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This chapter outlines the purpose of this study, and the research design used. Details of sample size, sampling method, study setting, and the tool devised are also included. Furthermore, the ethical considerations and the method used for data analysis are explained.
The aim of this research study was to explore the perceptions of patients with COPD towards a physiotherapy patient-education leaflet on COPD, given to them at the Local General Hospital of Malta.
To determine whether patients with COPD are satisfied or not with the physiotherapy patient-education leaflet on COPD, given to them at the Local General Hospital of Malta.
To determine the readability of the physiotherapy patient-education leaflet on COPD using the SMOG readability formula.
To determine what aspects of the physiotherapy patient-education leaflet on COPD could be improved.
To produce suggestions and recommendations for future practice, if any.
3.4 The research design
A qualitative study seemed to be most compatible with the purpose of the research study since one of the goals of qualitative research is to appreciate the complex world of lived experience from the point of view of those who live it (Jones, 1995).
A small-scale, non-experimental, descriptive, exploratory design, involving face-to-face self-designed interviews using both open and close-ended questions, was considered to be the most suitable to meet the study aims and objectives. Since this study is not one where a hypothesis is being tested, a non-experimental descriptive approach was deemed appropriate. Polit and Beck (2006) state that non-experimental research is an exploratory, descriptive and explanatory design useful in collecting data without making any changes or manipulating subjects and conditions.
Holm and Llewellyn (1986) define interview as a method of data collection using verbal questionining technique. Collecting information through face-to-face interviews with the respondent allowed the researcher to gather information from non-verbal communication, while enabling him to observe the level of the respondent's understanding, providing the interview with high credibility and face validity (Polit and Beck, 2006). The use of open-ended questions offered spontaneity to the interviewee, allowing participants to give a rich perspective on the topic. This is evidenced by Polit and Beck (2006), who pointed out in their study that using open-ended questions in an interview may allow for an increase in the information given and for strengthening the external validity of the results, thus allowing better exploration of the objectives. On the other hand, Polit & Hungler (1999) showed that open-ended questions are more difficult to analyze due to the fact that subjects are free to use their own words when conveying their perceptions.
Cormack (2000) and Polit and Hungler (2004) argue that interviews have a high response rate, while Robson (2002) explains that face-to-face contact with the researcher promotes participation and involvement in interviews, with all questions being answered. Parahoo (1997) adds that interviews ensure that the person being interviewed is the intended respondent. Apart from this, interviews allow collection of data from subjects unable or unlikely to complete questionnaires and may offer protection against ambiguous or confusing questions (Polit and Hungler, 2004).
Despite the fact stated by Polit and Hungler (2004) that the strengths of interviews far outweigh those of questionnaires, Polit and Beck (2006) have demonstrated that questionnaires, compared to interviews, are simple, less costly, and require less time and energy to administer. Polit and Hungler (2004) also pointed out that some negative aspects of interviews are that they prevent respondent anonymity and are subject to interviewer bias. Bias was defined by Polit and Beck (2006) as "the systematic over-representation or under-representation of some segment of the population in terms of a characteristic relevant to the research question."
In spite of this, since the researcher was dealing with a small number of participants in geographically-accessible areas, the Medical wards setting and the Physiotherapy Department, both located at the local general hospital of Malta, and since a schedule of questions was used in this research study, the high cost in researcher time and energy to analyze and discuss the findings of the gathered data, were reasonably contained.
Prior to conducting the interviews, the researcher also opted to calculate the readability of the physiotherapy patient-education leaflet given to patients with COPD at the Local General Hospital of Malta. The SMOG grading readability formula was used for this purpose.
3.5 The research setting
The study was conducted with patients having COPD who have received the physiotherapy patient-education leaflet about COPD used for the purpose of this study. These patients were either in one of the Medical wards or were attending as outpatients at the Physiotherapy Department, both within the Local General Hospital of Malta.
3.6 The target population and the sampling technique
The target population is defined by Polit and Beck (2006) as the entire population under study in which the researcher focuses on and to whom the results of a study could reasonably be generalised.
In this qualitative study, the target population encompassed patients with COPD who have received the physiotherapy patient-education leaflet about COPD either during their stay in one of the Medical wards situated in the local general hospital of Malta, or whilst they were attending as outpatients at the Physiotherapy Department of the same hospital.
