WAGNER’S CHRONIC CARE MODEL

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INTRODUCTION

This chapter presents the research design and methods utilised in conducting this study.  The chapter also presents methods of data analysis, ethical considerations and steps taken by the researcher to ensure trustworthiness of the research. Data were collected using unstructured descriptive FGDs, held in six locations of the six geopolitical zones of Nigeria. The study followed a qualitative research paradigm.

RESEARCH SETTING

This study took place in a natural environment where study participants usually held their support group activities, to depict their lived experiences; thus, their naturalistic setting. This is in line with Patton’s (2002:280) stipulation, that  qualitative studies are undertaken in a natural setting to be able to put the participants’ experiences into context.This study took place in six state public health facilities providing ART services, representing the six geopolitical zones of Nigeria. Specific states where the study took place include Yobe (located in the North-East zone of Nigeria), Sokoto (North-West), Federal Capital Territory (North-Central), Lagos (South-West), Edo (South-South) and Anambra State (located in South-East geopolitical zone of Nigeria). See Figure 3.1 showing map of Nigeria with the study sites marked. A cumulative number of over 20,000 end users attend ART services in the 6 study sites, with approximately 3,000 monthly attendances per site. Of this number, about 228 are new end users enrolled into the ART programme monthly, across all the 6 study sites (See Annexure H for the 2011 annual breakdown of cumulative number of end users who ever received ART in the 6 study sites. Different cultural practices are found in each geopolitical zone of Nigeria. For example, although there are three major languages spoken across all the six geopolitical zones of Nigeria, the north has a predominance of Hausa speaking people, while the South West has Yoruba and the South Eastern part of the country has a predominance of Ibo speaking people.

RESEARCH DESIGN

Research paradigm/approach

 A qualitative paradigm was applied for this study. The qualitative research paradigm was chosen for this study because of its heuristic value, or its usefulness as a tool for exploration related to knowledge development. It often informs clinical practice by raising questions and providing fertile ideas for improving quality of care and prompting additional research activities. This study requires an understanding of the perceptions of end users concerning quality of ART service provision in public health facilities in Nigeria. It is obtainable through data collection and interpretation (qualitative research). Stommel and Wills (2004:442) define qualitative research as that research that eschews measurement and focuses on interpretive, non-numerical, narrative interpretations. Qualitative research aims to describe social phenomena and behaviours using rich contextual data that emphasise the subjective experiences of social actors (Malta, Maya, Clair, Freitas & Bastos 2005:1426). While qualitative studies use “open-ended” questions, quantitative studies use “closedended” questions. Chow et al (2009:441) elucidate that the open style of questioning in qualitative studies allows the end user freedom to comment on areas of care from which we infer end user satisfaction. With “open-ended” questions, an end user is asked to comment on an area of care. The end user responds by explaining in detail. He/she is then probed by the interviewer or FGD facilitator to continue to get deeper into the subject matter, until he/she gets to a point where there is nothing else to share (point of saturation). While the end users are openly sharing their perceptions regarding the question(s) under consideration, the investigator is at liberty to discover satisfaction and dissatisfactions with health care services. In qualitative studies, direct questions are also asked. Chow et al (2009:441) state that direct questions tend to serve as probes in qualitative studies, to discover satisfaction or dissatisfaction with areas of care that may not be mentioned with an open-ended question.Stommel and Wills (2004:178) maintain that the main characteristics of qualitative research are as follows: qualitative research is oriented towards theory discovery and the development of a conceptual framework. It attempts exploration in a “naturalistic” way, under uncontrolled conditions. Its goal is to understand behavior or actions within their naturally occurring contexts. It focuses on behavioral or meaningfully understood action variables only. It has a tendency to focus on smaller samples. It has preference for open-ended, un-standardised, reactive data collection procedures. It is oriented toward completeness of description. It is open-ended to inquiry (reactive to preliminary results). It emphasises the uniqueness of individuals or special population groups, preferring narrative summaries or descriptions.“Closed” form of questioning in quantitative studies involves direct questions asked about satisfaction with specific services. Closed questioning gives more quantitative evaluations, but does not provide the situation the end user is referring to (Chow et al 2009:441). For example, a change from satisfied to dissatisfied may represent either an accumulation of small shifts in a separate component area or a large shift in a single component. Responses to this form of rating tend often to fall into two narrow bands, being only superficially indicative of high satisfaction levels.Due to the obscurity of bringing out the inert perceptions of end users in quantitative methods, the qualitative methods of studying end user satisfaction remain the most viable option. Qualitative methods influence respondents to bring out new areas of thought that were never preconceived by the quantitative instrument developer/ researcher. It was against these merits of qualitative study methods that the researcher opted to use qualitative study approach in this study.The qualitative research approaches are most appropriate for this study because they demonstrate the appropriate study architecture, strategy, and tactics for exploring the views of end users through focus group discussions (to the point of redundancy or saturation). However, Stommel and Wills (2004:291) conclude that although qualitative research is indispensable, it can be criticised for placing too much trust in the credibility and integrity of the individual researcher. In the ordinary scientific canon, methods that produce results that cannot be replicated may be heuristically useful, but they do not meet the standards of objectivity, which demand that results can be corroborated by other independent researchers. However, the researcher enhanced the trustworthiness of the research through strategies described.

