In this chapter, the procedure and techniques used for the conduct of this research are explained. These include the research framework, research approach, data collection techniques and tools, sampling process, participants of the study, research procedure, data analysis, quality of the research and ethical approval.
Research Framework
The framework of this research has been adapted from the work of Plant and Douglas (2006) on the performance management continuum in municipal government organizations. It explains performance management as a continuous process from the formulation of organizational strategy based on the mission of the organization through implementation to the results. Using this framework, this research examines the performance management system of PHOs by investigating how the performances of PHOs working at health facility level were aligned to the strategy of the Ministry of Health and Social Welfare (MOHSW). The strategic component of the framework refers to the aspects of the strategy of MOHSW as contained in the Health Policy (2011-2015) which were related to the responsibilities of PHOs. This was used as a reference to compare the responsibilities of PHOs against its contents.
The operational performance implementation and improvement component of the framework which comprised planning, implementation, measurement and corrective action provided the main basis against which the research questions were designed. Thus, the alignment of performance and strategy was investigated by examining whether planning, implementation and measurement were done based on the strategy. Also, this component helped to explain the current system of managing the performance of PHOs.
The enabling conditions for performance (the performance enhancers) i.e., environmental support and personal factors have been adapted from Chyung (2005,
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p.25), human performance technology based on Gilbert’s (1978) behavior engineering model. Under the environmental supports, ‘resources’ instead of ‘instruments’ has been maintained as in Plant and Douglas’s (2006) model. However, these factors in both the Behavior Engineering Model and Plant and Douglas’s (2006) performance management continuum were similar. It was considered necessary to include the factors in this study because their availability was crucial for performance to take place. Figure 3.1 shows the framework of the research.
Personal factors
Motives Capacity Knowledge Environmental
supports
Data Incentives Resources Operational performance
implementation and improvement Planning
Execution Corrective
action Measurement
Strategy of MOSHW
Figure 3.1 Research framework
Results
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Research Approach
The research was conducted using a qualitative approach. This was because the opinions and experiences of PHOs as regards the relationship between their work and strategies of MOHSW were explored. According to Myers (2008), qualitative research methods are designed to help researchers understand people and what they say and do enabling a researcher to see and understand the context within which decisions and actions take place. Also, according to Mertens (2005) the nature of the research question may determine the choice of using qualitative research. He mentioned that the types of research questions for which qualitative methods would be appropriate can be when the focus of the research is on the process, implementation, or development of a program or its participants. In accordance with these views, this research was done on the performance management system of the public health cadre by investigating how aligned was the performance of PHOs to the strategy of MOHSW. In order to achieve this, information was generated through interviews of the PHOs and their respective supervisors in the regions. Documents that were required by PHOs for the execution of their duties were also reviewed for their consistency with the operational requirements and the strategy of the MOHSW. The availability of the enabling conditions for performance was assessed using a questionnaire to help the researcher gain more understanding about alignment.
Data Collection Techniques and Tools
This is a qualitative research in which three procedures were used for collecting the data: personal interviews, document review and a questionnaire. The design of data collection tools went through peer review and expert review. The peers who helped in the review consisted of public health officers some of whom were practicing in the field while some were students pursuing various health-related graduate programs in Taiwan. Others were colleagues who were pursuing their masters in
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human resource development and had familiarity with the field on which this research was being conducted i.e. performance management. The experts who undertook the review process were senior public health officers who had gathered vast experiences in public health practice and had participated in numerous healthcare researches. Data collection was done by the researcher.
Personal Interviews
The questions were in two sets because the respondents were PHOs and RPHOs.
Even though most of the questions were similar, there were some differences as some questions were not applicable to a group in some cases. The first set was for the supervisors of PHOs (i.e., RPHOs) while the second set was for the PHOs. The questions in both sets were designed to answer the research questions. Questions designed for the investigation of the level of alignment investigated the responsibilities of the PHOs, how they were communicated and what were the targets for those responsibilities. Questions which dealt with the effects of alignment investigated the impact of alignment on the performance of PHOs from the perspectives of PHOs and their supervisors. The question on the support available to PHOs to carry out their responsibilities was included in only the RPHO questions because there was a questionnaire on this dimension for PHOs. All the questions together helped answer the last research question i.e. performance management.
The design of both sets of questions went through peer review and expert review.
When the questions were designed originally, they were peer reviewed by colleagues in both the fields of public health and human resource development. In both sets, the sequences of the questions had been altered to allow for logical sequencing. In the RPHOs’ questions, Question 1 had been adjusted to key responsibilities instead of responsibilities. The listing of support available for each responsibility had been omitted for Question 3 to only mentioning whether necessary support was available
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for the sake of simplicity. This question had been moved from 3 to 5 in the final version. Question 4 had been deleted completely by the expert panel because they advised that a checklist would be more appropriate for that purpose. The questions about the availability of targets and how they were set i.e., Questions 3 and 4 were included only in the final version of the expert review panel. The final version also added how and why to some questions and deleted some statements like ‘check for evidence’ from the previous versions. Appendix A shows the full procedure of the review of RPHOs’ questions.