Patients with COPD who have received the physiotherapy patient-education leaflet about COPD
Male and female
Above 18 years of age
Willing to participate by taking part in an audio-recorded interview
Patients not suffering from COPD
Patients not willing to participate
Patients who are illiterate
Patients who are cognitively impaired
"Sampling is the process of selecting a portion of the population to represent the entire population" (Cormack, 2000). A sample size of fifteen patients who satisfied the inclusion criteria was conveniently selected from the target population. Convenience sampling, a type of non-probability sampling, is utilized in qualitative exploratory research where the researcher focuses on human feelings and experiences as the sole foundation for factual knowledge (Polit and Beck, 2006). In this research, the most readily available group of subjects were conveniently chosen for the study in an effort to get an overall estimate of the results without encountering the cost or time required in random sampling.
3.7 The research tool
Prior to conducting the interviews, the researcher opted to calculate the readability of the COPD leaflet in question using the SMOG grading readability formula. Using this formula, the researcher calculated the total number of multisyllabic words in ten consecutive sentences at the beginning, middle, and end of the COPD leaflet. These were then applied to a SMOG conversion table (Appendix ) that gives the corresponding grade level.
Later, the researcher opted to collect data by means of self-designed face-to-face interviews. The research tool was made specifically for this research, whilst relying upon literature and similar studies on patient-education leaflets. Such practice aided the researcher to build up the research tool in close adherence to the aims and objectives of the study (Holm and Llewellyn, 1986).
The interview schedule was based on a physiotherapy patient-education leaflet about COPD given to patients suffering from this condition at the Local General Hospital of Malta, either as inpatients or as outpatients. The leaflet measures 21 cm x 15 cm, and consists of 22 pages with information, exercises and illustrations. It was published both in English (Appendix ) and Maltese (Appendix ).
The idea of producing a physiotherapy patient-education leaflet catered for patients with COPD was of Ms. Anabel Sciriha B.Sc (Hons), M.Sc (Sheffield) SRP (Specialist physiotherapist in respiratory care), in view of the decleration of the year 2010 as the Year of the Lung. This initiative came about to facilitate the physiotherapists' work and to ensure continuation of treatment with better explanation of the condition and the role of physiotherapy. Work started from mid-July 2010 and included compiling the information and translating it, reviewing the material, photo taking, and designing the leaflet at the Medical Illustrations Unit at the Local General Hospital of Malta. Finally, after reviewing draft copies, the leaflet was officially launched on the 17th of November 2010, the World COPD Day, during a day of activities held at the Physiotherapy Department at the Local General Hospital of Malta.
3.8 Validity and Reliability
A research process that is credible has to be primarily valid and reliable (Cormack, 2000). Validity is "the degree to which an instrument measures what it is supposed to measure", and reliability is "the consistency with which an instrument measures its attributes" (Polit, Deck, & Hungler, 2001).
The face validity of the research tool (interview questions) used in this study was evaluated and approved by a dissertation board. In addition, the supervisor who guided the researcher throughout the study also contributed to ensuring a sound research tool in terms of validity.
The researcher's direct involvement in data collection also contributed to enhance face validity since the researcher in persona could easily clear out participant's misunderstandings that could have arose during the interview. However, this is also a source of bias.
Another essential feature in a sound research is reliability. Despite the fact stated by Holm and Llewellyn (1986) that reliability is a prerequisite for validity, yet, in studies like this one, reliability is not easy to ensure since the nature of the research involves the exploration of the individuals' perceptions, which tend to change over time. In summary, if the research was to be replicated over a period of time, different results can be obtained from same individuals.
3.9 Ethical considerations
Permission to conduct this study was granted from the Research Ethics Committee of the University of Malta and the Faculty of Health Sciences (Appendix ), the Manager of Physiotherapy Services (Appendix ), the Physiotherapy Course Co-ordinator (Appendix ), the Senior Principal Physiotherapist at the Physiotherapy Department at the Local General Hospital (Appendix ), the Principal of Medicine (Appendix ), the Principal of Nurses (Appendix ), and from four Consultant Respiratory Physicians whose patients were involved in the research study (Appendix ).
