Journal of Addiction Research & Therapy
Open Access

Before a researcher plans to undertake research, he/she has to be impressed and motivated with the actual problem in the study area. Besides, the researcher has to give due attention for a problem and decided to address this problem in any alternative ways to best address the problem [1]. In light of this, the idea of this study steamed from Pragmatic philosophical assumption, and it is mostly called the pragmatists’ world view.

Those individuals who have Pragmatic philosophical view do not see the world as an absolute unity. Hence, this group of people does not accept the idea of one reality and believe that there is a need to check this reality in a certain context as it is influenced by actions, situations and experiences of that particular society. According to the Pragmatists’ stand, the overall goal of a research relay on actions, situations, and consequences rather than procedures. In addition, this philosophical assumption or world view, gives a great emphasis to understand the problem rather than methods and there is freedom of choice for methods, strategies and procedures to best address a problem [2].

Therefore, due to the very interest of the researcher to see the situation and reality of the problem in different angles in the new context (Gumuz Community) and his intention to collect the diversified type of data on the issue, this study ultimately takes the pragmatists view to meet the overall and specific objectives [3].

Brief description of the study area

Metekel zone is one of the three major administrative zones in Benishangul Gumuz Regional State. It consists of seven woredas and Dibatie woreda is one of these woredas with in this zonal territory. Dibatie Woreda is located at 546 kilometers northwest of the Country’s Capital, Addis Ababa. It is also located at 223 kilometers southwest of Bahir Dar on the way to the Great Renaissance Dam of Ethiopia. The neighboring woredas of Dibatie include; Bulen in the west, Yaso in South and South Eastern, the Amhara regional State in north east and Mandura woreda in north. The total population of the woreda is estimated to be 81,976 out of this figure, 39,345 (48 %) are women. The total number of Gumuz people in the woreda is about 23,987 of which 11,347 (47.3%) is women. This woreda consists of twenty nine kebeles [4].

Here, the researcher has selected three kebeles namely Wobigish, Gesses and Qiddo out of the twenty nine kebeles in the woreda purposely as they are consisting of predominantly Gumuz population at which the primary target of the study rests. The rationale for preferring Dibatie woreda to other woredas is due to the fact that this particular district has kebeles with relatively Gumuz dominant population which is the nucleus of this study. Besides, the researcher has long term working experience with the community and he knew the existence of different factors including socio-cultural practices affecting pregnant women in using prenatal care services. Hence, the researcher was also interested in exploring these context specific Practices in this particular area [5].

Research methods

To undertake this particular study, the researcher used the mixed method approach which combines both qualitative and quantitative methods. The rationale for preferring mixed method to other methods to conduct this study is arising from the very nature of the research questions identified in the research. Here, this study consists of research questions that need qualitative exploration and investigation as well as quantitative measurement. As it is explained by author, exploration requires going deep in to people’s day to day life, interactions and expression of past experiences that can better be captured through gathering qualitative information. Therefore, to explore deep into participants’ opinion about factors influencing prenatal care service utilization in their natural settings qualitative inquiry was used.

Moreover, in this study questionnaire was developed to provide broader base to some factors hindering women’s utilization of prenatal care services identified qualitatively. To this effect, questionnaire was designed to measure knowledge, attitude and decision making power of women in using prenatal care services for extra explanation [6]. As author explained mixed research method is useful in minimizing the weaknesses in either the quantitative or qualitative approach as these methods complement to each other to address the problem in a study. Hence, mixed approach is found to be more preferable for valid and reliable findings [7]. To sum up, the rationale for selecting mixed method for this specific research could be the nature of the research questions which need both qualitative as well as quantitative techniques to address them and its advantage to minimize weaknesses or maximizing validity of data. Due to these reasons, mixed method is much more important and convenient than others to address the research questions of this particular study [8].

Research design

There are a number of designs or strategies under mixed method approach to be used by researchers based on the objectives of their research. To undertake this study, sequential exploratory is found to be a more useful design. This is because the Objectives of this study focus on exploring factors affecting women first and then doing statistical measures among the identified themes to support the qualitative findings. This design consists a qualitative method followed by a quantitative one [9]. First the qualitative method was used to explore factors affecting women’s Prenatal Care Services in-depth in the study area. Second, the quantitative method was used to quantify some factors identified through the qualitative approach to make generalization about the population. More emphasis was given to exploration and investigation of factors due to the fact that the study area is expected to have its own distinct socio-cultural influences that need investigation. Hence, this specific study used qualitative methods to explore and investigate factors and the quantitative one to measures some identified variables sequentially [10].

