Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: a mixed-method study protocol

Reproductive Health, Volume 18, No. 1, Year 2021

Interpretation

Background: We aim to assess competencies (knowledge, skills and attitudes) of midwifery care providers as well as their experiences and perceptions of in-service training in the four study countries; Benin, Malawi, Tanzania and Uganda as part of the Action Leveraging Evidence to Reduce perinatal mortality and morbidity in sub-Saharan Africa project (ALERT). While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This paradox may be explained by the standard and quality of intrapartum care provision which depends on several factors such as health workforce capacity and the readiness of the health system as well as access to care. Methods: Using an explanatory sequential mixed method design we will employ three methods (i) a survey will be conducted using self-administered questionnaires assessing knowledge, (ii) skills drills assessing basic intrapartum skills and attitudes, using an observation checklist and (iii) Focus Group Discussions (FGDs) to explore midwifery care providers’ experiences and perceptions of in-service training. All midwifery care providers in the study facilities are eligible to participate in the study. For the skills drills a stratified sample of midwifery care providers will be selected in each hospital according to the number of providers and, professional titles and purposive sampling will be used for the FGDs. Descriptive summary statistics from the survey and skills drills will be presented by country. Conventional content analysis will be employed for data analysis of the FGDs. Discussion: We envision comparative insight across hospitals and countries. The findings will be used to inform a targeted quality in-service training and quality improvement intervention related to provision of basic intrapartum care as part of the ALERT project. Trial registration: PACTR202006793783148—June 17th, 2020. The study will use a cross sectional sequential exploratory (QUAN—qual) mixed method design. The mixed-method paradigm is based on the principles and logic of pragmatism. According to this paradigm, a mixed use of qualitative and quantitative approaches results in a better understanding of the problem [21]. In this case, a mixed-method design was chosen due to the complexity of the research questions. Employing a participatory approach is anticipated to help providers in acknowledging possible gaps in their intrapartum competencies. One arm of the ALERT project is end-user participation. This enables providers to voice their training needs and allows the intervention to develop in a manner that meets these needs. This will be achieved by using findings from our baseline qualitative and quantitative data that includes the opinions and views of both health care providers and clients regarding the gaps in intrapartum care. While training is likely to be successful if the providers understand why the topic is important to address, ownership of the whole process and responsibility for their own learning are elements which will guide the training. Applying these participatory concepts is expected to enhance engagement during the in-service training. The quantitative study will provide an assessment of knowledge, skills and attitude of the midwifery care providers related to basic intrapartum care. The FGDs will enable provider’s experiences and perceptions of in-service training to be explored and contextualised from multiple perspectives. This protocol is conducted in accordance with the STROBE Statement—for cross-sectional studies [22] included in Additional file 1. The research approach is summarised in Fig. 1. Methodological approach of the assessment of intrapartum competencies and experiences and perceptions related to in-service training The study will be conducted in maternity wards of all the 16 ALERT project hospitals in Benin, Malawi, Tanzania and Uganda. The hospitals were selected based on the following criteria: The number of midwifery care providers in each hospital ranges from 20 to 70 providers. For the survey which aims to assess knowledge, all midwifery care providers providing intrapartum care in the 16 maternity wards are invited to participate. For the skills drills assessment, a stratified sample of midwifery care providers will be randomly selected from each hospital/maternity ward according to the size of the facility and ensuring that all professional titles; midwives, nurse-midwives, doctors etc. are represented proportionately. We will apply a stratified sample stratifying by provider professional titles and as described in Table Table2.2. We will sample 25–30% of the providers in each hospital depending on the number of providers working at each hospital. Midwifery care provider selection details Two FGDs will be conducted in each study country and a “purposive” sample will be used. Six to −10 providers will be invited to participate based on their function at the maternity ward. Focus groups will be homogenous in composition in terms of sex, age and hierarchy, to support participants to feel more comfortable expressing their opinions. The quantitative part of the study will apply two different data collection tools; a self-administered survey and an observation skills drills checklist. The assessment will focus on basic intrapartum care as described in the Essential Competencies for Midwifery Practice Framework 2019 [23] as several training packages and initiatives have focused on emergency intrapartum care training [24, 25] and often basic midwifery care has not been given the appropriate and needed attention. The International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice Framework, 2019 update [23] was used as the theoretical framework for the development of the self-administered survey and the observation checklist related to the skills drills. Details of the Essential Competencies for Midwifery Practice Framework 2019 related to intrapartum care is described in Additional file 2. The self-administered