DIAGRAMAS DE MOMENTOS Y CORTANTES
3.2.3. Fase empírica
This chapter presents the philosophical approach, research design, and procedures that emerged as a means to explore perceptions and experiences of supportive supervision for health extension workers in Ethiopia. The chapter concludes with a presentation of my influence on the study as the researcher.
Philosophical Foundations
My aim in exploring experiences and perceptions of supportive supervision in the context of Ethiopia’s Health Extension Programme was to describe and interpret supportive supervision via the subjective voices of participants. This was influenced by my ontological belief that reality is constructed and understood through multiple
viewpoints. Therefore, a constructivist approach was the most appropriate theoretical paradigm, as it is based on the epistemological tenet that “human beings do not find or discover knowledge so much as construct or make it” (Schwandt, 2000) p. 197.
Constructivist researchers aim to understand the multiple constructions of knowledge by allowing them to emerge as they have been constructed by participants (Mertens, 2015). This is in contrast to positivist approaches which aim to identify constant
relationships between variables, based on the ontological perspective that an objective reality exists and the epistemological perspective that this reality can be identified and classified. Within constructivism, multiple constructions of reality can be understood, while allowing for the fact that some of these realities may be in conflict with each other and perceptions of reality may change throughout the research process (Mertens, 2015). My study aimed to understand how individuals experience and perceive the phenomenon of supportive supervision, and my constructivist ontological perspective is evident in my interpretation of the multiple realities of supervision of HEWs in the Ethiopian Health Extension Programme.
Within constructivism, an inquiry is an interpretive process; a researcher interprets a phenomenon by understanding how those who experience and construct reality interpret it themselves (Mertens, 2015). The current study aimed to uncover
experiences and perceptions of supportive supervision via a case study focusing on the perspectives of those who construct the reality of supportive supervision in Ethiopia’s Health Extension Programme.
Research Design
This instrumental case study was informed by descriptive and interpretive research methods, as described below.
Case Study Design
This study was designed as a case study exploring the perceptions and experiences of supportive supervision among HEWs, supervisors, and health system managers in Ethiopia’s Health Extension Programme. A case study was selected as the most appropriate methodology through which to explore the topic because the research question aimed to explore a specific phenomenon in a real-life context (Tellis, 1997).
As an instrumental case study, the study aimed to understand a particular issue and a case was selected to best understand the problem (Stake, 1995). In order to develop a comprehensive understanding of supportive supervision in the context of Ethiopia’s Health Extension Programme, this case study captured multiple perspectives through interviews conducted at a variety of levels in the health system. Interviews were conducted with health extensions workers, supervisors, and health system managers.
Several alternative qualitative research methodologies were considered in formulating this study’s research design. These included grounded theory (Glaser & Strauss, 1967), interpretive phenomenological analysis (Smith, Flowers, & Larkin, 2009),
Giorgi’s descriptive phenomenological method (Giorgi, 2009), and Van Manen’s phenomenological research method (Van Manen, 1990). Following this careful examination of alternative methods, a case study design was selected because I considered it be the best approach to addressing the research question. This case study drew on descriptive and interpretive approaches to qualitative research, which emphasise flexibility in research design based on the context, and rigour in
interpretation and abstraction of findings (Elliot & Timulak, 2005).
Selection of Participant Groups
For this case study, I chose to include a range of participants in order to develop a deep understanding of supportive supervision in the health extension programme. As demonstrated in the Chapter 2, while supportive supervision has been well defined as a policy by the Ethiopian Ministry of Health, there is relatively little known about the process of supportive supervision.
First and foremost, this study sought to shed light on the perceptions and experiences of supportive supervision among those who experience it first-hand – health extensions workers (HEWs) and supervisors. In addition, I included health system managers as a participant group, in order to understand their perceptions of the process of supportive supervision for HEWs.
Health system managers were sampled from each level of the Ethiopian health system (see Figure 2 below). Those from the Ministry of Health and the Regional Health Bureau were selected in order to understand the management of the policy process regarding supportive supervision, and those from the district health office and health centre were selected for their insights into the implementation of that supportive supervision policy.
It is important to note that health system managers may have been unlikely to be critical of supportive supervision or of the health system as a whole, because they might have an incentive to be complimentary of the system of which they are a part. Despite this potential constraint, this group was included since their perception of supportive supervision for health extensions were deemed to have potential to deepen my understanding of the process of supportive supervision.
Figure 2. Structure of Ethiopia’s Health System
The study did not include participants below the level of HEWs, including voluntary community health workers and model families. These groups were not included because the study focused on the formal heath system, and as volunteers these two groups are not part of the formal health system. The formal health system was the focus of the research because the supportive supervision policy for HEWs was implemented by formal health workers at multiple levels of the health system.
Development of the Interview Schedules
This study’s exploration of perceptions and experiences of supportive supervision was guided by four domains of inquiry: the context in which supportive supervision took place; the implementation of supportive supervision; the outcomes of supportive supervision; and challenges to supportive supervision. These domains were selected to capture the depth of experiences and perceptions of supportive supervision among participants, without being overly prescriptive. Interview schedules were developed for each participant group based on these domains (see Appendix A).