Data sources

There are two major sources for any study to gather data using the more appropriate data gathering instrument, these are primary and secondary sources. The primary data sources are those from which afresh and a first time data could be available, and thus happen to be original in character. The secondary data sources, on the other hand, contain those data which have already been collected by someone else and which have already been passed through the statistical process [11].

Here, exploration and in depth study of factors influencing Pregnant Women and making statistical measurements on some identified variables basically need firsthand information. Accordingly, for the realization of the objectives of this study, the researcher gathered information from primary sources such as interviewees, key informants, focused group discussants and Respondents [12].

Data gathering methods and instruments

As a mixed study, in this typical research there are different kinds of tools employed to gather information from primary sources. Major data gathering methods used to gather information for this particular study were in-depth interview, focused group discussion and questionnaires [13].

Interview

In-depth interview was employed in this particular Study to gather detailed information about factors affecting women’s prenatal care service utilization. Both semi-structured and unstructured interviews were used to produce views and opinions from women participants. According to author interviews are useful to see different perspectives, attitudes or behaviors about some topics of interest. One of the major advantages of interview according to him is its key role to gather data with minimum time, energy and in a less restrictive as well as less standardized way. Here, key informant interviews were prepared to gather information from those individuals selected as key informants by the researcher on the specific criteria. These key informants were selected based on the criteria being knowledgeable at least in the topic under discussion and be in continuous relationship with the researcher to exchange information [14].

Hence, three informants were selected; from health extension workers, religious leaders and Dibatie woreda health personnel. This is due to the fact that these individuals from different categories could have a diversified knowledge on the issue. Therefore, key informant interview was used in this particular study to gather detailed information about factors hindering women in using prenatal care services and context specific socio-cultural factors through semi structured and unstructured interviews. Here, the purpose of using this interview is to strengthen the findings through interview and focus group discussion [15].

Focused group discussion

Focused Group Discussion is the second major data gathering method which was employed in this exploratory research. Thomas, explained that focus group discussion gives the researcher a privilege to access group conversations which contain ‘indigenous' terms and categories in the identified issues. Moreover, it used to study group norms and group understanding concerning a certain issue.

Practically, the researcher in this study conducted a focus group discussion with Semi-structured and unstructured interview guidelines to get information or group understanding on factors affecting women’s prenatal care service utilization particularly context specific socio-cultural factors in the area. However, it is to be expected that deviant experiences will be overlooked. Hence, to get individuals’ ideas, attitudes and feelings which are deviated and muted during the focus group discussion, the researcher also used independent in-depth interview [1].

Questionnaires

As author explained, Questionnaries are mostly used to generalize about the population from the findings of samples. Considering this, the researcher developed questionnaires with closed ended or structured questions from qualitative findings and gathered information on some factors. In other words, questionnaires were developed and used to gather information on knowledge status of women about the prenatal care services, their attitude towards these services and their decision making power to use such services.

Here, the rationale for quantifying the three themes out of the total factors identified in the first phase of this study was that these themes are emerged from both the data and literature review and these are easy to compare with findings of studies with same variable elsewhere in the country unlike the rest factors which might be peculiar to other places in the country [3].

Sampling techniques

According to author, in probability sampling, each member of a target population has equal chance of being selected and included in the sample whereas in non-probability sampling each member of a target population may not have equal chance of being selected and included in the sample. . In this research both probability and non-probability sampling methods were used. Purposive sampling technique was employed to select research participants of the qualitative method. The rationale for selecting purposive sampling technique for this research was that due to the need for personal judgments as to what level these participants are important to meet the objectives of the study [15].

Here, the inclusion criteria for women interview participants and focus group discussants were; women with experience of pregnancy or child birth and with access to health centers in the age category of 18 to 49 years. The rationales for these inclusion criteria were; in the first place women in this age category were expected to have experience for pregnancy and birth. In the second case, as it is clearly indicated in the delimitations and problem statement part of this study, the focus was made to explore those factors apart from accessibility. Key informants were selected from different categories expecting that they have a diversified knowledge to deal with the problem and willing to have continuous relationship with the researcher.