survey consists of seven sections illustrated in Box 1. The questions are mainly closed questions with a mix of multiple choice and some “yes, no or don’t know” questions. The full survey is included in Additional file 3. The observation study will be carried out as skills drills due to ethical considerations. The observation study has two components related to two clinical scenarios. The first scenario will assess the skills and attitudes of midwifery care providers during the admission process. The second scenario will focus on the second stage of labour and immediate postpartum newborn care. For the skills drills a “Laerdal Mama Birthie Kit” will be used [26]. One ALERT team member will play the “woman” (the client) and one the companion (client’s companion) and will be given instructions on how to answer the questions that the midwifery care provider may ask using the “drill script”—[see Additional file 4]. For the skills drills a checklist will be used to record which clinical practices are performed and which may not be executed. The checklist will include all clinical evidence-based aspects which would be expected to be addressed in each scenario. The complete skills drills checklist tool is included in Additional file 5. The tools and skills drills scripts will be translated into French and Swahili. For the FGDs an interview guide will be used. The questions in the interview guide will aim to encourage participants to discuss their experiences and perceptions of in-service training and will contain probe, follow-up and exit questions. Discussions during the course of the FGDs may prompt further questions from the FGD facilitator and the participants. The pre-test study facilities will be selected to be representative of at least one of the study hospitals in terms of level of facility type and size of workforce. A pre-test of the two tools will be conducted. This will allow understanding of the content of the survey to be assessed, any language problems to be identified, and allow for an approximation of how much time it takes to complete the survey. Pre-testing of the skills drills observations checklist as well as the script for the client will also take place. Feedback will be used to modify the tools if needed. The data collection will be conducted by one ALERT co-investigator with a midwifery background and a data collection assistant with nurse-midwifery training in each project country. The teams will be trained by an ALERT team member in conducting both the quantitative and qualitative components of the study. Tablet computers will be used for data collection. The providers will fill in the survey in an undisturbed location and the survey will be conducted at different time points to ensure providers working different shifts will be able to complete the survey during working hours. For the skill drills the data collectors will use an electronic observational checklist to record the clinical care provided by the study participants. The FGDs will take place after the quantitative study, and at least one to two focus groups will be conducted in each of the facilities. Each FGD is expected to last between 60 and 90 min and will take place in meeting rooms in the hospitals. We will ask for participant consent to record but cannot guarantee that we will be allowed to record. If not, there will be two notetakers in each group. Notes will be transferred to a NVivo software programme for analysis. The qualitative team members in each country will do the coding and be involved in the development of the code book. Assuming there will be discrepancies in coding they will dealt with through continuous discussions on interpretation of data among the team members in each country and in a second phase across countries. The interpretation of data and the appropriate codes will also be assessed through method and participant triangulation. Data from the surveys and skills drills observation tools will be exported from the tablets to REDCap (Research Electronic Data Capture). The data will be stored on a server at Karolinska Institute, Stockholm, Sweden. The collected data will be analysed using STATA and descriptive statistical methods and will generate summary statistics for each hospital and aggregated at country level. Data collected from the survey will be analysed using a summary score from each sub-section. The findings from the observation study will be quantified and a final score will be given to the two different skills drills scenarios. The findings from the quantitative studies will be used to triangulate and understand the potential (dis)connect between competencies and the actual clinical practices, and the perceptions and experiences related to in-service training. Any comments provided on the survey and/or the observation tools will also be analysed. All FGDs data will be transcribed in the local languages verbatim (English, French and Swahili), then where required, translated into English and transferred into electronic files containing one transcript for each data collection event. The data from the FGDs will be coded and analysed using “thematic analysis” [27]. Thematic analysis allows for patterns (themes) arising from the data to be identified, analysed and reported in a systematic way. The analysis will use an inductive, exploratory approach rather than a confirmatory approach driven by specific questions and ideas. NVivo will be used to support the management and coding of data collected in FGDs. Data from the different assessments will be combined to facilitate the interpretation and understanding of midwifery care providers’ experiences and perceptions of in-service training and how this impacts their own clinic practice. A joint display will be developed to provide a structure to discuss the integrated analysis and assist both researchers and readers in understanding how this study may provide new insights [28]. Study participants will be asked to provide informed, written consent prior to participation in this study and will, at any given time, be able to withdraw from the study.

