5. RESULTS
5.1 Background of study participants in two sectors characteristics
Out of 229 eligible healthcare professionals, who were approached in both sectors, only 99 responded and returned the questionnaire. Total response rate was 43%. The response rate among nurses in Sabya sector was lower (14%) than in Tathleeth (68%) (Table 2)
Table2: Target population approached and responded in both sectors
Characteristics SABYA TATHLEETH
Total Responded Percentage Total Responded Percentage
Doctors 50 36 72% 45 24 53.3%
Nurses 96 13 13.5% 38 26 68.4%
Total 146 49 33.5% 83 50 60.2%
More females participated in the survey than males. Majority of participants were between 31 to 50 years old and mean age of participants is 38.5 years. In both sectors, participants were from different countries and mostly graduated from their native countries. Indian and Sudanese participants were predominant in the study (Table 3).
Table 3: Demographic and National characteristics of participants by study region
Characteristics
Other 0 0% 4 8% 4 4%
Majority of participant graduated after the year 1990.There was preponderance of doctors among participants. The service duration of about 40% of participants was between 3-10 years in KSA.
Only 4% participants had the post graduate qualification. About 70% participants did not get any IMNCI training during their studies. Only 6% of participants got on job IMNCI training. About 41% participants did not work in children ward (Table 4).
Table 4: Professional, training and educational characteristics of participants by region
Characteristics
In both sectors mean scores equal 7.03, the maximum score obtained by a participant is 13.2 out of 15(in Sabya)and minimum is 2.1 (in Tathleeth) see Table 5.
Table 5: Survey test scores by study sector
5.2. Comparison of mean score between study groups
Overall, mean knowledge score about clinical case management of IMNCI among the study respondents were 7.03 (2.4). Mean knowledge score obtained by health care personnel in Sabya was 7.04 and Tathleeth was 7.02. Those who were trained for IMNCI during studies scored one much higher (9.09) than the untrained (6.13). Those who got on job training of IMNCI also scored one reasonably higher (9.75) compared to untrained (6.85) but the participants having on job IMNCI training are quite less (06) in numbers . In both sectors Sudanese and those graduated from Sudan were the top scorer (8.19). In both sectors nurses scored little less (6.49) than doctors (7.38). Males have mild high mean obtained score (7.23) than females (6.86). These who have experience of working in children ward for more than 12 months scored higher (7.11) than those having less experience. Those who have not attended other courses on child health scored little less (6.90) as compared to those who have attended (7.21) such courses.
Table 6: Comparison of mean obtained score between study groups
Characteristics N Means SD
Female 54 6,86 2.25
11 8.46 2.39
5.3Relationship between variables – Univariate ANOVA
Table 7 shows basic information of variables such as levels or categories and their numbers.
There are 6 variables of interest with their level numbers.
Table 7. Basic information about levels of variables and number of participants.
Between-Subjects Factors
Country of graduation 1 Bangladesh 4
2 Egypt 13
3 Philippine 6
4 India 30
5 Pakistan 17
6 KSA 4
Table 8 is showing values of parameter estimates (B) on SPSS output. Parameter estimates give differences in the predicted from the respective category to the reference category. R-square value in the model is 0.469 which means that about 47% of variability of obtained score (dependent variable) can be explained by the independent variables and model is significant.
The value of B (Estimate) for age is - 0.052 with p-value = 0.36 which means that every unit increase in age will decrease approximately 0.05 point in obtained score in case management of IMNCI questionnaire survey. The value of Estimate (B) for male participants is -0.76 and p- value = 0.22, So every unit increase in male health care givers may decrease about 0.76 points in obtained score in case management of IMNCI. Female participants have value of zero which is not significant. All participants having graduation from different countries such as Sudan(-1-86), India(-1.18), Pakistan(-0.19), Saudi Arabia(-2.42), Bangladesh(-1.67), Egypt(-1.69) and Philippine(-1.61) have values of B in negative which means that every unit increase in country of graduation may decrease in obtained score in IMNCI questionnaire.
