THE STRUCTURE OF THE ELEMENTS OF A PMTCT PRACTICE MODEL

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CHAPTER 3 RESEARCH DESIGN AND METHOD

INTRODUCTION

The previous chapter gave a detailed discussion on relevant literature reviewed regarding PMTCT. It also highlighted the challenges experienced by the women on the PMTCT programme. Finally it addressed the systems theory in relation to the PMTCT programme. As this study was conducted in two phases, this chapter provides detailed information regarding methodology for each phase. Phase one provides a detailed process of the situational analysis on the experiences of PMTCT clients. Phase two provides detailed process followed for the model development.

PHASE ONE: SITUATIONAL ANALYSIS

Phase one describes detailed information on the research paradigm, approach, design and methodology for the situational analysis. A description of the study site, sampling method, data collection and analysis is also provided. Measures to ensure trustworthiness and ethical considerations for the study are also provided in this section

Research Paradigm

According to Kuhn (2011:1), a research paradigm is a framework that contains acceptable views or beliefs about a subject or a pattern of thinking of a person. The paradigm formed a critical role, in that it provided a structure and direction of how the research was undertaken and how the results were interpreted. In this study an interpretivist paradigm was utilised. This paradigm according to Green and Martelli (2015:22) has its origins in sociology and phenomenology. The authors further indicate that interpretivism is more common in social sciences, the domain within which PMTCT services fall. This paradigm assumes that people are social actors on their environment and thus promote the idea that subjective thought and ideas are valid. Within this perspective, the lived experiences of the PMTCT programme as experienced by the participants were explored.
This paradigm reflects the epistemological, ontological and methodological assumptions of the study. Hofstee (2011:88) indicates that assumptions are beliefs or views that are taken to be true by the researcher with or without evidence based testing of the truth. According to Bryman (2012:30-32) assumptions are enmeshed in the philosophical foundation or paradigm for the study and form the base line for research design and interpretation of research findings. Below is a reflection of the epistemological, ontological and methodological assumptions of the study:

Epistemological assumptions

Epistemology according to Greener and Martelli (2015:41) is a debate or assumption of how knowledge is generated. The researcher belongs to the school of epistemology that postulates that knowledge is a social construct and that individuals experience a phenomenon in a unique way and hence requires detailed exploration. In this context, the researcher aimed at generating knowledge from the perspective of participants involved in the study, to understand their actions which are influenced by their social world (Bryman et al 2014:15). In this study the epistemological assumptions were as follows:
Narrative data from the in-depth interviews would reveal the experiences of PMTCT clients. Exploring these experiences would form the baseline for determining the level of utilisation and acceptance of the programme and will be utilised to improve the quality of PMTCT services.
The research participants would be able to narrate their experiences as lived by them. These would be unique for each participant.
The research process would continue until saturation of rich data, about the experiences of PMTCT clients have been obtained.
Model development in this study will enhance the care made available for PMTCT clients.

Ontological assumptions

Apart from their specific epistemology, the interpretivists have their own ontology. Ontology is a philosophical perspective of reality (Curtis & Drennan 2013:21). According to Bryman (2012:32), ontology refers to the nature of social reality. Within the interpretivist context, reality is assumed to be socially constructed. As an interpretivist, the researcher’s assumptions were as follows:
Human beings are social and unique in nature. Participants would be able to narrate their experiences as lived by them and these would be distinctive.
Reality/meanings are socially constructed during social interaction.
Multiple realities exist with regards to the experiences of PMTCT clients and therefore these were explored individually using a qualitative approach.

 Methodological assumptions

Methodological assumptions provide structure and direction of how the research is to be carried out scientifically. This implies that reality is a social construct that is flexible, has emergent properties and is influenced by an individual’ experience and context (Bryman 2012:36).
Phenomenological research approaches generated data inductively and this data will form the baseline for model development.
In qualitative research data is collected in naturalistic settings with the view that knowledge is social determined and is contextual.
According to Bryman et al (2014:32), interpretivists assert that social phenomenon and their meanings are established during social interaction and are in a state of continuous change.
The above mentioned paradigm was used to establish the meaning about the lived experiences of PMTCT clients during the utilisation of PMTCT services. In this context, the researcher aimed at generating knowledge from the perspective of women of the PMTCT programme. As a point of departure, this paradigm formed the philosophical foundation of exploring the lived experiences of HIV positive PMTCT clients as they utilised the PMTCT services. This in turn reflected the services offered and how the PMTCT programme was interpreted by clients, and how they felt about certain practices and different treatment they experienced. The researcher belongs to the school of thought that holds that there are multiple realities in knowledge generation. The researcher assumed that what was previously side-lined or ignored would emerge. Therefore this philosophical perspective influenced the research methodologies to gaining knowledge in this study.