Interview schedule for HEWs. The interview schedule for HEWs first asked questions focused on demographic data:
• What is your age?
• Are you married?
• Do you have children?
These were included so that my interpretation of the data could be based on a general understanding of their life status. HEWs were then asked about the length of time that they had worked as HEWs, to contextualise their experience of supportive supervision within their careers as HEWs.
HEWs’ perceptions of supervision were then explored using the following questions:
• What does the word supervision mean to you?
• Why do you think supervision exists?
o What is the purpose of supervision?
o What is it supposed to achieve?
• Who benefits from supervision?
Understanding their perceptions of supervision contextualised their experiences of supervision and facilitated a deeper interpretation of those experiences.
HEWs experiences of supervision were then examined with the following questions:
• How has supervision changed since you became an HEW?
• When did your supervisor last visit?
o What happened?
o What did your supervisor do?
o What did you do?
o How long did they stay?
o Was that a typical visit?
• How often does your supervisor visit?
o How often do you want your supervisor to visit?
• How would you describe your working relationship with your supervisor?
After this question, I chose to include a question explored HEWs’ gender preferences regarding supervision. This question was important to include as part of HEWs’ perceptions of supervision, because I knew before the study that all HEWs are female and supervisors could be either male or female. Therefore, gender dynamics could potentially play a role in their perceptions of supervision. This was explored with the following question:
• Which do you think is better, a male or female supervisor? Why?
Finally, the following questions explored key aspects of HEWs’ perceptions of supervision:
• What is positive about the supervision you receive?
o What is helpful?
• What is challenging about the supervision you receive?
o What do you not like about it?
• Does supervision help you with your work? If so, how?
The interview schedule for HEWs is also included in Appendix A on page 240. Table 1 below indicates how interview questions for HEWs related to the four domains of inquiry.
Table 1: Domains and Interview Questions – HEWs
Domain Interview question
Context What does the word supervision mean to
you?
Why do you think supervision exists?
Implementation How has supervision changed since you
became an HEW?
1. When did your supervisor last visit? a. What happened?
b. What did your supervisor do? c. What did you do?
d. How long did they stay? e. Was that a typical visit?
How often does your supervisor visit? a. How often do you want your supervisor to visit?
Outcomes Who benefits from supervision?
How would you describe your working relationship with your supervisor? Which do you think is better, a male or female supervisor?
What is positive about the supervision you receive?
a. What is helpful?
Does supervision help you with your work? If so, how?
Challenges What is challenging about the supervision
you receive?
a. What do you not like about it?
What would you change about
supervision to make it most helpful for you?
Interview schedule for supervisors. The interview schedule for supervisors first asked questions focused on demographic data:
• What is your age?
• Are you married?
• Do you have children?
As with HEWs, these were included so that my interpretation of the data could be based on a general understanding of their life status.
Supervisors were then asked about their initial experiences of supportive supervision, focusing their recruitment and training. This was included because it forms a key part of the process of supportive supervision. The following questions explored this:
• How were you selected to become a supervisor?
o How did you find out about the training program to become a supervisor of HEWs?
• Did you have supervision training?
o If yes - how long did your supervision training last?
o If no - did you have other trainings?
o Do you want more training?
After this, supervisors were asked about key aspects of their perceptions of supportive supervision using the following questions:
• What does the word supervision mean to you in the context of the Health Extension Programme?
• Thinking back to when you started as a supervisor, how did you think supervision would work? What are your thoughts on that now?
• Do you want to continue working as a supervisor?
Supervisors were then asked about their experiences regarding supervising HEWs with the following questions:
• For how long have you been a supervisor?
• How many health posts do you supervise?
• How has supervision changed since you have been working?
• How often do you visit each health post?
• How often would you like to visit each health post?
• How far do you travel to your health post?
• When did your last supervisory visit take place? And what happened?
o What did you do?
o Did you use a checklist?
o What did the HEWs do?
o How long did you stay?
o Was that a normal visit?
o What happens after a visit?
• How would you describe your working relationships with the HEWs that you supervise?
Finally, supervisors were asked further questions about their perceptions of supervision:
• What is positive about the supervision that you provide to HEWs?
o What do you like about it?
• What is challenging about the supervision?
o What do you not like about it?
• Is there anything that makes it easier for supervision to be carried out?
• Do you think that supervision helps HEWs with their work? If so, how?
• What would you change about supervision?
By exploring supervisors’ perceptions and experiences of supportive supervision, I sought to use the interview schedule to develop a deep understanding of supportive supervision in the health extension programme. The interview schedule for supervisors
is also included in Appendix A on page 244.
Interview schedule for health system managers. The interview schedule for health system managers focused on eliciting their perceptions of supportive supervision for health extension workers. As with HEWs and supervisors, health system managers were first asked the following basic demographic questions:
• What is your age?
• Are you married?
• Do you have children?