Graduation upto 1980 has value of B (Estimate) 4.59 which means every unit increase in graduation upto 1980 will increase 4.59 points in obtained score in case management of IMNCI.
The p-value is 0.02and is less than 0.05, so graduation upto 1980 has significant effect on obtained score in IMNCI survey questionnaire. Graduation from 1981 to 1990 has value of B 1.52, so for every unit increase in graduation from 1981 t0 1990, we expect 1.52 points increase
in obtained score in case management of IMNCI. The p-value = 0.21 which is more than 0.o5 and is not significant statistically. Graduation from 1991 to 2000 has value of Estimate (B) 0.84, so every unit increase in graduation from 1991 to 2000, may increase 0.84 points in obtained score in IMNCI questionnaire survey. The p-value is 0.27 which is more than 0.05 and is not statistically significant. Doctors have value of Estimate (B) - 0.76, so every unit increase in doctors, we expect 0.76 decrease in obtained score in case management of IMNCI questionnaire.
The p-value = 0.09 and has no significant effect on obtained score. The participants having no training during studies in case management of IMNCI program has value of parameter estimate (B) -3.37, so every unit increase in training during studies in IMNCI case management program, we expect 3.37 points decrease in obtained score in IMNCI questionnaire survey. The p-value = 0.001 which is less than 0.05, so there is significant effect of IMNCI training during studies on obtained score in IMNCI questionnaire study.
There are values of Variance Inflation Factor (VIF) which checks the Multi-collinearity.VIF should be less than 10 for all variables. All the variables in the model have Variance Inflation Factor (VIF) is less than 10, which means that there is no severe multi-correlation among independent variables.
Table 8: Relationship among dependent and Independent variables-Univariate ANOVA Parameters Levels Estimates
B
P-value VIF
Intercept 11.41 0.001
Age 1 - 0.05 0.362 7.681
Designation 1 1.40 0.098 4.643
Gender 1 -0.75 0.225 2.630
Country of graduation 1 -1.66 0.223 1.966
Country of graduation 2 -1.69 0.130 3.915
Country of graduation 3 -1.61 0.278 3/455
Country of graduation 4 -1.18 0.316 8.053
Country of graduation 5 -0.18 0.869 4.978
Country of graduation 6 -2.14 0.105 2.316
Country of graduation 7 -1.85 0.108 5.807
Graduation 1 4.59 0.022 3.150
Graduation 2 1.51 0.218 6.926
Graduation 3 0.84 0.275 3.615
IMNCI training during studies
1 - 3.369 0.001 1.000
5.4 Comparison between the groups: One way ANOVA and Post Hoc Tests
Table 9 shows results of One way between subjects Analysis of Variance test which is operated to compare the effect of nationality on obtained score in case management of IMNCI. There are participants of 7 different countries. The p-value is 0.013 which is less than0.05, so there is statistically significant effect of different nationalities on obtained score in case management of IMNCI at p-value < 0.05 level for the different nationalities as F (7, 91) = 2.72, p = 0.013
Table 9: Comparison of variability between Nationality and Obtained Score in IMNCI – One Way between Subjects-ANOVA
ANOVA obtained Score
Sum of
Squares df Mean Square F Sig.
Between
Groups 97.245 7 13.892 2.718 .013
Within Groups 465.156 91 5.112
Total 562.401 98
Table 10 is showing the results of one way between Subjects ANOVA. These results are SPSS output files conducted to compare the effect of country of graduation on obtained score in case management of IMNCI. The table shows the values of sum of square, degree of freedom, mean square, F-value and significance (p-value). The p-value is 0.03 which is less than 0.05 and is significant statistically. So there is significant effect of country of graduation on obtained score in case management of IMNCI questionnaire at p-value less than 0.05 as F (7, 91) = 2.33, p = 0.031
Table: 10. Comparison of variability between country of graduation and obtained score in IMNCI – One way between Subjects-ANOVA
ANOVA IMNCI program. The p-value is 0.02 which is less than 0.05, so there is statistically significant effect of working in children ward on final score obtained in case management of IMNCI questionnaire, F (3, 95) = 3.37, P = 0.02.