Research Approach

This study took a qualitative research approach. According to Polit and Beck (2012:60) in qualitative studies, the researcher collects primarily qualitative data that is narrative descriptions. Narrative information can be obtained by having conversations with the participants, by making detailed notes about how participants behave in naturalistic settings. Qualitative research according to Houser (2012:36) is based on a naturalistic paradigm. This belief system is represented by a view of reality that is constructed by the individual, not the researcher. In the naturalist view, reality is not a fixed entity, but rather in the context of what the research participant believes it to be. Qualitative researchers believe that many different views of reality are possible, and all of them are right and that there are always multiple interpretations of reality, and that can only exist within an individual. In addition, the author highlights the fact that qualitative methods focus on an understanding of the meaning of an experience from the individual’s perspective.
The researcher saw the qualitative approach as the most suitable for this study as the study purpose was to gain understanding of the experiences of clients regarding their utilisation of PMTCT services at a central hospital in Bulawayo. The in-depth understanding of the women experience was possible when women where narrating their experiences.

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Research Design

Moule and Goodman (2011:168) indicate that a research design is a map of the way in which the researcher will engage with the research participants in order to achieve the outcomes needed to address the research aims and objectives. The research study in question used a descriptive phenomenological design-a type of phenomenology developed by Husserl, whose philosophy emphasised descriptions of human experience (Polit & Beck 2010:268, Rees 2011:43-44). Kisber (2010:60-61) further indicates that participants may not experience the phenomena in the same way, given that each context, no matter how similar, is always unique to an individual. On a related note, Englander (2012:25) states that in phenomenological research the aim is to encounter the phenomenon via the person‘s description. In this particular instance, the researcher was interested in understanding the meaning of the experiences of the PMTCT clients as described by them. Descriptive phenomenological studies often involve bracketing, intuiting, analysing and describing. Therefore, in this study the researcher made all efforts of identifying and holding in abeyance preconceived beliefs and opinions about the experiences of the clients in the PMTCT programme.
The researcher also entered the field with an open mind and remained open to the meanings attributed to the experiences of the PMTCT clients. The researcher utilised this research design because in its exploration it focuses on the integrated whole as stated by Streubert and Carpenter (2011:88). In addition, as the authors observe, nursing practice grounds its practice in a holistic belief system of care for the human being as a whole (concentrating on mind, body and spirit). This makes this design the most appropriate (Streubert and Carpenter (2011:88).
Streubert and Carpenter (2011:88) further highlight the fact that since professional nursing practice is enmeshed in the life and experiences of people it makes the phenomenological approach the most suitable approach to nursing research. It was against this background, and in this context that the lived experiences and perceptions of HIV positive PMTCT clients as they interacted with the PMTCT services were best investigated qualitatively and phenomenologically.

Research Methods

According to Rees (2011:244) research methods refers to the steps, procedures, principles and strategies for collecting and analysing the data in a research investigation. This section will address study setting, sampling, data collection and data analysis.

Study setting

According to Polit and Beck (2010:261) a study setting refers to the actual physical location and conditions where data collection takes place. In addition to this, the authors indicate that qualitative researchers usually collect their data in real-world, naturalistic settings. The study was conducted in Bulawayo which is one of the Provinces of Zimbabwe. (Detailed information about Zimbabwe is provided in chapter 1, see map on figure 1.1). A map of Bulawayo province is reflected in figure 3.1 below. Bulawayo has a population of 676 650 thousands adult HIV prevalence of 19% (Zimbabwe National Statistics Agency (2012a:220). In addition to this the HIV positivity rate among pregnant women was 14% in 2012 (National AIDS Council 2013:17). In this particular scenario the study setting was a central hospital, one of the major referral centres in the city of Bulawayo. The hospital provides specialist services of midwives, gynaecologist and paediatricians, just to mention a few relevant services for the target population under study (HIV positive women in the PMTCT programme). The hospital also provides ART for PMTCT clients, other clients plus children. Care in this hospital is provided by specialist physicians, gynaecologists, paediatricians, anaesthetists, midwives and counsellors. All these constitute part of the team that provides care. In addition to this, the study setting is a training institution for nurses, midwives and medical doctors. The hospital receives referrals from Matabeleland, Midlands and Masvingo provinces for specialised care.