Research design

A descriptive and explorative research design was used in this study. This research design was preferred for this study because it provides an accurate and real-life situation, experiences and characteristics about the end users participating in this research. Polit and Beck (2004:528) define descriptive research as research studies that have as their main objective the accurate portrayal of the characteristics of persons, situations, or groups, and the frequency with which certain phenomena occur. Thus, descriptive and explorative research is designed to summarise the status of some phenomena of interest as they currently exist, introducing no new treatments or changes. The use of a descriptive and explorative research design to this research is justified on the basis of the flexibility of the design in promoting descriptions or exploration of the quality of antiretroviral therapy in public health facilities in Nigeria and the perceptions of the end users.Descriptive and explorative research designs, when compared with the formal measurement models used for quantitative scaling and the efforts to standardise data collection procedures for quantitative measures, qualitative (descriptive and explorative) design appear to lack rigour and objectivity. However, it would be erroneous to conclude that clinical research can “do without” the flexible methods provided by qualitative research approaches (Stommel & Wills 2004:291). In the current study the descriptive/explorative design will provide a platform for the participants to present their perceptions concerning quality of ART in Nigerian public health facilities to the point of saturation, or the point whereby they have nothing else to contribute to the research question.

RESEARCH METHOD

This section presents systematic and detailed information that will allow a reader to replicate or otherwise evaluate the study findings (Stommel & Wills 2004:420). It provides a detailed description of the key characteristics of the study sample, including the inclusion and exclusion criteria used in the study. It also presents the ethical issues in the protection of human subjects. It provides a detailed description of methods used to collect data, including steps taken in data collection, data analysis and ensuring trustworthiness of the data.

Population, sample and sampling
Population

Stommel and Wills (2004:297,441) define population as any universe of subjects, cases, units, or observations containing all possible members. Polit and Beck (2004:534) define a population as the entire set of individuals (or objects) having some common characteristic(s) sometimes referred to as universe. The population for this study was the end users of health services in Nigeria. This population was ideal for the study because they form the core reason for the existence of public health facilities in Nigeria.Target population, according to Stommel and Wills (2004:444), refer to the population of all potential study units that meet the study inclusion criteria (that is, in whom or which the researcher is interested). Polit and Beck (2004:537) define target population as the entire population in which the researcher is interested and to which he or she would like to generalise the results of a study.The target population for this study includes end users of health services in each of the six geo-political regions of Nigeria. The accessible population includes all end users of ART services in government designated ART centres in public health facilities in Nigeria. Stommel and Wills (2004:299) define study population as the subset of the target population that are accessible to the researcher, at least in principle, if there are sufficient resources. These accessible study populations are more limited in time and space and are also defined in terms of specific inclusion and exclusion criteria. Eligibility criteria refer to pre-determined benchmarks that must be attained before one is qualified to be selected as a sample. Thus, for this study, the researcher included end users only (male or female) who met the following inclusion criteria:
attending ART in the government designated centre in a public health facility in Nigeria
at least 18 years old
attending the ART programme for at least 6 months on a continuous bases willing to provide written consent to participate in the study
For the purpose of this study, the researcher purposively approached/included participants who met eligibility criteria for inclusion in the FGD, and also gave written informed consent to participate. Those who did not meet the eligibility criteria or refused to grant consent to participate were excluded from the study. Purposive sampling technique was used to obtain a study sample in each of the 6 health facilities. The study sites refer to the 6 health facilities that were units from a larger population of health facilities, while the study sample refers to the end users that participated in the study (Stommel & Wills 2004:443).