AI Digest

Study Justification:

– The study aims to assess the competencies of midwifery care providers in four sub-Saharan countries (Benin, Malawi, Tanzania, and Uganda) as part of the ALERT project.
– The study seeks to understand the experiences and perceptions of in-service training among midwifery care providers in these countries.
– The assessment of competencies and training experiences is important to improve the standard and quality of intrapartum care, which can contribute to reducing maternal and neonatal mortality.

Study Highlights:

– The study will use a mixed-method design, combining quantitative and qualitative approaches, to gain a comprehensive understanding of the research questions.
– The quantitative component will involve a survey using self-administered questionnaires to assess knowledge, skills, and attitudes of midwifery care providers.
– Skills drills will be conducted to assess basic intrapartum skills and attitudes using an observation checklist.
– Focus Group Discussions (FGDs) will be conducted to explore midwifery care providers’ experiences and perceptions of in-service training.
– The study will be conducted in maternity wards of 16 hospitals across the four countries, involving a diverse sample of midwifery care providers.

Recommendations:

– The findings of the study will be used to inform a targeted quality in-service training and quality improvement intervention related to the provision of basic intrapartum care.
– The study highlights the importance of participatory approaches, involving end-users (providers and clients) in identifying training needs and developing interventions that address these needs.
– The study emphasizes the significance of basic midwifery care and the need to give it appropriate attention alongside emergency intrapartum care training.

Key Role Players:

– Midwifery care providers in the study facilities
– ALERT project team members
– Data collection assistants with nurse-midwifery training
– Qualitative team members in each country for coding and analysis
– Researchers and readers who will benefit from the study findings

Cost Items for Planning Recommendations:

– Training and capacity building for the ALERT project team members
– Data collection tools (tablet computers, Laerdal Mama Birthie Kit)
– Translation of tools into French and Swahili
– Meeting room rental for FGDs
– Data storage and analysis software (REDCap, STATA, NVivo)
– Publication and dissemination of study findings
Please note that the provided cost items are general examples and may not reflect the actual cost of implementing the study recommendations.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are areas for improvement. The study protocol outlines a mixed-method design, which is appropriate for addressing the research questions. The methods include a survey, skills drills, and focus group discussions, which provide a comprehensive approach to assessing midwifery care providers’ competencies and experiences. The study also mentions using established frameworks and tools for data collection and analysis. However, the abstract lacks specific details about the sample size, data analysis methods, and potential limitations of the study. To improve the evidence, the abstract should provide more information on these aspects, as well as the expected outcomes and implications of the study.