Population

According to Parahoo (2014:411) population is defined as the entire set of individuals or objects having some common characteristics, from which data are collected and in this case who meet the sampling criteria. Furthermore De Vos et al (2012:223) defines a population as the totality of person, events, organization units, case records or other sampling units with which the research problem is concerned. In this study, the population was that of women that were HIV positive and were on the PMTCT programme at central hospitals in Bulawayo Province. The set inclusion and exclusion criteria were used to develop the desired sample.

Sampling and sample size

A sample is a subset of the population that is selected to participate in a research study (Polit and Beck 2012:750). The researcher used judgemental purposive sampling. According to Borbasi and Jackson (2012:135) in this type of sampling the units to be observed are selected on the basis of the researcher’s judgement about which one will be most useful or representational. Another author, Parahoo (2014:44) indicates that this type of sampling involves making a judgement or relying on the judgement of others in selecting a sample. In qualitative research, although participants are selected (sampled) according to the inclusion and exclusion criteria, relevant to the purpose of the study, the number of participants is essentially determined by the level of saturated data. Researchers use knowledge of potential research participants in the recruitment exercise. The author further states that the purpose of such type of sampling is to obtain as many perspectives of the phenomena as possible. It is important to note that from the foregoing this type of sampling is appropriate for labour intensive; in-depth studies of very small samples and populations within qualitative research, hence the relevance of this sampling method. The judgement for selecting the sample was based the following criteria:
Being a woman living with HIV.
Aged from 18 to 49 years.
Booked and received antenatal care at the study setting.
Having utilised PMTCT programme at the study setting.
Delivered a live baby at the study setting
Attended post-delivery services of follow-up baby care at the study setting up to the time their babies are two years old
A total of fifteen HIV positive women in the PMTCT programme were utilised for the study. The number was determined by data saturation. The issues of data saturation were asserted by Mason (2010:2) who indicated that the concept of saturation is the most determining factor for sample size in qualitative research. Nakkeeran and Zodpey (2012:8) describe data saturation as a stage in data collection when the researcher feels that no new themes, ideas, or insights are emerging and continuing data collection does not enrich or expand explanations already arrived at. It marks the end of data collection. For this study, saturation was attained (at participant number twelve) when no new information emerged and there was only repetition of previously collected data. Three more additional participants were interviewed before closure was reached at participant number 15. The demographic data of the participants are shown in chapter four, table 4.1.

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Data collection

Burns & Grove (2011:536) defined data collection as a precise, systematic gathering of information relevant to the research purpose or the specific objectives, questions or hypotheses of a study. The researcher was the main data collection tool for this phenomenological study. Christensen, Johnson and Turner (2011:274) mentioned that a researcher should adhere as closely as possible to the data collection procedure as planned. According to Waltz, Strickland and Lenz (2010:293-297) there are steps that can be followed when choosing interviews as a method of data collection in a qualitative research. This study followed the steps below in order to improve the trustworthiness of the research findings:

Pilot study

Moxham (2012:35) views a pilot study as a micro version of the main study to assess how adequate and feasible the main one will be. This process will facilitate identification of potential problems and taking of remedial action. Before conducting the actual data collection the researcher conducted a pilot study in one of the Central hospitals in Bulawayo that was not part of the study site with three HIV positive clients on the PMTCT programme. The pilot study was done so as to establish if research participants would understand the central question used in the study “what have been your experiences in the PMTCT programme from the time you tested HIV positive up to now”. This process enabled the researcher to rephrase the question particularly in vernacular (Ndebele and Shona) and how to explore and ask probing questions. However the grand question remained basically unchanged.

Recruitment of study participants

Before conducting face to face interviews, the researcher introduced herself to potential study participants, showed them the ethical clearance obtained from the University of South Africa and one from the institution of study. Study participants were assured that the information obtained during the course of the study would be used solely for study purposes. The researcher sought permission from each individual participant prior to each individual procedure. In addition to this, the researcher requested for permission from each participant to tape record each interview.