Table 11: Comparison of variability between months worked in children ward and obtained score in case management of IMNCI
ANOVA
Within Groups 508.265 95 5.350
Total 562.401 98
Table 12 shows the SPSS output file of One way between Subjects-ANOVA. A one way between subjects Analysis of Variance is conducted for comparison between age range of study participants and obtained score in IMNCI program. The p-value is 0.67 which is more than 0.05, so there is no statistically significant effect of age range of participants on the obtained score in case management of IMNCI, F(3, 95) = 0.52, P = 0.67
Table 12: Comparison of variability between Age range and obtained score in IMNCI ANOVA
Obtained Score
Sum of
Squares df Mean Square F Sig.
Between
Groups 9.082 3 3.027 .520 .670
Within Groups 553.320 95 5.824
Total 562.401 98
Below is SPSS output file of one way between subjects ANOVA as shown in Table 13.This test is conducted to compare the effect between service duration in KSA and obtained score in case management of IMNCI. The p-value is 0.39 which is greater than 0.05. It means there is no statistically significant effect of service duration in KSA on obtained score in case management of IMNCI program questionnaire, F(2, 96) = 0.94, P = 0.39
Table 13: Comparison of variability between obtained score in case management of IMNCI and service duration in KSA – One way ANOVA
ANOVA Obtained Score
Sum of
Squares df Mean Square F Sig.
Between
Groups 10.764 2 5.382 .937 .395
Within Groups 551.637 96 5.746
Total 562.401 98
Table 14 is showing SPSS output file of one way ANOVA test. The test is conducted to compare the effect of graduation year on obtained score in IMNCI questionnaire. The p-value is 0.701 which is higher than 0.05, so there is no statistically significant effect of graduation year of study participants on obtained score in case management of IMNCI, F(3, 95) = 0.47, p = 0.701at p <
0.05 level
Table 14: A one way ANOVA comparison between graduation year and obtained score ANOVA
Obtained Score
Sum of
Squares df Mean Square F Sig.
Between
Groups 8.297 3 2.766 .474 .701
Within Groups 554.105 95 5.833
Total 562.401 98
Table 15 is showing the results of Turkey’s Post Hoc Test. Post Hoc test is done for those variables which are statistically significant such as nationality, country of graduation and work experience in children ward. This test compares all categories of variable of interest with each other. In Turkey’s Post-hoc comparison test, the participants from Sudan obtained higher mean score (M = 8.41, SD = 3.2) in case management of IMNCI than other nationalities. In pairwise comparison most of the p-values are more than 0.05 `except Sudanese * Saudi group where the Sudanese have significant higher score than Saudi participants. The p-value = 0.02 and is less than 0.05, so this group has statistically significant effect on obtained score in case management of IMNCI questionnaire survey.
Regarding country of graduation, Sudanese have again higher score (M = 8.19, SD = 3.2) in case management of IMNCI questionnaire than graduates of other countries. In pairwise comparison, all the pairs have p-value more than 0.05, so are not significant statistically. Study participants worked in children ward more than 12 months obtained higher score (M = 8.5, SD = 2.9) than other three groups such as not worked (M = 6.26, SD = 1.7), less than 6 months (M = 7.56, SD = 2.9) and 6-12 months (M = 7.11, SD = 2.1) as shown in table 16. In pairwise comparison, not worked to more than 12 months work in child ward group has p-value 0.03 which is less than 0.05, so participants having more than 12 months work in child ward scored higher significantly than not work in child ward. So work in child ward has significant effect on obtained score in IMNCI survey. Overall these SPSS output results suggest that nationality, country of graduation and months worked in children ward have significant effect on obtained score in case management of IMNCI questionnaire study
Table 15: Comparison among statistically significant groups-Results of Post Hoc test-pairwise comparison
Characteristics Number Score Standard Deviation
Turkey’s post hoc test
Significance
N Mean SD Pair-wise
comparisons
p-value
Nationality 99 7.031 2.4
Bengali 4 6.00 1.2 Bengali-Egyptian 1.00
