MATERNAL HEALTHCARE

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CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY

INTRODUCTION

The literature review was presented in Chapter 2. In this chapter, the research design and methods that would be appropriate to answer the research objectives and questions are discussed. The research method discussion includes the research population, sampling and sampling technique, and data-collection and data-analysis methods. The validity and reliability of the instrument and ethical issues are also described.

RESEARCH CONTEXT

The Afar Region

The Afar Regional State is one of the nine regional states of Ethiopia, and is the homeland of the Afar people. The Afar Triangle, the northern part of which the Danakil Depression, is part of the Great Rift Valley of Ethiopia and one of the lowest points in Africa. The southern part of the region consists of the valley of the Awash River, which empties into a string of lakes along the Ethiopia-Djibouti border. Based on the 2007 census conducted by the CSA, the Afar Regional State has a population of 1,390,273, consisting of 775,117 men and 615,156 women (CSA 2007:76). This region has 34 woredas; Awash Fentale is the woreda where the study was conducted.

Awash Fentale woreda

The Awash Fentale woreda is located 215 km east of Addis-Ababa, the capital city of Ethiopia. Awash is a market town in central Ethiopia. Located in Administrative Zone 3 of the Afar Region, above a gorge on the Awash River, after which the town is named, the town lies on the Addis Ababa-Djibouti Railway, which crosses the gorge by a bridge. It is the largest settlement in Awash Fentale woreda.
Awash lies outside the Awash National Park, which is known for its wildlife, for the Mount Fentale caldera, and for the “Filwoha” hot springs. Its market is held on Mondays, where Afar and “Kereyu” crafts can be found. Based on the 2007 census conducted by the CSA, this woreda had a total population of 29,775, of whom 15,471 are men and 14,304 are women. Taking the annual population growth of Ethiopia to be 2.5%, the current total population for Awash Fentale woreda was calculated by2.5% x29.775=744.375. This is the annual population growth for Awash Fentale woreda. To obtain the current total population for Awash Fentale woreda,744.375×10=7,443.75.This population count was thought to be the total increment within ten years (2007 to 2017).

RESEARCH DESIGN

Research design is concerned with creating a blueprint of the activities to perform in order to satisfactorily answer research questions identified in the exploration phase of a research study. This includes selecting a research method, operationalizing constructs of interest, and devising an appropriate sampling strategy (Bhattacherjee 2012:67).
The researcher used a quantitative, descriptive, cross-sectional design for this research.

Quantitative design

Quantitative research deals with quantities and relationships between attributes; it involves the collection and analysis of highly structured data in the positivist tradition and is appropriate in situations in which there is pre-existing knowledge, which permits the use of standardized data-collection methods (Bowling 2014:214).In this study, quantitative research was applied because most of the factors that influence maternal healthcare services utilization were measured.

Descriptive research

Descriptive research focuses on the characteristics of a population at a single point in time or on changes within a population over time (Houser 2015:258). Hence, in this research study, aspects such as the socio-demographic, socio-economic, cultural, and other characteristics that are thought to affect maternal healthcare services and the preferences of women for delivery services were investigated within the study period.

Cross-sectional design

Cross-sectional research is used to simultaneously examine groups of subjects who are in various stages of development with the intent of describing the differences among them. A cross-sectional study is based on the assumption that the stages that are identified in different subjects at a single point in time are representative of a process that progresses over time. In cross-sectional research, the population of interest is carefully described (Houser 2015:258-259). In this research, women who gave birth starting from the last two years up to the time of data collection were involved. Furthermore, the factors that could hinder them from maternal healthcare services utilization were explored.

RESEARCH METHOD

The research method is defined as the steps, procedures, and strategies for gathering and analyzing data in a study (Polit & Beck 2014:385).

Sampling

Sampling is the statistical process of selecting a subset (called a “sample”) of a population of interest for purposes of making observations and statistical inferences about the population (Bhattacherjee 2012:67). In this study, probability sampling was applied. Probability sampling is a technique in which every unit in the population has a chance(non-zero probability) of being selected in the sample, and this chance can be accurately determined (Bhattacherjee 2012:67). As the researcher wanted a representative sample, stratified sampling was used.
Stratified sampling is used in situations in which a researcher knows some of the variables in the population that are critical for achieving representativeness (Grove & Gray 2015:260).
In stratified sampling, the sampling frame is divided into homogeneous and non-overlapping subgroups (called “strata”), and a simple random sample is drawn within each subgroup (Bhattacherjee 2012:67).Variables commonly used for stratification include age, gender, race and ethnicity, socio-economic status, diagnosis, geographic region, type of institution, etc. Stratification ensures that all levels of the identified variables are adequately represented in the sample (Grove & Gray 2015:260). In this study, the strata were based on the ethnicity of the study subjects. Study subjects were selected by simple random sampling from each stratum. Since the sampling fractions varied for each stratum, a disproportionate stratified sample was taken. The diagram below indicated how the stratified sampling technique was applied in the study area.

