THE INFLUENCE OF WORKING CONDITIONS ON RETENTION OF HEALTH WORKERS.

ACASE STUDY OF KABALA REGIONAL REFERRAL HOSPITAL

INTRODUCTION

1.0 Introduction

This chapter presents background of the study, the problem statement, purpose, objectives of the study, research questions, study scope, justification of the study, significance, Hypotheses, conceptual framework, as well as operational definition of key terms and concepts.

1.1 Background

The section presents, historical background, theoretical, contextual background, conceptual background.

1.1.1 Historical Background

The world faces a global shortage of well-trained health workers, which is considered as one of the biggest barriers to quality health-care services for millions of people throughout the world (World Health Organization, 2018). It is estimated that there currently is a shortfall of approximately 7.2 million doctors, nurses and midwives and that this shortfall is likely to rise to at least 12.9 million in the coming decades (Sidibe and Campbell, 2017). Although the health workforce crisis affects virtually all countries worldwide – including the high-income countries – sub-Saharan Africa and parts of Asia are most affected, as these regions have the lowest health worker densities when compared globally and are also strongly affected by poor attraction and retention as well as high attrition of health professionals (Kabbash et al., 2021). These problems are exacerbated in rural and remote areas, as health workers tend to stay in or migrate to the urban centres, leaving the countryside in short supply and consequently with insufficient health service coverage (Dal Poz, 2018).

Recent health sector studies, as well as policies, strategies and plans, acknowledge that Human Resource for Health constraints are hampering health sector planning, service delivery and ultimately health outcomes in Kenya and world at large. Human Resource for Health inequities showed that America has 14 % world population compare to sub-Saharan Africa with 11 % of world population but Sub-Saharan Africa carries 25 % of the global disease burden and Americans taking 10 % of global disease burden. Further, America has the global health workers of 42 % compared with Sub-Saharan Africa with only global health workers of only 3%. Equally, the Americans allocate 50 % their annual expenditure to health as compared to Sub-Saharan Africa with less than 1 % annual budgetary allocation to health (WHO, 2016).

While it is true that people produce their own health, the effectiveness of health services depends upon health workers and support systems. Put otherwise, money and medicines apart, health achievements depend on the frontline health workers who connect people and communities to services and technologies. Health systems cannot operate without the people to run them. In other words, health personnel are the people “who make health happen”. Africa’s health labor force crisis goes much deeper than the shortage and migration of health professionals. Uncertain health systems are further strained by the HIV/AIDS pandemic which is claiming the lives of already overburdened health personnel and resulting in more and more people in need of treatment, care and support. In spite of a projected continuing shortfall of tens of thousands of health professionals, training institutions are not stepping up production of trained and qualified health personnel. Thus, there have been a myriad of challenges in the areas of staff training, deployment, motivation and retention; in the inequitable spatial distribution of health workers resulting in severe urban-rural imbalances; in poor monetary and non-financial incentives; in generally difficult working conditions and the lack of technical competence. A chronic under investment in human resources for health underpins the problem (Samuel, 2017).

The poor quality of healthcare in sub-Saharan Africa is related, in large part, to its critical shortage of healthcare workers. This region lacks an adequate number of doctors, nurses, midwives, laboratory professionals and community healthcare workers. This deficit of human resources for healthcare has characterized sub-Saharan Africa throughout history. It persists in the present day because of factors such as a lack of medical graduates, outbreaks of diseases and infections, and the emigration of healthcare workers. The shortage of healthcare workers affects almost every facet of public health in sub-Saharan Africa, including child and adult mortality, the quality of maternal healthcare and the treatment of human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS). While many of these public health problems, such as the maternal mortality rate, have been alleviated in recent years, progress continues to be limited by a lack of human resources for healthcare. Possible strategies to combat this crisis include various task-shifting approaches along with policy changes on the national and international levels. The implementation of these strategies will allow countries in sub-Saharan Africa to decrease and eventually eliminate their shortage of healthcare workers, leading to an overall improvement in public health within the region.