They were then asked about the length of time that they had worked in their current role, to contextualise their perceptions of supportive supervision relative to the
implementation of supportive supervision in 2012. Health system managers were then asked the following questions regarding their perceptions of supervision:
• What does supervision mean to you in the context of the Health Extension Programme?
• What is the purpose of supervision from your perspective? o What is it supposed to achieve?
• What should take place during supervisory visits?
o What should supervisors do? What should HEWS do?
o Prompt for those with previous experience as supervisors: What took place during supervisory visits when you worked as a supervisor?
• Do you feel that policy regarding supervision is being implemented on the ground as it is intended to be?
• Do you think there are any barriers to implementing supportive supervision? If so, what?
• Do you think there are any facilitators to implementing supportive supervision?
• How do you think supportive supervision impacts HEWs’ work overall? • Is there anything that you would change about supportive supervision policy?
As described previously, exploring health system managers’ perceptions of supportive supervision for HEWs facilitated a deeper understanding of the process of supportive supervision. The interview schedule for health system managers is also included in Appendix A on page 240.
Procedures
Ethical Approval
Ethical approval for this study was received from the Centre for Global Health’s
Research Ethics Committee at Trinity College Dublin as well as the Institutional Review Board of the School of Public Health at Addis Ababa University in Ethiopia (see
Appendices B & C).
Research Sites
Research took place in the Southern Nations, Nationalities, and Peoples' Region (SNNPR) and in Addis Ababa, the capital of Ethiopia. HEWs, supervisors, and regional health system managers were interviewed in SNNPR, and national health system managers were interviewed in Addis Ababa. The quality of this study was dependent on the participation of a skilled translator. While the districts within SNNPR in which the study took place speak a local language in addition to Amharic, I chose to recruit an Amharic translator. This is because all HEWs speak fluent Amharic, because it is the official language of Ethiopia and because fluency in Amharic is a recruitment criterion for the role. Highly skilled Amharic translators are much more readily available than translators of the local language spoken in the districts in which my research took place. For this reason, and because I felt that HEWs would be able to fluently express themselves in Amharic, I recruited an Amharic-speaking translator.
From SNNPR’s 14 zones, I selected one zone in order to develop an in-depth understanding of supportive supervision in the context of one geographic area. The zone that was selected was chosen due to its proximity and thus relative accessibility to Awassa, the capital city of SNNPR, where I was based during data collection. Transportation is a challenge in the remote areas where HEWs and supervisors are based, and as such accessibility was an important criterion. The zone is not named here in order to ensure confidentiality.
Within the zone, HEWs were selected from one district and supervisors were selected from another district in order to avoid HEWs having to answer questions about their own supervisor in the knowledge that I would also be interviewing that supervisor, and vice versa for supervisors. This could have resulted in both HEWs and supervisors being less open in their responses to interview questions, and therefore two districts were selected from the zone. The two districts that were selected were chosen for their accessibility and because neither is located in the extreme highlands or lowlands, making them comparable geographically relative to other districts in the zone. They are not named here in order to ensure confidentiality.
Letters of Support from Local Authorities
After selecting the study sites, I requested letters of support from local health
authorities. This necessitated two in-person visits to both SNNPR’s Regional Health Bureau and the Zonal Health Office (see Appendix D). Both offices granted letters of support for the research.
Sampling Strategy
As a qualitative case study, non-probabilistic sampling was the most appropriate sampling technique for this study. Sampling decisions involved careful consideration of the specific research aims, so that the people, settings, events, and processes that
were sampled aligned appropriately with the research question, as suggested by Miles and Huberman (1984). In this regard, Elliot and Timulak (2005) emphasise that if a study “aims to depict central, important or decisive aspects of the investigated phenomenon, then sampling should assure that these are covered” (p. 152). Therefore, the current study’s sampling strategy aimed to cover a range of perspectives regarding perceptions and experiences of supportive supervision in Ethiopia’s Health Extension Programme. The strategy entailed my recruiting participants who experienced supportive supervision firsthand (HEWs and supervisors), as well as health system managers at various levels who provided valuable insights regarding their perceptions of supportive supervision.
Participants were selected via purposeful sampling, the most common sampling strategy in qualitative research, in which individuals are chosen according to
predetermined criteria deemed relevant to the research objectives (Creswell, 2013). Specifically, this study was carried out via a mixed purposeful sampling technique, which included random purposeful sampling (involving random selection from a purposefully selected sampling frame) and convenience sampling (in which
participants are selected according to their availability and willingness to participate) (Onwuegbuzie & Leech, 2007). Random purposeful sampling was applied to the selection of HEWs and supervisors. The alternative would have been to ask local district officials to select participants, and this might have skewed participants towards best-performing or favoured HEWs and supervisors. Convenience sampling was applied to the selection of health system managers because there were fewer potential participants to draw from in this category, which necessitated a more flexible and inclusive sampling strategy in order to reach my predefined sample size of 10 participants for this category.
Within purposeful sampling in descriptive and interpretive research, although