Population

Setting: The research setting is the environment within which studies are conducted (Houser 2015:256). The setting of this study was Awash Fentale woreda. Awash Fentale woreda is found in Zone 3 of the Afar National Regional State, Ethiopia, which is 200km from Addis Ababa.
The total population of Awash Fentale woreda for the year 2017 was 7,444+29,775=37,219 population, of which 17,880 were women and 19,339 were men. To obtain the target population, 23.5% of the population of Awash Fentale woreda were women between the ages of 15and49. Therefore, the target population was calculated as 23.5% x37,219=8,746. The list of candidates who gave birth in Awash Fentale woreda (including home delivery) within the last two years was obtained from Awash Health Center Maternal and Child Health (MCH) Department. Hence, the number of women who gave birth in Awash Fentale woreda within the last two years were 3,570.
To apply stratified sampling, identifying the proportion of each ethnic group was very important. The seven largest ethnic groups reported in the woreda are the Afar (54%), Amhara (22%), Oromo (10.4%), Welayta (5.9%), Argoba (4%), Tigray (1.9%), and Somali (1.4%); all other ethnic groups make up 0.5% of the population. Based on the above proportion of ethnicity, 422 participants were selected by the lottery method. Nearly 65.2% of the population are Muslims, 22% Orthodox Christians, 10.4% Protestants,2.4% Catholic Christians, and the remaining 0.2% are followers of traditional beliefs such as “Waquefecha” (Awash Fentale Health Office 2017). Based on the above information, several strata were made.
Population: A population is the entire set of subjects who are of interest to a researcher (Houser 2015:258-259). In this study, the population comprised the entire population of Awash Fentale woreda. This woreda has a total population of 29,775, of whom 15,471 are men and 14,304 are women. More than 90% of the population are pastoralists (CSA 2007:76).
The target population of this study consisted of all women of reproductive age group residing in Awash Fentale woreda of the Afar Regional State. The study population was women of reproductive age group(15 to 49 years) (EDHS:2016:14-16) who gave birth in the past two years until the time of data collection.

Sample

A sample is a subset of a population of interest for purposes of making observations and statistical inferences about that population (Bhattacherjee 2012:65).
The quantitative approach uses a sample since it is impractical to study a whole population due to time, financial, and other constraints. However, for generalization to the general population to be realistic, the sample should be representative of the population (Bhattacherjee 2012:66).
The sample population of this study was women of reproductive age group (15 to 49 years) who gave birth within the last two years and who are residents of Awash Fentale woreda.

Sampling criteria

Inclusion criteria : Women of reproductive age group (15-49) residing in Awash Fentale woreda who gave birth within two years duration.
Exclusion criteria:
Any women in a reproductive age group residing in Awash Fentale woreda who gave birth beyond two years duration and women who didn’t listen.

Sample size determination

As there are multiple variables treated in this study and since the proportion of women who use maternal healthcare services in Awash Fentale woreda was unknown, the sample size estimation was based on the maximum sample size for estimating single proportion approach (Bui &Taira 2010:414).
To calculate a sample size for proportion (P) at a given confidence interval with margin of error W, the following equation was used.
n= (Z α/2)2p (1-P)
w2
Where:
n=required sample size.
Zα/2=critical value for the chosen confidence level at 95% (standard value of 1.96).
p=estimated prevalence of the problem (variable being assessed).
w=margin of error of 5% (standard value of 0.05).
Taking the above formula into account with absolute precision (5%), and anticipated population proportion to be 50%, the total sample size n for this study was calculated as follows:
n= (1.96)2x50x50=384+10% non-response rate=422 study subjects will be selected. 5)2
Since the target population was less than 10,000, a correction formula was required to calculate the minimum sample size using the following equation:
nf=n/1+n/N
Where:
nf= Final sample size.
n= sample from an infinite population.
N= Sample from a finite population (the target population).
Therefore, according to the correction formula, the required sample size for this study was calculated as follows:
nf=422/1+8746=422/1+0.05≈422 study subjects selected for this study.

