Familiarisation with the field site
During the first three months, visits to local health facilities and shadowing of field site research staff was conducted. This formative period was essential in understanding the context and local culture. Therefore observations, informal conversation and field notes began from the onset.
Experience of clinics within the study site
During the preliminary stages, introductory and scoping visits to several primary health clinics were conducted. The main objective of these visits was to obtain an overall understanding of how the clinics operated on a daily basis. Time was spent with a Wits researcher and clinician, understanding the Integrated Chronic Disease Management model through his ‘Vunene study’. This research was very relevant to the Vutivi study to inform my understanding of rural chronic disease care and the general organisation of the primary care environment.
Experience of villages within the study site
To ensure that the research was within the ‘Fieldworker and Researcher Guidelines’ (Agincourt, 2016), I accompanied several fieldworkers familiar with the healthcare facilities and clinic staff. Time was spent with them working on the 2013 census in two villages, at community members’ homes. The example extract in Table 14, describes the experiences of the home visits.
lady came out of the brick house, with a tin roof and brought three plastic chairs. We greeted each other. The lady was the eldest child and she would respond on everyone’s behalf. The form had to be dated next to the dwelling number and village number.
House 4. We sat on the stoop, whilst the gogo (Grandmother) sat on a handmade mat cracking her peanuts. She said the rains were coming soon so she was preparing the peanuts to be planted. She also had an extensive vegetable patch. I asked the fieldworker – if the men are not working away as migrants – what employment do they find in and around the study site – she said either teachers, work for the municipality or they are just on the booze (alcohol). This was the first house where I noticed that when the fieldworker requested a cell phone number and the respondent did not know it off by heart – the respondent would hand the cell phone over to the fieldworker to go through the phone book and check the numbers on the census form.
Table 14. Extract from field notes during preparation for fieldwork (October, 2013)
Two further days were spent with the ‘Verbal Autopsy Fieldworkers’ who collect cause of death data from the deceased’s family (Byass et al., 2010:2). Time was also spent with the Nkateko fieldworkers as part of the preparation for the cluster-randomised trial. The Nkateko research team was conducting a questionnaire and collecting clinical measurements related to high blood pressure at community members’ homes in a further two villages.
Overall, the experience within the villages was fundamental to gain an understanding of how and where people live, village locations and the general running of the census and other research projects.
Experiences within the district hospital
After this formative period in the field, preparations began for the mini pilot conducted at the district hospital. Permission was granted in writing from the acting hospital CEO. This opportunity allowed for the nurse and patient interview schedules to be piloted and adjusted accordingly. Informal discussions and general non-participant observations took place over one-week situated at the reception desk, with the data clerk manning the phone and computer and in the consultation room. This pilot allowed me to gain an understanding about the provision of antenatal care.
Preparation to conduct research in health facilities and sampling of clinics
The LINC team translated participant information sheets, posters and consent forms from English to Xitsonga.
As is usual in case study research, four clinics were purposively sampled (Patton, 2005) to include two clinics within the study site and two clinics on the periphery (Figure 17). The decision to choose two clinics outside of the study site was to ensure a sample of patients and nurses who had no prior experience of Wits research. This also alleviated the research load from the study site clinics, which had been subjected to many projects over the years.
Description of the clinics recruited
Within the study site: one small old clinic accessible via a newly built tar road and one newly built clinic only accessible via dirt roads, both in small study site villages.
A brief presentation was given to the nurses at each clinic and a date agreed for the interviews to commence. We requested to spend four days in each clinic from 7am- 4pm (clinic opening hours). The nurses were provided with a research folder, including a study summary and poster in both English and Xitsonga, for staff and patients to read (Appendix 3).
Description of patients recruited
The patient groups were from the general adult population attending outpatient chronic disease services and/or antenatal care.
Ethnography and non-participant observation in primary healthcare facilities
Obtaining informed consent for general clinic observations
Before conducting non-participant observation and interviews, consent was requested from the clinic nurse. The fieldworker informed all other staff about the study and its purpose at a staff meeting.
Ethnographic process in the community and within clinics
Non-participant observation of the general environment, waiting rooms and clinic consultation rooms was conducted to understand the research environment. Clinics were observed at different times and days over a few months, in such a way to not disrupt the everyday running of the clinics.
Formally these observations were non-participatory, recorded as field notes and structured through ‘an observation checklist framework tool’ (Appendix 4). This tool
providers. Less formally, we were often drawn into the daily routine such as drinking tea with the nurses in the staff kitchen, singing and dancing during the morning prayers and chatting to patients in the queue who were intrigued of my presence and the fact I spoke basic Xitsonga to them. The purpose of these observations was to generate small stories nested with the bigger narratives generated by the interviews. Box 6 describes the observation procedures of the clinics.
i) After receiving permission from the district manager and provincial ethics committee granted, the researcher arranged a general meeting with staff in advance to let them know that an observation as part of a research study is going to take place.
ii) An information poster was displayed in each facility to let staff and patients know about the research.
iii) The researcher was identified by a clear ID badge and the fieldworker an Agincourt fieldwork T-shirt.
v) The researcher will make it clear that she is not clinically trained.
vi) In the event of observing professional practice that is of concern or a patient in distress, the researcher will speak to a senior member of the research team or other relevant member of university staff for advice.
Box 6. Procedures for clinic research observations
Obtaining informed consent for consultation observations
Oral consent to observe routine consultations was provided by the nurse and patient. This experience allowed me to understand the patient-health-worker face-to-face clinical process.
There were no audio recordings of any brief conversations. Only field notes were taken and these did not include any personal identifiers. Data from observations were
Vutivi participant list
The participant groups were specifically chosen to answer Research Questions 2-4. Interview schedules are in Appendix 10.
Table 15. Participant list and total number of people interviewed in the Vutivi study, including recruitment and interview location
Phase Participant Groups Interviewed
Participants Total Recruitment and
Interview location Phase 1 Fieldwork preparation (General)
Pilot with nurses, gynaecologist, pregnant women and data clerk
- 1 District hospital, clinics and study site villages
Phase 2
Chronic disease patients
Vutivi patients with any chronic disease
51 4 clinics: 2 clinics in the study site, 2 clinics outside the study site Nkateko patients with chronic disease (hypertension) 18 3 clinics: 2 clinics win the study site, 1 clinic outside the study site Phase 3 Pregnant women Pregnant women interviewed 28 4 clinics: 2 clinics in the study site, 2 clinics outside the study site
Pregnant women in focus groups
16 2 health facilities: 1 clinic and 1 district hospital
Phase 4
Health professionals
Nurses (clinic and hospital)
32 4 clinics: 2 clinics in the study site, 2 clinics outside the study site Doctors (Private/ Government) 11 1 District hospital, 1 private surgery in town Clinical associate students (mid-level health-worker) 4 1 District hospital
Phase 5
Health-workers (additional)
Psychologist 1 1 District hospital, 1 private pharmacy in town, 1 health train, healers homes Optometrists 2 Occupational therapist 1 Traditional healers (indigenous) 2 Home-based carers (HBC) 4 Lay health-workers (LHW) 4 Phase 6 Community members Community members
14 1 study site village and 1 town on periphery of study site, next to district hospital Phase 7 Policy-makers Department of Health policy- makers: National 7 Johannesburg, Pretoria, Nelspruit and Cape Town, in person or via Skype*
Department of Health policy- makers: Provincial 7 Department of Health policy- makers: District 1 Phase 8 eHealth and mHealth experts eHealth and mHealth experts (e.g. Mobile operators) 26 Johannesburg, Pretoria, Nelspruit and Cape Town, in person or via Skype