The study method for the situational analysis phase is discussed as follows:
3.6.1 Study design
The research design used in this phase is convergent parallel mixed method study design. Convergent parallel mixed method study design is explained as “a study design which collect both types of data at roughly the same time; assessing information using parallel constructs for both types of data; separately analysing both types of data; and comparing results through procedures such as a side-by-side comparison in a discussion, transforming the qualitative data set into quantitative scores, or jointly displaying both forms of data” (Creswell, 2013). The use of
convergent parallel design in the collection of data for diabetes patients permitted the researcher to collect data through questionnaire and interviews, and subsequently
comparing the quantitative and qualitative data of patients with consideration of the strengths of the two methods. Quantitative strand used a cross-sectional descriptive study design, while qualitative strand used phenomenological exploratory study design.
Figure 3.5: Schematic representation of the convergent parallel design.
3.6.2 Pilot study
The pilot study was conducted at the non-participating clinics of Blouberg Municipality.
The pilot study was used to pre-test or validate quantitative and qualitative data collection instruments. Permission to conduct pilot study was obtained from nursing
managers and participants also signed informed consent. For the quantitative, it determined average time required to complete the questionnaire which was 15-20 minutes for both questionnaires, including determining how well the questions are understood by participants. The findings of pilot study produced no changes to the questionnaires. The number of participants used for the pilot study of the quantitative strand were 10 diabetes patients and 10 family members. For the qualitative, it used to identify vagueness of the interview guide, and no modification was done. Three participants were interviewed. All participants of both quantitative and qualitative pilot study were not included in the main study.
3.6.3 Quantitative strand
Participants for the quantitative strand are both diabetes patients and their family members. The quantitative strand dealt with the following objectives in the situational analysis in phase 1:
• To determine anthropometric parameters (BMI and waist circumference) of diabetes patients in Blouberg Municipality, Limpopo Province.
• To determine knowledge of nutrition and exercise in the management of diabetes among patients and families of Blouberg Municipality, Limpopo Province.
• To determine attitude of nutrition and exercise in the management of diabetes among patients and families of Blouberg Municipality, Limpopo Province.
• To determine practice of nutrition and exercise in the management of diabetes among patients and families of Blouberg Municipality, Limpopo Province.
The rationale for determining knowledge, attitudes and practices of family members regarding nutrition and exercise in the management of diabetes was to ascertain the level of support.
3.6.3.1 Study design
Cross-sectional study design was used. It was relevant in this study because it enabled the researcher to determine anthropometric measurements as well as obtaining information about knowledge, attitude and practices of both diabetes patients and their family members regarding nutrition and exercise diabetes care.
3.6.3.2 Sample size, sampling and sampling procedure of participants
The first step in selecting a sample is to outline the population of interest. In this study, the target population was diabetes patients and their non-diabetic family members.
The clinics in Blouberg Municipality are clustered, therefore, the list of clinics per cluster provided sampling frame for diabetes patients. Since clinics in Blouberg Municipality are clustered according to 4 areas, there are 6 clinics per area, clinics with more than 20 patients per month per area were purposively sampled. Participants in the quantitative strands were diabetes patients and their family members, therefore sample size and sampling is described for both patients and family members.
The sample size for diabetes mellitus patients was calculated as follows using Yamane (1967):
n=N ÷ 1+N (e) ² n = Sample size N = Population size e= error margin (5%)
Therefore, the sample size was calculated at 95% confidence interval.
n=N ÷ 1+N (e) ²
= 406÷ 1+406 (0.05) ² = 406÷ 1+406 (0, 0025) = 203 (rounded off to 200)
An additional 10% which amounted to 20 patients were included on quantitative sample to cater for attrition and spoilt questionnaires, and finally yielded a diabetes patients’ sample of 200 participants. Systematic sampling techniques was used to select diabetes patients, where every second patient in each participating clinic was selected. From each clinic, every second diabetes patient was selected to participate in the quantitative strand of the study. The family members were selected through the sampled diabetes patients who were each requested to bring a non-diabetic family
member. Moreover, family members were not in any medical treatment and stays patients with diabetes most of the time.