The crisis of human resources for healthcare in sub-Saharan Africa is one of the most complex global issues of the modern age. Numerous public health systems across the world are currently facing a critical shortage of healthcare workers. According to statistics from the World Health Organisation (WHO), there is a growing deficit of approximately 4.3 million workers, including doctors, nurses and midwives, in the global healthcare workforce. This shortage of medical personnel is distributed among 57 countries and is present in almost every region of the world. However, nowhere is this deficit of human resources for healthcare more severe than in sub-Saharan Africa, where the ratio of healthcare workers to the population is the lowest worldwide, 46 out of the 54 countries within this region have significantly less than 2.28 physicians or nurses per 1,000 people, which is widely regarded as the minimum threshold required to deliver basic health services. This region of the world also carries nearly 24% of the world’s disease burden while containing only 3% of its healthcare workforce and only 1% of its financial resources for healthcare.

The health sector is heavily dependent on people who provide health services to clients. Despite of this, over a long period of time attention and support to the health workforce was not accorded the needed priority, and emphasis was instead given to the provision of commodities, procurement of equipment, and the construction of health facilities. Especially in sub-Saharan Africa the health workforce was considered to be too complicated and not sustainable for the international community to engage and was primarily left as the responsibility of national and local governments (Omaswa, 2018). The perception of the importance of human resources for health changed considerably in the past decade, not least owing to the Joint Learning Initiative (2019) that warned the world in its human resources for health report about 10 years ago that the sustainable Development Goals (SDGs) cannot be reached without adequately responding to health workforce needs, which was further highlighted by the World Health Organization (WHO, 2016) in their “World Health Report: working together for health”.

In 2006 and mainly in response to these reports, the Global Health Workforce Alliance was launched, which brought together a wide spectrum of stakeholders across the world most importantly national governments, international agencies, finance institutions, civil society, and researchers as a common platform for identifying and implementing solutions to the health workforce crisis (Campbell et al., 2018). In the Kampala Declaration and Agenda for Global Action from 2008, the alliance agreed on six strategic areas of human resources for health development, which, besides scaling up the health workforce through education and training, also stressed the importance of retention of health workers through both financial and non-financial incentives as well as regulating the exodus of health professionals from the low and middle-income countries (LMICs) to high-income countries through a code of practice on the international recruitment of health workers. In addition, strengthening national governance and coordination frameworks as well as scaling up the financial basis for health workforce development was also agreed (Global Health Workforce Alliance, 2018).

Throughout history and in the modern day, healthcare workers have been emigrating from lower-income countries in sub-Saharan African to higher-income countries within North America and Europe. This pattern of emigration has decimated the medical workforce in several areas. For instance, 70% and 75% of the physicians originally from Angola and Mozambique, respectively, are currently practicing abroad. In total, approximately 65,000 doctors and 70,000 nurses from sub-Saharan Africa, which is equal to approximately 28% of the region’s medical workforce, are working internationally. The outward flow of healthcare workers from sub-Saharan Africa is related to several push and pull factors. The push factors identified by emigrant healthcare workers include low salaries, poor working environments, underfunded healthcare facilities and the lack of opportunities for career advancement. Furthermore, there is a strong correlation between political instability in a country and its loss of medical personnel. The pull factors for emigration include higher salaries, better healthcare facilities and more opportunities for career advancement. To limit the emigration of healthcare workers from sub-Saharan Africa, it is necessary to minimize the influence of both the push and pull factors.

In September 2015, world leaders met to adopt a set of Sustainable Development Goals (SDGs), which are to replace the MDGs once those expire at the end of 2015. It is a major step towards overcoming the health workforce crisis that the SDGs recognise human resources for health as essential for reaching its health related development goal by calling for substantially intensified “recruitment, development, training and retention of the health workforce in developing countries” (United Nations, 2014). However, at the outset of the post-2015 era the health workforce crisis has the potential to become worse in the coming years. The high-income countries are facing an increase in the number of chronic and degenerative diseases due to population aging resulting in an increasing demand for healthcare, while at the same time low fertility rates induce a decline of the working-age population thus increasing the demand for health workers from abroad. High population growth rates in the LMICs combined with unresolved infectious disease agendas and the rapid emergence of chronic diseases will also increase the demand for health care, while rapid urbanisation processes in these countries are likely to intensify already great health workforce shortages in rural areas (Dal Poz, 2013). Because of these trends, it will be undoubtedly essential to massively scale up the number of existing health workers. However, because of the time lag in training new staffs, high training costs, and of the difficulties in attracting sufficient numbers of health workers to rural and remote areas, human resources for health deficits must also be addressed by improving the performance of the existing and future health workers through improved retention, distribution, and effectiveness (Dieleman et al., 2019).