Egyptian 13 6.30 1.8 Bengali-Phlipino 0.98
Philippine 6 7.30 1.3 Bengali-Indian 1.00
Indian 30 6.54 2.2 Bengali-Pakistani 0.93
Pakistani 17 7.48 1,4 Bengali-Saudi 0.96
Saudi 4 4.34 2.8 Bengali-Sudanese 0.51
Sudanese 23 8.41 3.2 Egyptian-Philipino 0.98
Egyptian-Indian 1.00
Egyptian-Pakistani 0.85
Egyptian-Saudi 0.79
Egyptian-Sudanese 0.14
Philipino-Indian 0.99
Philipino-Pakistani 1.00
Philipino-Saudi 0.46
Philipino-Sudanese 0.96
Indian-Pakistani 0.87
Indian-Saudi 0.59
Indian-Sudanese 0.07
Pakistani-Saudi 0.20
Pakistani-Sudanese 0.90
Saudi-Sudanese 0.02
Country of graduation
99 7.031 2.4
Bangladesh 4 6.0 1.2 Bangladesh-Egypt 1.00
Philippines 6 7.3 1.3 Bangladesh-Saudi
Arabia
months
To calculate P-value One-way ANOVA and post hoc tests was used 6. DISCUSSION
6.1. Findings of the study
Study results revealed that sector of work, gender, designation, level of qualification and other courses on child health had no interaction with knowledge score. IMNCI training during studies, graduation from Sudan and graduation year up to 1980 showed a positive association with knowledge score. In both sectors, IMNCI trained professionals and graduate from Sudan scored better on knowledge scale than untrained and graduation from other countries. Health professionals graduated up to 1980 scored higher as shown in table 7.There is mild difference of mean obtained score among health professionals having graduation between 1980 and 2010.
During the period of survey very few Saudi doctors were working in study sectors and only four from Sabya sector participated in the study. They all were not trained in case management of IMNCI with mean knowledge scores of only 4.34 out of 15. More than half of nurses working in Sabya sector were Saudi nationals compared to only one in Tathleeth sector. None of the Saudi nurses participated in the survey; their poor response might be due to poor English language proficiency or self-perceived expected low performance.
The participation of healthcare professionals in this survey is small and difficult to draw a conclusion that survey results are representative of knowledge level of other health workers working elsewhere in the KSA.
6.2 Validity and reliability of study
Convenience census survey among healthcare providers irrespective of their training status regarding IMNCI case management strategy is the strength of this study. Survey among healthcare professionals of different nationalities is also support the validity of this study. Work place (job) in the same study sector and in big city is also strength of my study because it was easy to approach the participants of countryside and main city health centers.
6.2.1. Response rate Issues
For the researchers, response or reply rate is an issue of worry in a study most of the time. Reply or return rate varies depending upon mode, theme and nature of surveys (Braithwaite et al. 2003, Pulakka 2009).The return rate is small in the study (43.28%) while in another IMNCI knowledge score study conducted in Pakistan in 2008, the response rate reached up to 75.2% (Khan 2009).
For the study, all accessible study participants were contacted personally by researchers and given the questionnaire. To enhance the return rate of questionnaires during study period, all feasible survey participants reminded twice to accomplish and return survey questionnaires.
Accessible participants of study had an appropriate time to fill in and return questionnaires.
In questionnaire studies, respond or reply rate by considered as indirect measure of non-response bias (Asch et al. 1997, Pulakka 2009,). To evaluate non-non-response bias, researchers normally correlate between major variables of respondent and non-respondents (Cummings et al.
2001, Pulakka 2009). In this survey, major return failure is hard to investigate due to unidentified nature of appraisal through questionnaire. Majority of the non-responders were Saudi nurses because of language barrier and some others refused to participate as having fear in mind of hidden aims of MOH Saudi Arabia.
Almost all probable study respondents were briefed regarding unidentified and unknown nature of questionnaire still some of the participants showed their verbal reservations by saying that the
information given by them may be used for some kind of evaluation by the Ministry of Health KSA.