3.6.3.3 Data collection of the quantitative strand
The data collections tools including procedures are outlined as follows:
3.6.3.3.1 Data collection tools
Data was collected using 2 sets of self-administered close-ended questionnaires. The advantage of using a questionnaire is that the researcher can gather data from many respondents in a relatively short space of time. First questionnaire was for people living with diabetes mellitus (See annexure C), with five sections, second questionnaire was for family members (See annexure D), with four sections. Section A had questions about socio-demographic profile, which was developed by the researcher. Section B was about Anthropometric Parameters (Family members’ questionnaire did not include this section). Section C had questions relating to knowledge of nutrition and exercise in diabetes management, which derives from a study by Muchiri, Rheeder, and Gericke (2013). Section D and E had questions relating to attitudes practice of nutrition and exercise., respectively, which derives from both Keakile and Skaal (2015), and Le Roux et al. (2016).
3.6.3.3.2 Data collection procedure and recruitment
The researcher and trained research assistants visited clinics for the introduction of the study, and its aims and objectives on the day chronic/diabetes patients consult.
The researcher made appointments with diabetes patients who were willing to participate, at a time which was convenient for them. However, those who were immediately available to participate, consent forms were distributed to them. After signing the consent, questionnaires were given to them for completion. Selected diabetes patients not accompanied by family members meeting inclusion criteria, and staying within a walking distance to the clinic were requested to bring the family member, who is not diabetic or on any chronic disease treatment, and stays full-time with patients. Other family members who followed home to get such family member.
Diabetes patients and family members were given 15 to 20 minutes to complete the questionnaire on their own, but the researcher and an assistant were available in case any clarity was required, and for those who cannot read or write they were assisted to
fill in the questionnaire (de Vos et al., 2011). Also, the research assistants measured and recorded anthropometric measurements i.e., weight, height and waist circumference.
3.6.4 Qualitative strand
Participants for the qualitative strand of the situational analysis phase were only diabetes patients, as targeted participants, because they could relay lived experiences of personally being diagnosed with diabetes and how they perceive quality of life. The qualitative strand of this study dealt with the following objective of the situational analysis phase of the study:
• To explore diabetes mellitus patients’ perceived quality of life post diagnosis in Blouberg Municipality, Limpopo Province
3.6.4.1 Study design
Phenomenological exploratory study design was used. Phenomenological exploratory study design was relevant since it helped in explaining quality of life of patients, including knowledge, attitude, and practices regarding nutrition and exercise diabetes care, as well as challenges of living with the disease and family support.
3.6.4.2 Sample size, and sampling and sampling procedure
Data saturation was reached at the 15th participant, but two more participants were interviewed to confirm the saturation, and added no new information, leading to discontinuation of data collection. Therefore, the sample size for the qualitative strand were 17 diabetes patients.
Purposive sampling was used to select diabetes patients from the clinics. The researcher purposively selected diabetes patients with more than six months receiving and on diabetes treatment from the clinic. The participants were chosen because of they can relay their quality of life and lived experience or challenges impacting on quality of life.
The selection of diabetes patients was done at the clinics at the same time with the quantitative study sampling. The selection was done on the days that chronic patients, including diabetes patients, receive their medication from the pharmacists from the
only hospital in the Blouberg Municipality. The selection of patients was done through assistance of clinic nurses.
3.6.5 Data collection
Informed consent was obtained from participants before the commencement of data collection. Data collection was done, until data saturation was reached. The data collection tool and procedure for diabetes mellitus patients is discussed as follows:
3.6.5.1 Data collections tools
Data were collected using semi-structured in-depth interview guide (See annexure E).
There was one interview guide written in English and Sepedi. The researcher observed non-verbal communication such as gestures and facial expression from the participants and at the same time observed their attitudes in order to eventually compile notes about the quality of life of patients. The central question for the interview of people living with diabetes mellitus was: ‘Kindly describe your perception of quality of life after having been diagnosed with diabetes mellitus?’ One-on-one interviews were conducted using voice recorders, and field notes for non-verbal cues observed which couldn’t be captured by the voice recorder during interviews. Probing and clarity seeking questions were asked to obtain in-depth information.
