recently, health extension workers, primary health care unit directors, midwives working on labour and delivery units, traditional birth attendants, district maternal health and youth reproductive health officers and heads of district health offices.
Sampling is a process of selecting study participants to represent the study population (Brannen & Halcomb 2009:78; Polit & Beck 2010:307; Singh 2007:89). A sampling technique is a process of selection of study respondents to represent the entire population that would enable to estimate the population parameters. It also refers to procedures or techniques that researchers would employ to obtain samples from the total population (Kothari 2009:55); and it includes non-probability (non-random) sampling techniques (Saunders et al 2009:213). A non-probability sampling, namely purposive sampling, refers to the chance of each study subject being selected from the total population (Saunders et al 2009:213). A non-probability sampling method was used in this study. Sample size is the number of study subjects in the sample and is affected by the research approached applied, for instance, quantitative versus qualitative (Polit & Beck 2010:316).
Sampling or eligibility criteria are the characteristics that delimit the population of interest. It further indicates that a study may have inclusion or exclusion sampling criteria (or both). The inclusion sampling criteria are those characteristics that a subject must possess to be part of the target group whilst the exclusion sampling criteria are those characteristics that can cause a person or subject to be excluded from the target population (Polit & Beck 2010:306). The researcher included women who were pregnant at the time of data collection and had given birth atleast once and women who gave birth within one year, and willing to provide informed written consent for the FGD. Furthermore, HEW who have worked atleast for two years in the selected health post, head of the PHCU, head of the district health office, maternal, reproductive, and youth health technical officers, and TBA who had functioned or currently functioning at the time of data collection, and willing to provide informed written consent included for the individual in-depth interview. Those who failed to meet the afformentioned inclusion criteria were excluded from the study.

Sampling of study sites

The non-probability sampling technique is useful when researchers cannot make sure that every unit in the population has an equal chance of being selected or do not need a sampling frame. Purposive sampling involves the selection of study subjects based on the researchers’ predefined selection criteria (Balnaves & Caputi 2001:95). In a purposive sampling, study participants are selected based on predefined criteria that are relevant to address specific research questions (Mack, Woodsong, Macqueen, Guest & Namey 2005:5). Therefore, a purposive sampling technique was used to select study sites in this study.
A multistage purposive sampling technique was used to select study sites in this research. Primarily, the Amhara regional state administration was purposively selected for this study because the skilled delivery coverage rate was very low (10.3%) in the region as it was reported in a 2014 mini Ethiopian demographic and health survey (Central Statistical Agency 2014:46). Then, West Gojjam zone was purposively selected because it is one among the eleven zones under the direct supervision of Amhara regional state administration and are among the zones with the lowest skilled delivery coverage in the region. Thereafter, Burie zuria and Womberema districts were also purposively selected because they are among the districts under the supervision of West Gojjam zone health department and are among the districts consisting of good and poor performing primary health care units (PHCUs) with respect to skilled birth attendance services.
Furthermore, Burie zuria district health office comprises of four PHCUs under its supervision namely; Tiatia, Kuche, Alefa and Dereqwua PHCUs and all of them were included in this study. Womberema district health office also consists of four PHCUs and three of them viz.; Shendi, Koki and Wogedade PHCUs were represented in the current study. Finally, one health post and one health centre was selected from each of the PHCUs. As a result, a total of seven health posts and seven health centres were included in this study. The details of the sampling of the study sites are portrayed in the following diagram (Figure 3.1).

Sampling of study subjects

Purposive sampling was used to select the study participants in this study. The study participants were composed of as follows:
• Pregnant women;
• Women who gave birth within one year;
• Health extension workers (HEWs);
• Primary health care unit directors;
• Midwives who were working in the maternity unit at the time;
• District health office maternal and youth reproductive health technical officers;
• Head of district health office; and
• Traditional birth attendants.
Purposive sampling is the main strategy for sampling in qualitative research and is defined as selection of study subjects to meet the needs of the study. These study subjects may be individuals who have knowledge of or experience with the research topic of interest or other sources of data that would help the researchers to comprehensively understand the area of interest (Waltz, Strickland & Lenz 2005:221). The women who were pregnant at the time and had previously given birth at least once were purposively selected because they had the experience of giving birth either at home, in a health facility or both.
The researcher selected the majority of women who gave birth within one year were also included because these women had the experience of giving birth at health facilities or at home, which enabled the researcher to comprehensively understand their perceptions and experiences.
Health extension workers who were working in the selected health posts at the time and have at least two years of experience in that specific health post were selected because they had adequate knowledge on the topic of research or had experience of referring or linking and monitoring women for skilled birth attendance.
The researcher selected primary health care unit directors because they were knowledgeable or had the experience of offering skilled birth attendance services for the catchment population. Besides, midwives who were providing skilled birth attendance services and heads of the maternity unit in the respective health centres were selected as they were responsible for providing skilled birth attendance services and overall management of the maternity unit.
The district health office’s maternal and youth reproductive health technical officers were selected because they were the technical lead, coordinate and manage with regard to the skilled birth attendance services in the district. As a result, they have the knowledge and experiences to address the topic of interest of the researcher.
The heads of district health office were purposively selected for the current study. Presumably, they were responsible for the overall management, coordination and leadership of the district health office, both technical and administrative activities so that they became key sources of information to address the research questions.
Traditional birth attendants who were functioning or had functioned as traditional birth attendants were also purposively selected because they had the awareness and experience regarding the utilisation of skilled birth attendance in the community.