For the PHOs’ questions, the experts suggested to ask for experience in the first question because this was vital to ascertaining their eligibility for participation. For this set too, the question concerning public health documents i.e., Question 3 was deleted both in the peer review and expert review. The question on explaining how targets were set i.e., Question 6 was added to the expert review version so as to have detailed information about PHOs’ knowledge concerning performance planning. In this set too, the questions why and how were added to some questions e.g., Questions 8, 9, and 15. The original version of PHOs’ questions was only 12, but the peer review and expert review versions had 15 and 16 questions respectively. The full procedure of the review of PHOs’ questions is shown in Appendix A.
Each interview lasted between 30 – 45 minutes. All the interview questions and the purpose of each and for which category it was intended are shown in Appendix A.
Document Review
Documents of the MOHSW related to the job of PHOs were reviewed. These included job descriptions, monthly health facility returns, public health monthly and quarterly returns, reporting tools, abatement notice books, fresh food certificates, condemnation certificate, seizure certificates, the Public Health Act, the Food Act, National Environment Management Act (NEMA). These documents were reviewed
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subject to their availability at the Regional Health Team (RHT). They were checked for their availability in the regions, standardization across users and consistence with the strategies of the MOHSW. Standardization was checked to find out whether the same tool was being used by all PHOs in a given region. The documents were checked for consistence to know whether they were in line with legal and operational requirements.
Based on the advice and support of the experts who helped review the tools a checklist was developed. The checklist contains most of the documents currently used by PHOs to execute their functions, see Appendix A.
Questionnaire
To help the researcher gain more understanding about the availability of factors that supported performance, a questionnaire was developed with reference to Cox, Blake, and Philibert’s (2006) work: valuing the Gilbert model: an exploratory study, with the assistance of classmates in the field of human resource development as well as colleagues in the field of public health. After it was pretested, it was found to be complicated and was not easy for most PHOs to fully comprehend. Therefore, comments from the pretest were incorporated by the expert review panel with reference to the updated behavior engineering model of Lemanski, Wisniewski, and Benson (2011): tales from the field - reaching the quality benchmark - case study and Gilbert’s (1978) work: human competence - engineering worthy performance. It was ensured that it captured the six dimensions of Gilbert’s Model and simplified further to enable respondents understand it better. Most of the items on the original questionnaire were either deleted or modified to suit the public health cadre. The original and final versions of the questionnaire are both shown in Appendix A. The questionnaire was used only to help the researcher understand the study subjects better.
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Sampling Process
There are six health regions in The Gambia. The selection of the three regions from the six was done using random sampling. In a random sample the nature of the population is defined and all members have an equal chance of selection (Marshall, 1996). This was done by writing the names of the six regions on separate pieces of paper which were rolled and balloted. Three pieces were selected at random in succession after thoroughly shuffling. These turned out to be Upper River Region (URR), Central River Region (CRR) and West Coast Region (WCR). Restricting the research to only three regions was dictated by similarity in PHO functions across regions and resource limitations in conducting a nationwide survey. After the selection of the regions, the supervisors of PHOs (RPHOs) in each of the selected regions then automatically qualified to participate by virtue of they being the supervisors of PHOs in those region.
Of the three regions selected Six PHOs were selected from URR and CRR each and eight PHOs were selected from Western Region which had the highest number of PHOs. However, the decision with respect to the number of PHOs to be selected from each region was discretionary. The selection of health facilities from which the PHOs were to be selected was also done through random sampling by balloting just as in the selection of the regions. Thereafter, PHOs were selected through purposive sampling.
According to Kelly and Richard (2000), purposive sampling is designed to enhance understandings of selected individuals or groups' experiences or for developing theories and concepts by selecting “information rich” participants that provide the greatest insight into the research question. As it was required of participants to have an in-depth understanding of the public health functions to be able to answer the questions, only those PHOs who had served for at least one year in the field were interviewed at the selected health facilities.
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Participants of the Study
The sample size of this research was 20 PHOs at public health facilities and their respective supervisors (RPHOs) from each of the three selected health regions. These health regions vary greatly in size and other demographics. They all have urban and semi-urban towns in which PHOs work. The work content of PHOs may be different with some devoting more time on one activity than others and vice versa. However, in general terms, their functions are similar regardless of location. PHOs at health facility level who had served for at least one year in the field were eligible to participate. One year was used as a criteria because from consultation with senior practitioners at facility level and some senior public health officers at both central and regional level, this duration was considered long enough for any PHO to engage in all public health activities. However, public health students on their practicum attachments and PHOs who had just graduated from the School of Public Health or the University of The Gambia awaiting appointment and postings even if they have previous work experience were not eligible to participate.
After the selection of the regions, the RPHOs of the selected regions became eligible to participate by virtue of their positions because each region had only one RPHO. RPHOs in all regions had accumulated much experience in the field of public health due to their lengths of service in the public health field. The genders and ages of participants as well as their respective regions are withheld as these may reveal their identity. Similarly, the names given here are not real and do not represent any of the respondents. This was done because the interviewees were promised the anonymousness of the research. Their experiences range from one to eight years and fourteen to twenty two years for PHOs and RPHOs respectively. The experiences of the PHOs and the RPHOs are displayed in the table below.