1.1.2 Theoretical Background

The study will use to theories in order to clearly understand the influence of working conditions the retention Health workers.

1.1.2.1 Herzberg’s two factor theory

Working condition is major determinant of job satisfaction and retention of employees, According to Herzberg’s motivational theory; factors that make people dissatisfied at work are dissimilar from those motivating them to do a good job. Dissatisfies relate to working environments rather than the task itself: low salary, poor career prospects and training opportunities, unsatisfactory access to equipment’s and support mechanisms, and disappointing human interactions with colleagues and managers all contribute to a sense of dissatisfaction. As oppose to these extrinsic motivational factors, intrinsic motivation relates to the real content of work, feelings of achievement, self-esteem and self-confidence; they add to job satisfaction and stimulate performance (Uta, 2018).

According to Herzberg, restricting dissatisfies motivates a worker to stay, but not to perform better. In line with this assumption, some authors argue that avoiding dissatisfiers is more significant to promote retention than building particularly high levels of job satisfaction. Others however dispute this view, especially for professionals, and suggest that turnover results more from low intrinsic job satisfaction than from experiencing difficult working environments. Many middle-and low-income countries today suffer severe staff shortages and/or misdistribution of health personnel which has been aggravated more recently by the disintegration of health system in low-income countries and by the global policy environment. Low wages, poor working environments, lack of supervision, lack of equipment and infrastructure as well as HIV /AIDS, all contribute to the departure of health care personnel from remote areas leading to retention (Uta, 2018).

1.1.2.2 Maslow’s hierarchy of needs and motivation

Maslow’s hierarchy can be used to clarify the kind of information people seek at different stages of development. For example, people at the lowest stage seek coping information so as to meet their basic needs. Information which is not directly linked to helping a person meet his or her needs in a very short time span is simply left unattended. Persons at the safety stage need helping information. They look for how they can be safe and secure. Informative information is sought by persons in quest for their belongingness needs. Many at times this can be seen in books or other materials on relationship development. Empowering information is wanted by individuals at the esteem stage. They are searching for information on how their egos can be developed. Finally, individuals in the growth stages of cognitive, aesthetic, and self-actualization seek enriching information. While Norwood does not specifically address the stage of transcendence, I believe it is safe to say that persons at this stage would sort information on how to connect to something beyond themselves or to how others could be edified (Norwood, 2019).

1.1.2.3 Human relations theory

The human relations theory emerged after scientists and managers recognized the powerful effects informal group dynamics had on performance in organizations (Steers et al., 2018). A well-known proponent of this theory is Elton Mayo (1933). Mayo did not see workers as mere parts in the organizational machine, but as complex beings with multiple motivational influences, and he thus emphasized that the management of an organization needed to establish good human relations with the workers as well as between workers in order to motivate employees to work together productively (Fulop and Linstead, 2014). Collaboration was thus given a much greater emphasis than individualism and self-interest in earlier research by at the same time stressing that social needs and interests of employees must become the primary focus of managers. In order to increase motivation and productivity, managers were advised to gain control over employees by paying attention to their social needs and facilitating group cohesion. Although the human relations school is acknowledged for having recognized the importance of the social element in motivation management, for which it still has enormous impact on organization theory and management practice, it was also attacked as being just a more indirect and covert attempt of manipulation and exploitation for the sake of productivity (Fulop and Linstead, 2019).