Ethical issues related to sampling

Permission to contact the list of women was obtained from Awash Fentale Health Centre. This health center has the authoritative power and responsibility of leading the healthcare facilities. Hence, a letter of permission was obtained from Awash Fentale Health Centre before contacting the study subjects (see Annexures B and D).
A written informed consent form (see Annexure E) was designed and was signed by each respondent before completing the questionnaire (see Annexure F). The researcher respected the right of the respondents to abstain from participation or to withdraw consent to participate at any time without reprisal. The participants were informed that the information they provided might not be of direct benefit to them but was extremely important to inform policy makers and program designers for stimulating discussion about the formulation of appropriate measures to address the factors that influence maternal healthcare services utilization by women in Awash Fentale woreda.

Data collection

Data collection is the process of acquiring subjects and collecting data for a study (Grove &Gray 2015:309). The actual steps of collecting the data are specific to each study and depend on the research design and measurement techniques (Grove &Gray 2015:310).

Data-collection approach and method

Data were collected using standardized structured questionnaires. The data were collected using questionnaires developed and included all the relevant variables to meet the objectives of the study. Prior to the development of the questionnaires, similar studies focusing on factors that influence the utilization of maternal healthcare services were reviewed and a few modifications were made to the prepared questionnaires to address the set objectives (Tebekaw et al. 2015).Before the actual data collection, the data collectors were provided with the location and the number of women to interview based on the proportion of their ethnicity. The households of the respondents, regardless of their place of delivery, were obtained from the MCH Department of Awash Health Centre. All women aged 15 to 49 years who gave birth within the past two years and who had been living there for at least one year (but not visitors) were eligible for the interview. The data collectors were required to do only one revisit and those households missed during the second visit were assumed as non-respondents. The study respondents were randomly selected from their ethnic strata and the number of respondents in each ethnic group who were interviewed by the data collectors were proportionally allocated by the researcher. During the data collection, the researcher consulted the heads of Awash Fentale Health Office and Awash Fentale Health Centre and some community members to make the data-collection process more effective. In this study, verbal face-to-face interviews were administered using structured questionnaires. The questionnaires were developed in English and further explanations were given for better understanding of enumerators and respondents.

Development and testing of the data-collection instrument

In this study, the Demographic and Health Statistics (DHS) Women’s Questionnaire was considered. However, this standardized questionnaire did not contain all the information needed for this particular study and the researcher was required to add information to the original questionnaire. For example, the DHS standardized questionnaire did not address information needed for preferences of maternal healthcare and PNC services.
The structuring and some components of the instrument were modeled from the Ethiopian DHS Women’s Questionnaire but others were developed by the researcher based on the objectives and research questions of the study and used the literature review as a frame of reference. The questionnaire was structured into four main sections, namely (1) household information, (2) background information of the respondent, (3) maternal healthcare services, and (4) other health-related issues.
Recall bias was taken into consideration during the development of the questionnaire. Women were therefore asked about their most recent or last birth and the date of birth of the child to minimize recall bias. The final version of the questionnaire was reviewed by the researcher’s supervisors, public health experts, and a statistician, and was accepted for its validity.
Before the commencement of the data collection, the final draft of the questionnaire was pretested and refined using ten copies to ensure that all possible responses were included in the questionnaire. Pre-testing was done by trained enumerators under the supervision of the principal investigator to minimize possible errors. During the pre-test, questionnaires were completed by respondents who had similar characteristics to the sample but among those outside the selected areas.

Characteristics of the data-collection instrument

A questionnaire was used as the instrument to collect data. A questionnaire is a self-report form designed to elicit information through the written, verbal, or electronic responses of the subject (Grove &Gray 2015:304). A questionnaire consists of a formalized series of questions (Moule & Goodman 2014:322).The information obtained from the questionnaire was similar to that obtained by an interview, but the questions tend to have less depth. In this study, structured questionnaires were prepared, printed, and distributed in person. Questionnaires were used in this study to gather a broad spectrum of information or facts about women who gave birth in the last two years. Using these questionnaires, information about beliefs, attitudes, opinions, knowledge, and the intention of the study subjects was gathered. In conclusion, questionnaires are useful in gathering relevant information in a short period of time although they are limited in assessing the depth of the information.