Abstract

The study will use a cross sectional sequential exploratory (QUAN—qual) mixed method design. The mixed-method paradigm is based on the principles and logic of pragmatism. According to this paradigm, a mixed use of qualitative and quantitative approaches results in a better understanding of the problem [21]. In this case, a mixed-method design was chosen due to the complexity of the research questions. Employing a participatory approach is anticipated to help providers in acknowledging possible gaps in their intrapartum competencies. One arm of the ALERT project is end-user participation. This enables providers to voice their training needs and allows the intervention to develop in a manner that meets these needs. This will be achieved by using findings from our baseline qualitative and quantitative data that includes the opinions and views of both health care providers and clients regarding the gaps in intrapartum care. While training is likely to be successful if the providers understand why the topic is important to address, ownership of the whole process and responsibility for their own learning are elements which will guide the training. Applying these participatory concepts is expected to enhance engagement during the in-service training. The quantitative study will provide an assessment of knowledge, skills and attitude of the midwifery care providers related to basic intrapartum care. The FGDs will enable provider’s experiences and perceptions of in-service training to be explored and contextualised from multiple perspectives. This protocol is conducted in accordance with the STROBE Statement—for cross-sectional studies [22] included in Additional file 1. The research approach is summarised in Fig. 1. Methodological approach of the assessment of intrapartum competencies and experiences and perceptions related to in-service training The study will be conducted in maternity wards of all the 16 ALERT project hospitals in Benin, Malawi, Tanzania and Uganda. The hospitals were selected based on the following criteria: The number of midwifery care providers in each hospital ranges from 20 to 70 providers. For the survey which aims to assess knowledge, all midwifery care providers providing intrapartum care in the 16 maternity wards are invited to participate. For the skills drills assessment, a stratified sample of midwifery care providers will be randomly selected from each hospital/maternity ward according to the size of the facility and ensuring that all professional titles; midwives, nurse-midwives, doctors etc. are represented proportionately. We will apply a stratified sample stratifying by provider professional titles and as described in Table Table2.2. We will sample 25–30% of the providers in each hospital depending on the number of providers working at each hospital. Midwifery care provider selection details Two FGDs will be conducted in each study country and a “purposive” sample will be used. Six to −10 providers will be invited to participate based on their function at the maternity ward. Focus groups will be homogenous in composition in terms of sex, age and hierarchy, to support participants to feel more comfortable expressing their opinions. The quantitative part of the study will apply two different data collection tools; a self-administered survey and an observation skills drills checklist. The assessment will focus on basic intrapartum care as described in the Essential Competencies for Midwifery Practice Framework 2019 [23] as several training packages and initiatives have focused on emergency intrapartum care training [24, 25] and often basic midwifery care has not been given the appropriate and needed attention. The International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice Framework, 2019 update [23] was used as the theoretical framework for the development of the self-administered survey and the observation checklist related to the skills drills. Details of the Essential Competencies for Midwifery Practice Framework 2019 related to intrapartum care is described in Additional file 2. The self-administered survey consists of seven sections illustrated in Box 1. The questions are mainly closed questions with a mix of multiple choice and some “yes, no or don’t know” questions. The full survey is included in Additional file 3. The observation study will be carried out as skills drills due to ethical considerations. The observation study has two components related to two clinical scenarios. The first scenario will assess the skills and attitudes of midwifery care providers during the admission process. The second scenario will focus on the second stage of labour and immediate postpartum newborn care. For the skills drills a “Laerdal Mama Birthie Kit” will be used [26]. One ALERT team member will play the “woman” (the client) and one the companion (client’s companion) and will be given instructions on how to answer the questions that the midwifery care provider may ask using the “drill script”—[see Additional file 4]. For the skills drills a checklist will be used to record which clinical practices are performed and which may not be executed. The checklist will include all clinical evidence-based aspects which would be expected to be addressed in each scenario. The complete skills drills checklist tool is included in Additional file 5. The tools and skills drills scripts will be translated into French and Swahili. For the FGDs an interview guide will be used. The questions in the interview guide will aim to encourage participants to discuss their experiences and perceptions of in-service training and will contain probe, follow-up and exit questions. Discussions during the course of the FGDs may prompt further questions from the FGD facilitator and the participants. The pre-test study facilities will be selected to be representative of at least one of the study hospitals in terms of level of facility type and size of workforce. A pre-test of the two tools will be conducted. This will allow understanding of the content of the survey to be assessed, any language problems to be identified, and allow for an approximation of how much time it takes to complete the survey. Pre-testing of the skills drills observations checklist as well as the script for the client will also take place. Feedback will be used to modify the tools if needed. The data collection will be conducted by one ALERT co-investigator with a midwifery background and a data collection assistant with nurse-midwifery training in each project country. The teams will be trained by an ALERT team member in conducting both the quantitative and qualitative components of the study. Tablet computers will be used for data collection. The providers will fill in the survey in an undisturbed location and the survey will be conducted at different time points to ensure providers working different shifts will be able to complete the survey during working hours. For the skill drills the data collectors will use an electronic observational checklist to record the clinical care provided by the study participants. The FGDs will take place after the quantitative study, and at least one to two focus groups will be conducted in each of the facilities. Each FGD is expected to last between 60 and 90 min and will take place in meeting rooms in the hospitals. We will ask for participant consent to record but cannot guarantee that we will be allowed to record. If not, there will be two notetakers in each group. Notes will be transferred to a NVivo software programme for analysis. The qualitative team members in each country will do the coding and be involved in the development of the code book. Assuming there will be discrepancies in coding they will dealt with through continuous discussions on interpretation of data among the team members in each country and in a second phase across countries. The interpretation of data and the appropriate codes will also be assessed through method and participant triangulation. Data from the surveys and skills drills observation tools will be exported from the tablets to REDCap (Research Electronic Data Capture). The data will be stored on a server at Karolinska Institute, Stockholm, Sweden. The collected data will be analysed using STATA and descriptive statistical methods and will generate summary statistics for each hospital and aggregated at country level. Data collected from the survey will be analysed using a summary score from each sub-section. The findings from the observation study will be quantified and a final score will be given to the two different skills drills scenarios. The findings from the quantitative studies will be used to triangulate and understand the potential (dis)connect between competencies and the actual clinical practices, and the perceptions and experiences related to in-service training. Any comments provided on the survey and/or the observation tools will also be analysed. All FGDs data will be transcribed in the local languages verbatim (English, French and Swahili), then where required, translated into English and transferred into electronic files containing one transcript for each data collection event. The data from the FGDs will be coded and analysed using “thematic analysis” [27]. Thematic analysis allows for patterns (themes) arising from the data to be identified, analysed and reported in a systematic way. The analysis will use an inductive, exploratory approach rather than a confirmatory approach driven by specific questions and ideas. NVivo will be used to support the management and coding of data collected in FGDs. Data from the different assessments will be combined to facilitate the interpretation and understanding of midwifery care providers’ experiences and perceptions of in-service training and how this impacts their own clinic practice. A joint display will be developed to provide a structure to discuss the integrated analysis and assist both researchers and readers in understanding how this study may provide new insights [28]. Study participants will be asked to provide informed, written consent prior to participation in this study and will, at any given time, be able to withdraw from the study.