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Table 3.1
Profile of Participants
PHOs PHOs RPHOs
Name Experience Name Experience Name Experience
Pa 1 year Mariama 3 years Bakary 22 years
Modou 1 year Bailo 3 years Omar 14 years
Isatou 1 year Musa 3 years Malafi 20 years
Ensa 2 years Sarjo 3 years
Dawda 2 years Haja 3 years
Elizabeth 2 years Paul 3 years Yankuba 2 years Ousman 4 years Mamadi 2 years Basir 5 years
Cherno 2 years Sira 5 years
Fatou 2 years Kawsu 8 years
Research Procedure
The topic for this research came about after doing the performance management course at the faculty of International Human Resource Development where this Masters Program is being pursued and as a result of the researcher’s own experience as a public health officer. After the identification of the research topic, literature was reviewed and the conceptual framework was developed. Due to the scarcity of literature specific to the area of this research, the methodology was largely shaped through consultations and reviews by peers and experts both in the field of public health and human resources development. This same procedure was pursued in the design of the data collection tools. The interview questions and the questionnaire were initially developed by the researcher in consultation with peers under the direction of the thesis advisor. After the design, both were further reviewed by experts. They were
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then pretested and modified accordingly. These processes where somewhat reiterative in nature. For instance, the questionnaire, though reviewed by both peers and experts, they were pretested and brought back to the experts for the final modification. This was the case for the interview questions too. Thereafter, data was collected by the researcher through interviews, the questionnaires were administered and the documents reviewed. All the collected data from the interviews were transcribed and coded for subsequent analysis while results from the questionnaires were analyzed using SPSS statistical software version 20. The results from the document review were tabulated. Thereafter, the results of all the aforementioned were interpreted based on the research questions to come up with the findings. The findings were then analyzed to draw the conclusions. Based on the conclusions, recommendations were made. The procedure adopted for the conduct of this research is shown in the Figure 3.2.
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Figure 3.2 Research procedure
Data Analysis
The data analysis procedure for the interview results can be described as had been done using the following steps:
1. Transcription of responses
2. Reading and rereading the transcripts 3. Segmenting and coding the data
4. Comparing , categorizing and inducing
5. Identifying relationships and answering the research questions
The researcher conducted all the interviews face-to-face and transcribed all the responses verbatim. The transcripts were read and reread several times to enable the
Collect data
3. Administer questionnaire 4. Record data
Generate results Transcribe/Code Interpret/Reflect
Review relevant literature
Propose suggestions
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researcher gain an understanding of patterns of similar ideas in the responses. The transcripts were then imported into MaxQDA 10 to summarize the data for further analysis and interpretation. MaxQDA 10 is a qualitative software program for managing qualitative analysis (Blake, Kohler, Culler, Hawley, & Rask, 2012).The software provided a medium for organizing the data and retrieving particular data segments for comparison and subsequent analysis. Similar data segments were grouped under the same concepts (referred to as codes in the software) which were then assigned code numbers (codes in this research). The codes were grouped into appropriate concepts. These concepts were further grouped under categories which were then categorized under themes upon which the analyses are based. This process facilitated the use of the themes to answer the various research questions as all the themes were based on the research questions. Memos were also created to explain the meanings of the categories and the assignment of codes. Figures 3.3 and 3.4 show the coding processes of RPHOs and PHOs respectively.
Code Response Concepts
A3-R07C1 I analyze the information on the checklists and from what I observe and make a report; these information are shared with PHOs during in-service meetings i.e.
feedback and appropriate actions are taken
Analysis
A3 –R07 C1
Concept 1
Response 2 of question 7 RPHO in region 3
Figure 3.3 Example of the coding procedure of RPHOs’ responses
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My responsibilities include immunization, inspection (food and premises), birth and death registration, disease surveillance and health education
Figure 3.4 Example of the coding procedure of PHOs’ responses
The responses of the supervisors and PHOs were coded together because both sets of questions were similar except for a few minor differences in their application as they pertain to the two groups. However, the codes for supervisors start with A1, A2 and A3 while those of PHOs start with B1, B2 and B3 for the three different regions respectively.
The analysis of the documents reviewed was done during the review process.
Documents were checked for availability in the particular RHT; standardization across the regions; and consistency with the legal and operational requirements of public health. These dimensions were checked against a checklist which was marked accordingly.
The responses to the questionnaire concerning the enabling conditions for
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performance were analyzed using SPSS version 20 statistical software to generate the descriptive statistics. The mean, minimum and maximum scores were generated to examine which necessary conditions for performance had the highest and lowest means as well as the minimum and maximum scores. This was done so as to be able to compare the extent of availability of environmental support factors against personal support factors. The results helped the researcher gauge the overall support available for PHOs to perform.
Quality of the Research
The interview questions were developed with reference to the review of literature
The interview questions were developed with reference to the review of literature