Sample size

According to Marvasti (2004:10) and Polit and Beck (2010:316), the sample size is the number of study participants in the sample. In qualitative research, there are no hard and fast rules for sample size. The size participants in a study is determined by the information needs of the research and guided by the principles of data saturation in which the investigator stops sampling when no new information is emerging or redundancy is achieved (Polit & Beck 2010:321). Smith et al (2008:90) further indicate that a saturation sampling technique is an approach often employed in qualitative studies. In this approach, the researcher will keep on sampling the study subjects until no new idea is generated in the data. This works well in exploratory studies where the purpose of the research is to explore the perspectives and concerns on the topics of the research from the study participants’ point of view. Hence, the current study employed this approach as it is utilising an exploratory study design to address the research questions.
The optimum sample size required to reach data saturation depends on a number of factors. The scope of the research questions, data quality, characteristics of participants (ability to reflect and effectively communicate their experiences), longitudinal data collection, type of sampling strategy employed and type of qualitative inquiry to determine the size of study subjects are needed to measure data saturation (Polit & Beck 2010:321). Therefore, the sample size for the different study participants was determined by the saturation of information during data collection and the number of individual interviews and FGDs conducted with various study participants is depicted in table 3.1.

Pilot study

Polit and Beck (2010:563) define a pilot study as “a small-scale version or trial run, done in preparation for a major study.” The main purpose of undertaking a pilot study is to fine-tune the data collection tools and as a result, study participants will have no problems in responding to questions and there will be no problems in recording the data. Furthermore, it enables the researcher to evaluate the validity of the questions and the likelihood of reliability of the data that will be collected (Saunders et al 2009:394). Willig (2013:162) argues that a pilot study enables the researcher to refine the research questions and provides useful information about the potential difficulties or challenges the researcher may encounter during the actual study. A pilot study ensures the examination of the acceptability and feasibility of study procedures and allows the researcher to check whether the data collected will address the research objectives (Smith et al 2008:16).
In this study, the researcher conducted a pilot study in one district health office, one health centre and two health posts that were not among the selected study sites for the actual research. The pregnant women, women who had recently given birth, health extension workers, PHCU directors, midwives, district health office heads and maternal and youth reproductive health technical officers were selected from the respective health posts, health centres and district health offices. This exercise helped in estimating the time required to conduct the interviews and FGDs, to improve the interview guides and questions, to check for appropriateness of data collection procedures and to familiarise the researcher with the data recording materials such as the audiotape recorder.

Data collection

Data collection approaches, methods and processes

Lyons and Doueck (2010:134) define data collection as the gathering of data from various data sources. Fitzpatrick & Wallace (2006:125) indicate that data collection is collecting a piece of information to address the research objectives. Yin (2010:130) refers to data collection as a collection of organized information, usually the result of experience, observation, experiment etc. and may consist of numbers, words, or images, particularly measurements or observations of a set of variables. According to Willig (2013:91), the objective of data collection in qualitative research is to create a comprehensive record of participants’ words and actions.
The choice of a method of data collection depends on the research questions and the nature of the problem or setting (Berg 2001:182; Wood & Ross-Kerr 2011:171-172). The qualitative data collection methods of in-depth interviews and group discussions are useful to generate rich, detailed data through the expression of participants’ own perceptions and experiences (Ulin, Robinson & Tolley 2005:71). The current study aimed to address the research questions related to the perceptions and experiences of the community regarding the utilisation of skilled birth attendance services. In this study, in order to answer the research questions in detail, individual in-depth interviews and focus group discussions were used.

Individual in-depth interviews

An in-depth interview is a structured encounter between the researcher and the research participants with the aim of generating information. Interviews relatively provide a practical, flexible and economical way of gathering research data (Carter & Henderson 2005:215). Ulin et al (2005:81-82) define in-depth interviews as an exchange between one researcher and one respondent to generate empirical data by enabling participants to talk freely about their lives. For this study, the conversation was between the researcher and study participants (HEWs, PHCU directors, district health office heads and technical officers, and traditional birth attendants) to describe and explore the perceptions and experiences of the community with regard to the utilisation of skilled birth attendance services. The purpose of interviewing participants is to generate and document information, in their own words, individuals’ or groups’ perspectives, feelings, opinions, values, attitudes and beliefs about their personal experiences and social world, in addition to the factual information about their lives (Saldaña 2011:32).
The researcher conducted individual in-depth interviews with health extension workers, PHCU directors, midwives, district health office head and maternal, youth reproductive health technical officers, and traditional birth attendants. In this respect, the study participants were interviewed to provide information about their perceptions and experiences of the community with regard to the utilisation of skilled birth attendance services.