Materials

Innovations

Based on the provided description, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services that provide information and support to pregnant women and midwifery care providers. These tools can offer guidance on prenatal care, nutrition, and postpartum care, as well as reminders for appointments and medication.

2. Telemedicine: Implement telemedicine platforms to enable remote consultations between pregnant women and healthcare providers. This can help overcome geographical barriers and provide access to specialized care, especially in rural areas.

3. Training and Capacity Building: Develop comprehensive training programs for midwifery care providers to enhance their knowledge and skills in intrapartum care. These programs can focus on evidence-based practices, emergency obstetric care, and communication skills.

4. Quality Improvement Interventions: Implement quality improvement initiatives based on the findings of the study. This can involve developing standardized protocols and guidelines for intrapartum care, conducting regular audits and feedback sessions, and promoting a culture of continuous learning and improvement.

5. Community Engagement: Engage local communities and traditional birth attendants in promoting maternal health and encouraging facility-based deliveries. This can be done through community awareness campaigns, training programs, and establishing referral systems between traditional birth attendants and healthcare facilities.

6. Public-Private Partnerships: Foster collaborations between public and private healthcare providers to improve access to maternal health services. This can involve contracting private providers to deliver services in underserved areas, subsidizing costs for low-income women, and ensuring quality standards are met.

7. Health Information Systems: Strengthen health information systems to collect and analyze data on maternal health outcomes and service utilization. This can help identify gaps in care, monitor progress, and inform evidence-based decision-making.

These innovations can contribute to improving access to maternal health by addressing barriers such as limited knowledge and skills of healthcare providers, geographical constraints, and inadequate infrastructure.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the described study is to implement targeted quality in-service training and quality improvement interventions related to the provision of basic intrapartum care. This recommendation is derived from the findings of the study, which aims to assess the competencies, experiences, and perceptions of midwifery care providers in four sub-Saharan countries.

The study will assess the knowledge, skills, and attitudes of midwifery care providers through a survey and skills drills. It will also explore their experiences and perceptions of in-service training through Focus Group Discussions (FGDs). The findings from these assessments will be used to inform the development of the training and improvement interventions.