3.6.5.2 Data collection procedure and recruitment
The researcher recruited participants from selected clinics. Those who were immediately available, interviews were conducted immediately, and follow-up appointments were arranged with those willing to participate and are not immediately available for interview. The interviews were conducted in Sepedi as a dominant language in the area, however, participants also mixed with English. Participants were informed when voice recorders were switched on and off. The interviews were done in Sepedi as the dominant language in the area. Each interview took about 20-40 minutes. A quite room conducive for interviews was used to ensure privacy and confidentiality during the interviews, however, noises from people outside were heard but never disturbed or compromised interviews. Participants were allowed to talk most with the researcher listening most of the time. Minimal remarks were made by the researcher to allow participants to tell more. Open-ended questions were asked at a time allowing participants to respond in their own way.
3.6.5.3 The role of the researcher
The researcher’s role was to facilitate the interview and therefore to allow participants to move freely from questions to questions. Also, the researcher directed the interaction and the enquiry using semi-structured questions contained in the interview guide. The researcher observed non-verbal communication such as facial expressions and gestures from participants. As the interview goes, field notes were taken by jotting down any observed action. Flexibility, empathy, and objectivity were maintained by the researcher throughout the interview. Good listening by the researcher permitted participants to talk more uninterrupted. The researcher as the interviewer remained open to the experiences of participants rather than attaching own meaning to participants’ discussion (Burns & Groove, 2011). The researcher used bracketing, intuiting and reflective remarks during the interviews.
Bracketing: It is explained in the qualitative data analysis “as the process of putting aside what is known about the study topic to allow the data to convey undistorted information” (Brink et al., 2012). The researcher laid aside what is known about quality of life post-diagnosis with diabetes in avoidance of preconceived ideas and beliefs.
Intuition is explained as “the accumulation of attitudes including beliefs and opinions derived from experience or literature” (Brink et al., 2016). The researcher adhered to the questions in the interview guide and remained naïve for the avoidance of his own views. A reflective diary was kept by the researcher throughout the study. The following communication techniques to clarify and get more details of the interviews were used as a guide to get rich data (de Vos et al., 2011):
Probing: Probing was used to obtain information from patients about their quality of life. The researcher used statements such as “may you please tell more” or “please let’s talk more about that” to encourage participants to give more information about their quality of life and how they maintain their QoL.
Making minimal response: It is explained as “verbal counterpart of occasional head nodding used during interviews, so as to assure participant that the research is listening” (de Vos et al., 2011). The researcher used verbal cues such as “Hmmm”,
“yes”, “I see”, to encourage participant to tell more. At times, the researcher nodded to communicate that he understood what the participants were saying.
Paraphrasing: It is explained as “restating an author’s ideas in other words that capture the meaning” (Gray et al., 2017). It also implies understanding and consequently refers to direct quotation for theoretical content that is part of a scholarly paper. The researcher stated participants’ words in another form with similar meaning, for example when a participant said “as a result of diabetes, I’m unable to sexually satisfy my wife”, the researcher would paraphrase it and say, “do you mean diabetes has complicated to the extent that you are unable to have sex or minimally having sex with your wife?”.
Clarifying: When the researcher needed more clarity from participants regarding quality of life of patient, used statement such as “could you please tell me more about that….”
Reflection: It is defined as “a process that requires integrating a wide range of perceptions to realize what is known within self; interacts with the process of response to challenge and authenticate personal knowledge” (Chin & Kramer, 2015). For this study, the researcher reflected on something interesting the participant had said, the researcher reflected on the feelings and non-verbal behaviour in order to get participants to expand more to get deeper meaning. Statements such as “so you believe eating healthy and exercising improves your quality of life”.
Responsive listening: It is explained as “the ability to detect change over time in a construct that has changed, commensurate with the amount of change that has occurred” (Polit & Beck, 2017). The researcher attended to verbal and non-verbal messages such as eye contact, body language, gestures, posture and underlying thoughts and feelings of the participants. The researcher listened attentively to the patients as they relayed their lived experiences and quality of life.
Silence: The researcher allowed participants to express their emotions for a particular time and the researcher remained quiet.
Reflective summarizing: It is regarded as the point at which the researcher summaries the participants’ ideas, thoughts and feelings verbalized so far to see if the participant is understood. Statements such as “so what you are actually saying is...”
The reflective summary has a structuring function and stimulates participants to give more information. The researcher tied together several views which has been
communicated. Major cognitive and affective themes were brought together. Member checking was done with patients for the confirmation of the information gathered were what they meant.