To select respondents for the questionnaires, systematic random sampling was used. The rationale for preferring systematic random sampling in this particular research is that the sampling frame of the target participants was well known and the sample size had been determined. Hence, fulfilling such conditions, systematic random sampling is much more easy and cost effective than the rest techniques.

Sampling size

To gather the necessary data for the qualitative inquiry, a researcher should continue interviewing them until he/she no longer hears or sees new information about the phenomenon from participants. This stage is known as data saturation. Here, after the ninth interviewee the researcher believed that saturation was reached and stopped interviewing another informant. As Dawson’s (2007) recommendations which justify that the number of group discussants in a group should be 6 to 8 individuals, six (6) women participants were selected to undertake the group discussion. To supplement the findings through interview and focus group discussions three (3) key informants were selected. Totally, 18 research participants were selected to undertake the qualitative part of this study.

On the other hand, to gather quantitative data on some selected variables, the researcher has adopted the statistical consensus for sequential exploratory studies from Heran (2008) which recommends selecting 10% of the total target population in the area. Again, Costello and Osborne (2005) indicated that 10% of the total subjects with minimum number of fifty (50) is the advisable sample size in sequential exploratory researches. Accordingly, the researcher selected 60 sample respondents from the sample frame of 602 women (the total number of women who are living in the three selected kebeles).

Sampling procedures

To access and communicate the participants of this study, the researcher used health extension workers as they are very close to these women. Moreover, these health workers are responsible for creating awareness about prenatal care service and its advantage at each kebele. Therefore, individual women for interview were selected purposely based on the inclusion criteria and women with interest and willingness to share their ideas were given priority. Again, key informants from different categories have been selected by the researcher assuming that they could have a direct or indirect connection and diversified knowledge on the problem.

Lastly, to select questionnaire respondents, a house to house survey was used in each kebele to find and register those women who are eligible according to the inclusion criteria. The criteria included those women with experience of pregnancy or child birth under the reproductive age of 18- 49 years and with access to service centers. Then final selection was made from each kebele using systematic random sampling technique. That was done after selecting a random starting point, every 10th household based on the formula was taken. When there was no eligible woman at the specified interval, the nearest household that satisfies the criteria was taken. For those households more than one eligible women, interview was done by selecting a woman using lottery method.

Procedures for data collection

Prior to any communication with the local administrators and participants of the study, the researcher had got a legal letter of cooperation from Bahir Dar University to facilitate data collection processes. As a first step towards data collection, data collecting instruments were developed. Accordingly, interview and focus group discussion with semi structured and unstructured guiding questions have been developed to gather the necessary data on the issue. In addition to this, selection of translators and data collectors was done to make conditions very convenient for data collection. Here, the researcher together with local individuals recruited 6 (six) female health extension workers as data collectors and translators from Amharic to Gumuzgna and vice versa during data collection process in their respective kebeles. This was done intentionally as these individuals are familiar with Gumuz women to get authentic data.

Completing the recruitment process, the researcher gave orientation on the general purpose of the study and how to collect data to have a common understanding about the study. Having done this, the researcher has made a pilot test on the developed interview and focus group discussion guiding questions using 5 (five) selected women in a nearby kebele (Berber) to check their clarity. The data gathering instruments were modified based on the comments given by the data collectors and the participants in the pretest.

The interview and focus group discussion responses have been put both in the actual responses of the interviewee and in narration form and according to these responses codes have been established to categorize them into themes. The responses from key informant interviews were gathered at all time in the course of data collection and analysis part of the study. All the data collected in these tools was organized and integrated for analysis to show the actual findings of the qualitative part. Based on the findings of the qualitative method, the researcher designed the structured questionnaire, translated into Amharic and pre-tested and administered it to gather the quantitative data. The qualitative data was gathered for 10 consecutive days (2-11/08/ 2006 E.C) by the researcher supported by translators. On the other hand, the quantitative data was gathered for 8 days (16-23/08/2006 E.C) by trained data collectors who speak the local language and the total data collection took 18 days. Then each filled questionnaire was checked manually for its completeness and clarity. Having done this, each questionnaire had been coded and entered in to SPSS software version.20 for further process.