6.2.2. Internal validity and bias control
A pre-used questionnaire was structured according to IMNCI guidelines of WHO for the survey to raise the internal validity. The same questionnaire was used for the evaluation of trainee doctors regarding case management in IMNCI in Pakistan during the year 2008. With few modifications, this questionnaire was used for survey by the research team in KSA to evaluate knowledge in IMNCI case management. The study questionnaire was prepared in English with the intension that all healthcare professionals would have their professional study in English, so language barrier issue was not a matter of concern in the study questionnaire. There is mild relationship between respond rate by participants and span of questionnaire as shown in some surveys (Pulakka 2009). In this study, the questionnaire was of suitable length, easy to understand and fill-in.
To enhance the respond rate in the survey, it is better to remind the study participants again and again effectively. So during the survey period two reminders were sent to the target population of this survey (Beebe et al. 2007, Pulakka 2009, Wakley 2005). Questionnaire was consisted close and open ended questions. By open ended questions, participants were given a chance to clarify and elaborate their answers. This action helped further to increase the sample size of the survey. Feasible survey participants were granted optimum time to think, fill and return survey questionnaires.
6.2.3. External validity
The study participants are doctors and nurses working in PHCCs in two sectors of KSA during the survey period. But the respondents are those who accepted and filled the questionnaire. So the eligible population for survey was only those who accepted and filled the questionnaire according to guidelines.
The main objective of this study and collection of data was to comprehend an illustrative community of healthcare workers in both sectors such as Tathleeth and Sabya. One criterion for inclusion was working in the respective sector during the survey period. Thus, the respondents stand for the target population.
The survey sectors were well represented in the survey. Out of 99 respondents, none reported any difficulties in understanding the survey questionnaire, which means that study respondents participated in the survey with kind heart and free of cost.
Response rate in the survey is 43.2% and seemed to be small. It is possible that some participants might return more than one answer sheets, in spite of purifying collected information properly before analysis. Validity of the survey is not seemed to be affected by issues such as less respond rate and proper cleansing of data information received through questionnaire.
6.3 Correlation with previous studies
Poor neonatal and child health, mainly affecting developing countries, are global concerns for decades. A great variation exists in death rates and causes of mortality in different geographical regions. To tackle this global challenge WHO and UNICEF adopted IMNCI strategy (UNICEF 2015).
Over the years, implementation of IMNCI strategy has delivered better care to sick children (Pariyo et al. 2005, Kumar et al. 2009). This study confirms better knowledge in terms of knowledge score among those who have training in IMNCI clinical case management and many earlier studies have confirmed that improved knowledge is beneficial at health centers for the treatment of ill babies. (Gouws et al. 2004, Kumar et al. 2009).
Overall, Sudanese got highest score in this survey. Indian and Pakistani doctors and nurses who were trained in IMNCI program also scored a bit higher. This may be because of adoption of IMNCI strategy in these countries. Results of this survey are relevant with a previous study done in Pakistan where trained health care staff scored higher compared to untrained (9.7 vs. 5.1).
Surprisingly, the mean knowledge score obtained by Pakistani doctors is almost the same (7.5 vs. 7.6.) as was reported in a survey conducted in 2008 (Khan 2009). An Indian study also found similar results; trained personnel got an average score 40.31 points compared to 33.71 in untrained (Armstrong et al. 2004).
Some earlier studies have related level of qualification (nursing / medicine) and job position as predictors of knowledge score. Our results did not very much different from earlier results.
(Gouws et al. 2004, Arifeen et al. 2004, Khan 2009).
Many studies were done where target population belong to only one nationality but in our study healthcare professionals from 10 different nationalities who studied in 12 different countries participated and their knowledge of clinical case management of IMNCI varied a lot.
6.4 Limitations of the present study
It was tried to minimize the limitations and assure validity in the current study but still there are some limitations about questionnaire, sample collection and recall issues.
It was tried to minimize the limitations and assure validity in the current study but still there are some limitations about questionnaire, sample collection and recall issues.