Sample and sampling techniques

A purposive sampling technique was used in this study. The purposive sampling technique was the preferred approach for this study because it enables the selection of most readily available end users for the study. This sampling method was preferred after the researcher verified from health facility records that end users listed in the ART records were necessarily not still available for continued care in the health facility. Some were dead, transferred out, lost to follow up or lost to other unknown reasons; thereby, creating difficulties in achieving accurate representativeness of samples. Polit and Beck (2004:527) refers to purposive sampling as the selection of the most readily available persons (or units) as subjects in a study; also known as accidental sampling. Stommel and Wills (2004:436, 437) on the other hand, view purposive sampling as a nonprobability approach to selecting participants based on their (easy) accessibility to the researcher.Procedurally, the researcher randomly selected one public health facility per geopolitical zone in Nigeria. Thus, of the 6 official geopolitical zones in Nigeria, 6 health facilities providing ART were randomly selected to participate in the study. A public health facility was selected per geopolitical zone to capture end users’ diverse perceptions concerning quality of ART in Nigerian public health facilities. The researcher was supported by trained research assistants and local leaders of support group of people living with HIV and AIDS in each study location to identify end users attending ART in the public health facilities. End users attending ART were approached by the support group leaders and screened for eligibility to participate in the study. Eligible end users were sequentially enrolled into the study based on first-come, first-eligible, first-enrolled bases, until the required number of 8-12 persons per FGD was achieved. End users who failed to meet the inclusion criteria listed in section, were excluded from the study. The main problem with purposive sampling is that members of such a sample may have some characteristics, often unrecognised, if not explicitly studied or thought about, that distinguish them from the overall target population. Membership of the study sample always involves a substantial element of self-selection, thus, subjectivity or bias. It is sometimes difficult to gauge the extent to which findings from a particular study are applicable to broader populations.

CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION RELATING TO THE RESEARCH PROBLEM
1.3 THE RESEARCH PROBLEM
1.4 AIM OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 FOUNDATIONS OF THE STUDY
1.7 RESEARCH DESIGN AND METHOD
1.8 SCOPE AND LIMITATIONS OF THE STUDY
1.9 STRUCTURE OF THE THESIS
1.10 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 WAGNER’S CHRONIC CARE MODEL
2.3 PERCEPTION OF END USERS CONCERNING QUALITY OF ANTIRETROVIRAL THERAPY
2.4 CONCLUSION
CHAPTER 3 RESEARCH DESIGN AND METHOD
3.1 INTRODUCTION
3.2 RESEARCH SETTING
3.3 RESEARCH DESIGN
3.4 RESEARCH METHOD
3.5 TRUSTWORTHINESS OF THE STUDY
3.6 REFLEXIVITY
3.7 CONCLUSION
CHAPTER 4 DATA ANALYSIS, PRESENTATION AND INTERPRETATION OF FINDINGS
4.1 INTRODUCTION
4.2 OVERVIEW OF DATA ANALYSIS
4.3 DATA ANALYSIS
4.4 DATA STRUCTURE
4.5 CONCLUSION
CHAPTER 5 DISCUSSION OF  FINDINGS
5.1 INTRODUCTION
5.2 ART SERVICES THAT MET END USERS’ REQUIREMENT
5.3 PARTICIPANTS’ PERCEIVED SUCCESSES IN ANTIRETROVIRAL THERAPY  SERVICE PROVISION
5.4  ART SERVICES THAT DISAPPOINTED PARTICIPANTS FROM MEETING THEIR REQUIREMENTS (DISSATISFACTION)
5.5 PARTICIPANTS’ SUGGESTIONS FOR IMPROVING END USERS’ REQUIREMENT FOR QUALITY ANTIRETROVIRAL THERAPY SERVICE PROVISION
5.6 CONCLUSION
CHAPTER 6 CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS
6.1 INTRODUCTION
6.2 CONCLUSIONS
6.3 LIMITATIONS OF THE STUDY
6.4 RECOMMENDTIONS
6.5 CONCLUDING REMARKS
CHAPTER 7 BEST PRACTICE GUIDELINES FOR PROVISION OF END USER FOCUSED ANTIRETROVIRAL THERAPY IN NIGERIAN PUBLIC HEALTH FACILITIES
7.1 INTRODUCTION
7.2 PROCESS OF DEVELOPING THE GUIDELINES
7.3 APPLICATION OF THE CONCEPTUAL FRAMEWORK TO THE DEVELOPMENT OF THE GUIDELINES
7.4 APPLICATION OF THE THEORETICAL FRAMEWORK TO THE DEVELOPMENT OF THE GUIDELINES
7.5 FORMULATION OF BEST PRACTICE GUIDELINES FOR PROVISION OF END USER FOCUSED ANTIRETROVIRAL THERAPY IN NIGERIAN PUBLIC HEALTH FACILITIES
7.6 ANALYSIS AND VALIDATION OF THE GUIDELINES
7.7 RECOMMENDATIONS FOR IMPLEMENTATION OF THE GUIDELINES
7.8 CONCLUSION
GET THE COMPLETE PROJECT
QUALITY OF ANTIRETROVIRAL THERAPY IN PUBLIC HEALTH FACILITIES IN NIGERIA AND THE PERCEPTIONS OF THE END USERS

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