Focus group discussion

According to Ulin et al (2005:89), a focus group is the use of group interaction to produce data and insights that would be less accessible without the interaction found in a group. A focus group is also defined as a qualitative data collection method in which researchers and groups of participants meet to discuss a given research topic. It helps researchers to learn the social norms of a community as well as the range of perspectives that prevail in the community (Mack et al 2005:51). In this study, the researchers, pregnant women and women who recently gave birth met as a group to discuss personal and community perceptions and experiences on the utilisation of skilled birth attendance services.
The researcher conducted focus group discussions with pregnant women and women who recently gave birth.

TABLE OF CONTENTS
CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 AIM OF THE STUDY
1.5 RESEARCH QUESTIONS
1.6 SIGNIFICANCE OF THE STUDY
1.7 DEFINITION OF TERMS
1.8 THEORETICAL FRAMEWORK
1.9 RESEARCH DESIGN AND METHODOLOGY
1.10 ESTABLISHING TRUSTWORTHINESS
1.11 ETHICAL CONSIDERATIONS
1.12 STRUCTURE OF THE THESIS
1.13 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 DESCRIPTION OF THE THEORETICAL FRAMEWORK
2.3 FACTORS AFFECTING THE UTILISATION OF SKILLED BIRTH ATTENDANCE SERVICES
2.4 THE THEORTICAL CONCEPT OF SKILLED BIRTH ATTENDANCE
2.5 PROGRESS TOWARDS MILLENNIUM DEVELOPMENT GOAL 5
2.6 DETERMINANTS OF UTILISATION OF SKILLED BIRTH ATTENDANTS
2.7 REASONS FOR NON-UTILISING SKILLED BIRTH ATTENDANCE
2.8 SKILLED BIRTH ATTENDANCE AND MATERNAL AND NEONATAL HEALTH OUTCOMES
2.9 INTERVENTION STRATEGIES TO IMPROVE THE UTILISATION OF SKILLED BIRTH ATTENDANCE
2.10 CONCLUSION
CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY
3.1 INTRODUCTION
3.2 RESEARCH DESIGN
3.3 THE RESEARCH METHOD
3.4 PHASE 1
3.5 PHASE II
3.6 ESTABLISHING TRUSTWORTHINESS
3.7 ETHICAL CONSIDERATIONS
3.8 CONCLUSION
CHAPTER 4 PRESENTATION, ANALYSIS, AND DESCRIPTION OF THE RESEARCH FINDINGS
4.1 INTRODUCTION
4.2 DATA MANAGEMENT AND ANALYSIS
4.3 BIOGRAPHICAL PROFILE OF THE PARTICIPANTS
4.4 ANALYSIS OF DATA OBTAINED FROM THE PARTICIPANTS
4.5 CONCLUSION
CHAPTER 5 DISCUSSION OF THE STUDY FINDINGS
5.1 INTRODUCTION
5.2 BIOGRAPHICAL PROFILE OF THE PARTICIPANTS
5.3 SKILLED BIRTH ATTENDANCE (SBA) SERVICES THAT CREATED GOOD EXPERIENCES FOR WOMEN
5.4 CAUSES OF DISAPPOINTMENT OF WOMEN WITH THE UTILISATION OF SKILLED BIRTH ATTENDANCE SERVICES
5.5 REASONS FOR NOT UTILISING SKILLED BIRTH ATTENDANCE SERVICES
5.6 FACTORS THAT INFLUENCED THE UTILISATION OF SKILLED BIRTH ATTENDANCE SERVICES
5.7 FACTORS THAT MOTIVATE WOMEN TO UTILISE SKILLED BIRTH ATTENDANCE SERVICES IN THE CURRENT AND FUTURE PREGNANCIES
5.8 COMMUNITY SUPPORT FOR WOMEN TO UTILISE SKILLED BIRTH ATTENDANCE SERVICE
5.9 PERCEIVED BENEFITS OF SKILLED BIRTH ATTENDANCE SERVICE
5.10 STRATEGIES IMPLEMENTED TO IMPROVE THE UTILISATION OF SKILLED BIRTH ATTENDANCE SERVICES
5.11 CHALLENGES OF OFFERING SKILLED BIRTH ATTENDANCE SERVICES IN HEALTH FACILITIES
5.12 CONCLUSION
CHAPTER 6 STRATEGIES TO IMPROVE THE UTILISATION OF SKILLED BIRTH ATTENDANCE SERVICES
6.1 INTRODUCTION
6.2 PRELIMINARY STRATEGIES
6.3 INTERIM STRATEGIES
6.4 VALIDATION OF THE STRATEGIES
6.5 FINAL STRATEGIES
6.6 CONCLUSION
CHAPTER 7 CONCLUSION AND RECOMMENDATIONS OF THE STUDY
7.1 INTRODUCTION
7.2 CONCLUSION
7.3 RECOMMENDATIONS
7.4 FURTHER RESEARCH
7.5 CONTRIBUTION OF THE STUDY
7.6 LIMITATIONS
LIST OF REFERENCES
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