The innovation lies in the participatory approach of involving the providers in identifying the gaps in their intrapartum care competencies and training needs. By giving providers a voice in the training process and allowing them to take ownership of their learning, engagement and effectiveness of the training can be enhanced.

The training interventions should focus on addressing the gaps in basic intrapartum care, as previous initiatives have primarily focused on emergency care. The International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice Framework will serve as a guide for the development of the training materials.

To ensure the success of the innovation, it is important to involve a representative sample of midwifery care providers from different hospitals and professional titles. The training should be conducted in a manner that accommodates providers working different shifts and provides an undisturbed location for completing the survey.

The data collected from the study, including the survey, skills drills, and FGDs, will be analyzed using descriptive statistical methods and thematic analysis. The findings will provide insights into the potential disconnect between competencies and actual clinical practices, as well as the experiences and perceptions of in-service training.

Overall, implementing targeted quality in-service training and quality improvement interventions based on the findings of this study can contribute to improving access to maternal health by enhancing the competencies and practices of midwifery care providers in the four sub-Saharan countries.

AI Innovations Methodology

Based on the provided description, the study aims to assess the competencies of midwifery care providers and their experiences and perceptions of in-service training in four sub-Saharan countries. The study will use a mixed-method design, combining quantitative and qualitative approaches to gain a comprehensive understanding of the problem.

To improve access to maternal health, here are some potential recommendations:

1. Strengthening Training Programs: Enhance in-service training programs for midwifery care providers, focusing on basic intrapartum care competencies. This can include updating training curricula, incorporating evidence-based practices, and providing ongoing professional development opportunities.

2. Task Shifting: Explore the possibility of task shifting, where certain responsibilities and tasks are delegated to lower-level healthcare providers, such as community health workers or nurse-midwives. This can help alleviate the burden on midwifery care providers and improve access to care in underserved areas.

3. Telemedicine and Mobile Health: Utilize telemedicine and mobile health technologies to provide remote consultations, education, and support to midwifery care providers and pregnant women. This can help bridge the gap between healthcare facilities and remote areas, improving access to maternal health services.

4. Community Engagement and Education: Implement community-based interventions that focus on raising awareness about maternal health, promoting early antenatal care, and encouraging facility-based deliveries. Engaging with communities and addressing cultural and social barriers can help increase access to maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline Data Collection: Gather data on the current state of access to maternal health services, including the number of facilities, healthcare providers, and utilization rates. This can be done through surveys, interviews, and analysis of existing data sources.

2. Modeling and Simulation: Develop a simulation model that represents the maternal health system, incorporating factors such as facility capacity, healthcare provider availability, and geographical distribution. The model should also consider the potential impact of the recommended interventions.

3. Intervention Scenarios: Define different scenarios based on the recommendations, such as increasing the number of trained midwifery care providers, implementing task shifting, or introducing telemedicine services. Each scenario should be quantified in terms of the expected changes in access to maternal health services.

4. Data Analysis and Comparison: Run the simulation model with the baseline data and the different intervention scenarios. Analyze the results to compare the impact of each scenario on access to maternal health services, considering factors such as the number of women receiving care, distance to facilities, and quality of care.

5. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the results and identify key factors that influence the outcomes. This can help understand the potential variability and uncertainties associated with the interventions.

6. Recommendations and Policy Implications: Based on the simulation results, provide recommendations on the most effective interventions to improve access to maternal health services. Consider the feasibility, cost-effectiveness, and sustainability of the interventions. Communicate the findings to policymakers and stakeholders to inform decision-making and resource allocation.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of different interventions on improving access to maternal health services and make informed decisions to prioritize and implement the most effective strategies.

Authors & Co-Authors

Statistics:

Authors: 11

Identifiers:

DOI: 10.1186/s12978-021-01109-8

Research Areas:

Community Interventions, Health System and Policy, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Benin, Malawi, Multi-Countries, Tanzania, Uganda

Study Design:

Cohort Study, Cross Sectional Study, Descriptive Study, Exploratory Study, Grounded Theory, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female