Data analysis techniques

The data gathered using different instruments were recorded as field notes, audio records and filled questionnaires. From these records the data was organized and presented using various types of data presentation mechanisms like tables, percentage compilations and narrations that made ready for analysis. In analyzing the qualitative data, the researcher has created codes for each response and categorized them into themes to better understand the findings. Specifically, thematic analysis has been employed in this particular study to meet the corresponding specific objectives.

On the other hand, the quantitative data analyzed using descriptive, bivariate and multivariate analysis methods. The descriptive analysis used to summarize the characteristics of each variable to support the qualitative findings. Moreover, bivariate analyses were used to compare categories and measure the association of each independent variable with dependent variable. However, a bivariate association between two variables does not necessarily imply a significant causal relationship between them, because in real life situation more than one predictor variables operate to influence the response variable.

Therefore, multivariate analysis had been done. Specifically, Chi-square test has been undertaken to check the association of the identified variables with prenatal care service utilization of women. The researcher prefers Chi-square as the dependent variable or prenatal care service utilization is a dichotomous variable with two options, utilized or not utilized. Again in this study, Binary Logistic Regression model has been used as it functions for non-parametric tests with categorical variables and due to the dichotomous nature of the dependent variable.

Finally, the findings of the quantitative methods were incorporated into themes to draw conclusions and recommendations.

Ethical considerations

In the first place, the respect for participants is a fundamental ethical consideration of this study and informed consent was obtained before the beginning of the study with each participant. Here, the purpose of the study was properly expressed to the participants as they were given their free consent to participate in the study and they were told that they have the right to with draw from being interviewed at any time. It is based on this consent participants gave to the researcher; he identified himself and his address to the participants. On the other hand, participants were told that, the information they provided would be used for research purpose only and their name will be kept anonymous and all their names in the research finding will be represented through codes and other techniques.

Moreover, participants were told about procedures to be used in the data collection, the expected impact the research will bring their privacy particularly while they were interviewed and as they have the right to ask questions. Finally, the researcher explained to the participants as the data used for this research will be kept for reasonable time only and will be discarded and assured as it will not fall in to the hands of other researchers.

Trustworthiness of the data

The trustworthiness or validity of this study was preserved in a number of ways throughout the research process right from the design to the completion of the research activities in the actual research site. In the beginning, pilot test was made on qualitative data gathering instruments before using them to collect the main data and based on the comment found in the area some modifications were made on these instruments. Moreover, to enhance the validity of the study, data source triangulation was done that is cross checking the data through different sources used such as interviewees, focus group discussants and key informants.

Again, in the quantitative part of the study, reliability test has been done to refine questions to best describe the identified variables specifically knowledge and attitude. Accordingly, the cronbach’s alpha value for variables in knowledge was about 0.82 and that of attitude was 1.00 (See Table 3 in Annex: 3). Hence, according to George and Mallery (2003), the cronbach’s alpha value for knowledge is good and for that of attitude was excellent. In other words, those questions which are less descriptive were removed and those best described knowledge and attitude were incorporated. Lastly, statistical tests were made to maximize validity of the findings through those qualitative instruments (Table 1).

Table 1: Demographic characteristics of interviewee, focus group discussants and key informants.

Results of the study

The background information of the participants of the interview, focus group discussion and key informant interview was registered and according to this profile, all of the participants of the interview fall between the age range of 21 and 37 years old and when we see the educational status of these participants, two of them can only read and write and seven of them were illiterate. Seven of the participants of the interview were traditional religion followers and the remaining two were Orthodox Christians. Seven of them were married followed by one separated and a widowed woman.

On the other hand, the back ground characteristics of the group discussants indicated that all of them fall between the age of 23 and 42 years and five of them were traditional religion followers and only one woman was Orthodox Christian. Again, five of the focus group discussants were illiterates and only a woman can read and write. In addition, five of them were married and one woman was separated. Lastly, the key informants fall between the age of 39 and 57 years and one of them was with college diploma, another one can read and write and the last informant is illiterate. Again, two of the informants were traditional religion followers and one was Orthodox Christian and all of the three informants were married.

Questionnaires were distributed and filled by sixty (60) respondents selected proportionately from the three target kebeles in the woreda. Accordingly, 30% of them were found under the age group of 18-25 years and most of the respondents are said to be illiterates as they constitute about 75% of the total number of respondents. Moreover, most of the respondents (68.3%) are followers of the local traditional religion in the area and 83.3% of the respondents were married (Table 2).

Table 2: Demographic characteristics of survey respondents.