Each participant was asked to sign an informed consent sheet prior to the interview (Appendix ). The consent procedure conforms to Polit and Hungler's (1999) advice, in that it is important for the researcher to make all possible efforts in protecting human rights when humans are used for the purposes of a study. Furthermore, the researcher gave participants a brief explanation about the main purpose of the research study, and the procedure of the interview, which reinforced the printed information on the informed consent form. They were informed that participation is voluntary and that they had the right to refuse or withdraw from the study without giving reasons for doing so, without any negative consequence to them. Participants were also informed regarding the audio-recording of the interviews, and that recordings and transcripts will be erased on completion of the study.
Participants have the right to privacy and security of data (Watson, McKenna, Cowman, & Keady, 2008). However, due to the use of face-to-face interviews, the researcher could not grant anonymity. According to Polit and Beck (2006), anonymity occurs when even the researcher cannot connect a participant with his or her data. Nonetheless, the participants were assured that the researcher will entirely adhere to the Data Protection Act. Code phrases were used on the interview transcripts in order to avoid any accidental breach of personal identifiable information. In no instance, were the names and identity of participants revealed as a result of the collection, analysis and reporting of the study. Moreover, all information obtained from the interviews, under no circumstances, was publicly disclosed in a way that would distinguish any specific person.
3.10 Pilot Study
As suggested by Polit and Hungler (1995), before the actual data collection, pilot work was carried out with two persons (above 18 years of age) to gather a fair idea of how the study was to evolve and to ensure that the interview schedule is able to collect appropriate data, thus improving the study's quality and efficiency. Polit and Beck (2004) stated that pilot work is frequently defined as a smaller version of the proposed study conducted, with one of its main purposes being to identify parts of the instrument that are difficult for the subjects to understand or that may have been misinterpreted by them.
In the pilot study, the participants were asked for feedback regarding the structure, content, and language of the questions, to ensure clarity of the questions and feasibility of the tool. The audio-recording equipment was also tested to ensure that it works properly. The interview schedule was considered appropriate for the main study and no changes were necessary.
3.11 Data collection
Data was collected over an approximately one month period using the self-designed interview schedule (Appendix ). All the physiotherapists working in the Medical Wards at the Local General Hospital of Malta were informed of the nature of the study, and were asked to notify the researcher when a COPD patient is referred for physiotherapy either in their wards or for treatment as an outpatient. Eventually, together with the physiotherapists, the researcher visited the wards and the Physiotherapy Department at the Local General Hospital of Malta to introduce self to the patients and to seek their consent for the interview by signing an informed consent sheet prior to the interview. Once consent was given by the participants, they were handed the physiotherapy patient-education leaflet on COPD and were informed that the interview would be carried out on the following day.
The interviews were then executed with each patient on the following day of handing the physiotherapy patient-education leaflet on COPD to each patient individually. As suggested by Watson et al. (2008), questions were kept clear, easy to understand and as unbiased as possible, to facilitate the flow of information. The interviews took an average of ten minutes each and were carried out either in Maltese or in English, according to the participants' preference. The interviews were held either at the Medical Wards or at the Physiotherapy Department, both at the Local General Hospital of Malta, depending on whether the participant is an inpatient or an outpatient.
As explained to the participants prior to their face-to-face session with the researcher, the interviews were audio-recorded as this enables further detail and accuracy than memory or note taking. Field notes were also taken by the researcher, but kept to a minimum, to prevent from appearing interested only in scribbling notes (Gerrish and Lacey, 2006). The audio-recorded responses were then transcribed by the researcher.
3.12 Data analysis
Despite the statement by Cormack (2000) that during analysis of qualitative data some value may be lost due to subjectivity of interpretation, Polit and Beck (2004) define data analysis as the organization and synthesis of research data.
First of all, the demographic information of the participants was converted to tables and figures. The data collected in this study was then analyzed using content analysis. This was defined by Polit and Beck (2006) as the process of arranging and integrating qualitative data as regards to emerging themes and concepts. Keeping in mind the study objectives, each response was broken down into themes, and the results were then presented in the form of tables under formulated themes, whilst including some excerpts and the number of times a theme emerged in the responses, to clearly demonstrate the data obtained.