Data-collection process

During the data-collection process, the researcher started by training the data collectors, recruiting study participants, implementing the study intervention, collecting data in a consistent way, and protecting the integrity and validity of the study(Grove & Gray 2015:310). In this study 6 data collectors who were trained for 3 consecutive days were selected to administer the questionnaires and to conduct the data collection within 30 days. All data collectors were experienced clinical nursing by profession who worked for more than three years in different areas of the Afar region.
The objective of this phase was to identify the factors that influence maternal healthcare services utilization in Awash Fentale woreda. To achieve this objective, the eligible subjects were interviewed by six trained health professionals using a structured questionnaire that was developed for this purpose.
The following steps of data collection were followed:
Step1: Obtaining permission for fieldwork
After obtaining ethical clearance from the University of South Africa (UNISA) (see Annexure C), a letter of approval to conduct fieldwork was obtained from the Bureau of Health of Afar National Regional State and the respective health offices of Awash Fentale woreda (see Annexure A and B). A letter of application requesting permission for the research was submitted to the respective offices (see Annexure D). The heads of the offices were briefed about the research topic, the relevance and appropriateness of the research, and the actual time needed to finish the data collection.
Step2: Selection of data collectors
The amount of time needed to complete the questionnaire was 25 minutes on average, which was estimated during the pre-test. It was then decided to recruit six interviewers to administer the questionnaires and to conduct the data collection within 30 days. Data collectors were selected from Awash Fentale woreda who were not engaged in providing maternal healthcare services at that time. This was done in consultation with Awash Fentale Health Centre. All the data collectors were required to have at least a bachelor’s degree in Nursing and were able to speak, read, and write using local languages. Some of the data collectors were able to speak more than two languages. Translators were pre-arranged in case the need arose but only two data collectors faced language barriers.
Step3: Training of data collectors
The training of the data collectors was conducted in Awash Fentale Health Centre in both the Amharic and English language to ensure that the concepts and questions were understood. The data collectors were given the chance to reflect on their ideas, including the challenges that could be faced. The training of the data collectors took three days. The training was facilitated by the principal investigator in collaboration with the head of Awash Fentale Health Centre. During the training, the informed concept, the parts of the questions on the questionnaire, and instructions were discussed in detail. The data collectors had the chance to discuss with the principal investigator any misconceptions, even during the actual fieldwork.
Step4: Questionnaire administration
This was a researcher administered questionnaire. A total of six interviewers, comprising five females and one male, carried out the data collection. Each data collector was given a support letter from Awash Fentale Health Centre. Data collection was mainly conducted early in the morning and after 3 pm in the afternoon to reduce the non-response rate, which was thought to happen as a result of high temperatures (harsh weather conditions) at mid-day. Every day at 6pm, the data collectors had meetings with the principal investigator to submit the completed questionnaires, discuss daily activities and challenges, and to prepare for the next day’s activities. Witness to assent forms were also used for respondents less than 18 years old since they were less likely to decide on their own health issues.
Step5: Supervision
Supervision was a continuous process during the data-collection process. The principal investigator supervised the data collectors throughout the entire process. The completed questionnaires were reviewed by the principal investigator on a daily basis for inaccuracies. The supervisor checked whether the respondents were interviewed correctly by examining the questions and answers for consistency. During the supervision, it was found that one data collector had faced a challenge of not tolerating the hot weather that was prevailing in Awash Fentale woreda and she was replaced by the principal investigator.

Data analysis

The researcher reviewed the data for logical consistencies and completeness before making data entries. Data were entered into SPSS and cleaned also using SPSS. The description of the study population was done by analyzing the distribution of the respondents by the variables in terms of frequencies and percentages. Chi-square tests were conducted to assess any association and to measure the strength of association between independent and dependent variables. Similarly, binary logistic regression was applied to assess any association and the strength of the association between dependent and independent variables.

Ethical considerations related to data collection

Permission from institutions

Ethical clearance to conduct this study was obtained from the Higher Degrees Committee of the Department of Health Studies, UNISA (see Annexure C). The study was thought to respect human subjects by treating completed questionnaires as confidential in accordance with the university’s and the country’s (Ethiopia) ethical principles to the collection, maintenance, use, and dissemination of data and information.

Confidentiality

Confidentiality is the ethical principle of safeguarding the personal information gathered in a research study (Moule & Goodman 2014:60).The researcher did not report data about the participants without their explicit permission.
The researcher ensured confidentiality and anonymity through using case identification numbers instead of their actual names, and collected data were protected and kept safe from disclosure to unauthorized persons by locking them in a box in the office of the head of the health center. The respondents were assured of their confidentiality throughout their participation.