The data gathered on factors affecting women’s utilization of prenatal care services in Gumuz community was organized and analyzed. At the beginning, codes were given to interview and focus group discussion participants to know who said what and arrange the responses accordingly. The data gathered through interview and focus group discussion was put in the form of field notes and tape records. Then reading these notes and hearing the audio records repeatedly, the actual responses or quotes of the interviewees and discussants were arranged in categories according to their similarity to form some pattern.

Again, these categories were further generalized based on their sense or descriptions to form what we call themes. Therefore, Knowledge, attitude of women towards prenatal care and their decision making power in using prenatal care services were emerged out of both the data of this study and the literature review. On the other hand, women’s commitments to traditional ways of life, treatment of ‘Gafia’ as an option to care pregnant women, food taboo as a means for treatment and the religious influences were emerged out of the data of the study.

1. Kunyk D (2015) Substance use disorders among registered nurses: prevalence, risks and perceptions in a disciplinary jurisdiction. J Nurs Manag 23:54-64.

Indexd at, Google Scholar, Crossref

2. Strobbe S, Crowley M (2017) Substance use among nurses and nursing students: a joint position statement of the Emergency Nurses Association and the International Nurses Society on Addictions. J Addict Nurs 28: 104-106.

Indexd at, Google Scholar, Crossref

3. King IM (2007) King's conceptual system, theory of goal attainment, and transaction process in the 21st century. Nurs Sci Q 20: 109-111.

Indexd at, Google Scholar, Crossref

4. Kubayi VS (2019) Nurses’ perceptions of impairment due to substance use in Gauteng Province. Doctoral dissertation, Stellenbosch, Stellenbosch University, USA.

Google Scholar

5. Cook LM (2013) Can nurses trust nurses in recovery re-entering the workplace?. Nursing 43: 21-24.

Indexed at, Google Scholar, Crossref

6. Cannon BL, Brown JS (1988) Nurses' attitudes toward impaired colleagues. Image J Nurs Sch 20: 96-101.

Indexed at, Google Scholar, Crossref

7. Ervin SM (2015) The Lived Experience of Registered Nurses with Substance Use Disorder who complete an Alternative to Discipline Program through a state board of nursing. UNLV Theses, Dissertations, Professional Papers, and Capstones. 2534.

Indexd at, Google Scholar, Crossref

8. Monroe T, Vandoren MM, Smith ML, Cole MJ, Kenaga H (2011) Nurses recovering from substance use disorders: A review of policies and position statements. J Nurs Adm 41: 415-421.

Indexd at, Google Scholar, Crossref

9. Comer SD, Sullivan MA, Yu E, Rothenberg JL, Kleber HD, et al. (2006) Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial. Arch Gen Psychiatry 63:210-218.

Indexed at, Google Scholar, Crossref

10. Monroe T, Pearson F, Kenaga H (2008) Procedures for handling cases of substance abuse among nurses: A comparison of disciplinary and alternative programs. J Addic Nurs 19:156-161.

Indexed at, Google Scholar, Crossref

11. Chiu W, Wilson D (1996) Resolving the ethical dilemma of nurse managers over chemically-dependent colleagues. Nurs Ethics 3: 285-293.

Indexed at, Google Scholar, Crossref

12. Carter TA, McMullan SP, Patrician PA (2019) Barriers to Re-entry into Nurse Anesthesia Practice Following Substance Use Disorder Treatment: A Concept Analysis. Workplace health & saf 67: 189-199.

Indexed at, Google Scholar, Crossref

13. de Vries MG, Brazil IA, Tonkin M, Bulten BH (2016) Ward climate within a high secure forensic psychiatric hospital: Perceptions of patients and nursing staff and the role of patient characteristics. Arch psychiatr Nurs 30: 342-349.

Indexed at, Google Scholar, Crossref

14. Strobbe S, Crowley M (2017) Substance Use among Nurses and Nursing Students: A Joint Position Statement of the Emergency Nurses Association and the International Nurses Society on Addictions. J Addict Nurs 28:104-106.

Indexed at, Google Scholar, Crossref

15. Gamble MA (2018) Implementation of Peer Support Groups for Nurses in Delaware's Professional Health Monitoring Program. Wilmington University (Delaware), ProQuest Dissertations Publishing, 10812395.

Indexed at, Google Scholar