Conducting Interviews

Data was collected by means of interviews. Babbie (2010:318) defines a qualitative interview as an interaction between an interviewer and a participant in which the interviewer has a general plan of inquiry including topics to be covered, but not a set of questions that must be asked with particular words and in a particular order. In this study, the researcher probed deeply to uncover new clues, to open up new dimensions of a phenomenon and give detailed accounts that are based on the personal experience of the research participants. The researcher conducted in-depth face to face interview stemming from the following central question: “May you kindly describe your experiences as an HIV positive woman as you received PMTCT services from the antenatal period up to now.”
The researcher used Kvales’s (1996) guidelines of interviewing as cited in Babbie (2010:322). The steps taken are outlined below:
The interview focused on the experiences of HIV positive women after utilising the PMTCT services.
The interview process utilised open ended questions in such a way that the research participants expounded on the topic.
The researcher used active listening skills in trying to clarify, understand and interpret what the participants were saying throughout the interview process. This facilitated the expression of lived experiences.
The interviews were audio recorded,
The researcher also made use of field notes during data collection. She recorded what she was hearing, seeing, experiencing and thinking in the course of collecting and reflecting on the process. She also observes both verbal and non-verbal behaviours of study participants.
The interviews were conducted in private consultation rooms at the PMTCT site.
The interviews were conducted in the language convenient to the study participants (Ndebele, Shona and English).
Validation was done by asking questions to verify facial expressions, verbal and non-verbal cues and gestures that were observed during the interview process.
Written notes included observations of both verbal and non-verbal behaviours as they occurred, and immediate personal reflections about the interview.
The researcher made sure that each of the audio recorded interviews were transcribed verbatim within 48 hours of conducting the interview. All transcripts were further coded. An independent analyst was requested to analyse all the transcripts and this report was compared with initial results for data analysis as a measure to enhance the credibility of the data. Data analysis, systems theory that underpinned the study and the literature review, all formed the baseline for the model development.

TABLE OF CONTENTS
PAGE
Dedication
Declaration
Acknowledgements
Abstract
Table of Contents
List of Figures
List of Tables
List of Annexures
List of Abbreviations
CHAPTER 1 ORIENTATION OF THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION TO THE STUDY
1.3. STATEMENT OF THE RESEARCH PROBLEM
1.4. AIM OF THE STUDY
1.5. SIGNIFICANCE OF STUDY
1.6. DEFINITION OF KEY CONCEPTS
1.7. THEORETICAL FOUNDATIONS OF THE STUDY
1.8 RESEARCH METHODOLOGY
1.9. SCOPE OF THE STUDY
1.10. STRUCTURE OF THE THESIS
1.11. CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1. INTRODUCTION
2.2. SCOPE OF THE LITERATURE REVIEW
2.3. THEMES THAT EMERGED FROM APPRAISAL OF LITERATURE
2.4. CONCLUSION
CHAPTER 3 RESEARCH DESIGN AND METHOD
3.1. INTRODUCTION
3.2. PHASE 1: SITUATION ANALYSIS
3.3. PHASE 2: MODEL DEVELOPMENT
3.4. CONCLUSION
CHAPTER 4 PRESENTATION, INTERPRETATION & DISCUSSION OF RESEARCH FINDINGS
4.1. INTRODUCTION
4.2. DEMOGRAPHIC DATA OF THE PARTICIPANTS
4.3. EMERGENT THEMES
4.4. CONCLUSION
CHAPTER 5 THE PMTCT PRACTICE MODEL
5.1. INTRODUCTION
5.2. DESCRIPTION OF A PMTCT PRACTICE MODEL
5.3. PURPOSE OF THE PMTCT PRACTICE MODEL
5.4. THE STRUCTURE OF THE ELEMENTS OF A PMTCT PRACTICE MODEL
5.5. DESCRIPTIVE SUMMARY OF PMTCT PRACTICE MODEL
5.6. TRUSTWORTHINESS/VALIDITY AND RELIABILITY OF THE MODEL
5.7. ASSUMPTIONS OF THE MODEL
5.8. IMPLICATIONS OF THE PROPOSED PMTCT PRACTICE MODEL
5.9. SUMMARY AND CONCLUDING REMARKS
CHAPTER 6 CONCLUSIONS AND RECOMMENDATIONS
6.1. INTRODUCTION
6.2. SUMMARY AND INTERPRETATION OF RESEARCH FINDINGS
6.3. CONCLUSIONS
6.4. RECOMMENDATIONS
6.5. CONTRIBUTIONS OF THE STUDY
6.6. LIMITATIONS OF THE STUDY
6.7. CONCLUDING REMARKS
LIST OF REFERENCES
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