 Veracity

Veracity is the ethical principle of telling the truth (Moule & Goodman 2014:58). The researcher and data collectors were honest with the participants and informed them of the potential risks and benefits, as well as the right to decide whether to participate or not without any coercion and the right to withdraw from the research study at any time.

Justice

Justice is the ethical principle of being fair to participants and not giving preference to some respondents over others (Moule & Goodman 2015:59). In this study, it was stated to respondents that there would be no discrimination or exploitation of participants on the ground of race, religion, sex, age, class, or sexual orientation.

Non-maleficence

Non-maleficence is the principle of doing no harm (Moule & Goodman 2015:59). It was the duty of the researcher to prevent physical, social, and economic harm. To reduce the economic and physical strain of mothers, the researcher mobilized the data collectors to make home-to-home visits to collect the necessary information. To protect mothers from social harm, the data collectors were well oriented by the researcher regarding the objectives of the data collection.

TABLE OF CONTENTS
DECLARATION
SUMMARY
ACKNOWLEDGEMENTS
DEDICATION
LIST OF TABLES
LIST OF FIGURES
LIST OF ACRONYMS AND ABBREVIATIONS
CHAPTER 1:ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 RESEARCH PROBLEM
1.4 THE AIM 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 SCOPE OF THE STUDY
1.10 THE STRUCTURE OF THE THESIS
1.11 CONCLUSION
CHAPTER 2:LITERATURE REVIEW
2.1 INTRODUCTION
2.2 MATERNAL HEALTHCARE
2.3 Maternal healthcare services
2.4 FACTORS THAT AFFECT MATERNAL HEALTHCARE SERVICES UTILIZATION
2.5 BARRIERS TO MATERNAL HEALTHCARE SERVICES UTILIZATION
2.6 APPROACHES TO MATERNAL HEALTHCARE
2.7 CONCLUSION
CHAPTER 3: RESEARCH DESIGN AND METHODOLOGY
3.1 INTRODUCTION
3.2 RESEARCH CONTEXT
3.3 RESEARCH DESIGN
3.4 RESEARCH METHOD
3.5 INTERNAL AND EXTERNAL VALIDITY OF THE STUDY
3.6 CONCLUSION
CHAPTER 4:DATA PRESENTATION, ANALYSIS, AND DESCRIPTION OF THE RESEARCH FINDINGS
4.1 INTRODUCTION
4.2 DATA MANAGEMENT AND ANALYSIS
4.3 RESEARCH RESULTS
5.4 PNC SERVICES UTILIZATION
5.5 WOMEN’S SATISFACTION WITH MATERNAL HEALTHCARE SERVICES
5.6 OTHER HEALTH-RELATED ISSUES
5.7 CONCLUSION
CHAPTER 6:PROPOSED IMPLEMENTATION STRATEGIES FOR PROVIDING OPTIMAL ANTENATAL, DELIVERY, AND POSTNATAL SERVICES UTILIZATION IN AWASH FENTALE WOREDA
6.1 INTRODUCTION
6.2 VALIDATION OF THE STRATEGIES
6.3 INTEGRATION OF THE FINDINGS WITH THE THEORETICAL FOUNDATION
6.4 IMPLEMENTATION STRATEGY
6.5 BASIS FOR THE DEVELOPMENT OF THE IMPLEMENTATION STRATEGY
6.6 POLICY CONTEXT
6.7 RESEARCH CONTEXT
6.8 THE HEALTH SECTOR STRATEGIC PILLARS
6.9 STRATEGIES TO IMPROVE MATERNAL HEALTHCARE SERVICES UTILIZATION
6.10 PRIORITIES FOR ACTION
6.11 IMPLEMENTATION OF THE STRATEGY
6.12 CONCLUSION
CHAPTER 7:CONCLUSIONS AND RECOMMENDATIONS
7.1 INTRODUCTION
7.2 RESEARCH DESIGN AND METHOD
7.3 SUMMARY AND INTERPRETATION OF THE RESEARCH FINDINGS
7.4 CONCLUSION
7.5 RECOMMENDATIONS
7.6 CONTRIBUTIONS OF THE STUDY
7.7 LIMITATIONS OF THE STUDY
7.8 CONCLUDING REMARKS
REFERENCES
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