1.1.3 Conceptual Background of the study

Retention is defined as the length of time a health worker actively performs appropriate health care tasks in a health facility and is usually measured by length of service, proportion of health workers in rural areas, turnover rates or survival rates (Dolea et al., 2019). It was suggested that the uneven distribution of health workers has more to do with retention than with attraction, because health practitioners in rural and underserved areas face higher workloads, unsustainable work environments and professional isolation causing them to leave the workplace in search of more satisfactory working conditions in urban areas or abroad (World Health Organization, 2017). However, retention must not be regarded in isolation from attraction, as factors that attract health workers to rural areas are often similar to those that retain them there (Dussault and Franceschini, 2019).

Retention has also been found to be contingent on the extrinsic rewards provided by the employer and the intrinsic rewards that come from within the individual, which are derived from the role and the work being performed (e.g., degree of autonomy and/or challenge) . For rural and remote allied health professionals, the most cited extrinsic factors with a negative influence on retention are lack of professional development opportunities, professional isolation and insufficient supervision, while the most cited intrinsic factors with a positive influence on retention are autonomy and community connectedness, However, recent analyses posit that health professionals’ decisions to stay or leave a rural health position (retention/turnover) are complex and influenced by ‘a myriad of highly interactive dimensions within personal, organizational, social and spatial domains’.

A motive is a reason for doing something. Motivation is concerned with factors that influence people to behave in certain ways Michael (2011). Michael says that motivating other people is about getting them to move in the direction you want them to go in order to achieve a result. Further Michael argues that motivational practices are likely to function effectively if they are based on proper understanding of what is involved. Herzberg et al (1957) identified two types of motivation; that is intrinsic and extrinsic motivation. However, the research carried out by Infosurv 2002 at Martz organization shows that an organization can improve employee morale, get the full benefit of its investment in its workforce and support the people that define its success with an employee retention program.

For them, employee retention programs connect professional achievement with personal rewards, helping people to do more and inspiring them to stay longer (Infosurv 2012). A lack of motivation in any member of the team can have a negative effect, reducing the effectiveness and possibly leading to the demotivation of others1. However, through this research, the researcher will discuss Herzberg‘s two factor theory of motivation and show the relationship between motivation and job a satisfaction and hence how these two aspects lead to employee retention.

The impact of job satisfaction upon health worker performance, retention and attrition has been explored in a number of research studies (Fogarty et al., 2016). However, most of the research has to date concentrated on high-income countries. For this reason, there is lack of knowledge on the sources of job satisfaction, its effects and the related factors affecting job satisfaction in LMICs – most notably in Africa (Rouleau et al., 2018). Little is also known on how district health managers in resource-constrained health systems can effectively address issues of job satisfaction in order to increase retention and reduce attrition of their health workforce.

Worker motivation can be defined as “an individual’s degree of willingness to exert and maintain an effort towards organizational goals” (Franco et al., 2018). It is a set of psychological processes that influences worker’s allocation of personal resources towards those goals, which in turn affect workplace effectiveness and productivity. However, motivation is also a transactional process, as it is the result of the interactions between individuals and their work environment, and the fit between these interactions and the broader societal context. The concept of worker motivation is related to job satisfaction, as greater satisfaction with one’s job often leads to higher levels of work commitment and willingness to expend personal resources for job accomplishments. As will be shown in the next section on motivation and job satisfaction theories, it would be misleading, however, to equate the two concepts, as job satisfaction is an outcome of motivation and thus not a prerequisite for motivation.

1.1.4 Contextual Background

Uganda Health Workforce Retention Study Manual, In 2006, the Uganda Ministry of Health (MOH), in partnership with the Capacity Project, designed a study to help the MOH better understand the specific recruitment and retention factors for health workers in Uganda. The goal of the Uganda Health Worker Retention Study is to provide the Ministry of Health with data on the satisfaction level of health workers, their intent to leave or stay in their jobs, and the magnitude of health worker turnover in both the public and not-for-profit sectors so that they can develop specific policies to address worker retention and out-migration. Job satisfaction has been identified as a key factor for health worker retention. As Lu et al. (2012) have pointed out, job satisfaction depends both on the nature of the job and on the expectations health workers have of what their job should provide, and is thus the affective orientation that employees have towards their work (Price, 2018). Job satisfaction can be regarded as a global feeling about the job or as a related constellation of attitudes about various aspects or facets of the job Studies conducted in recent years suggest that key factors of job satisfaction include remuneration, work environment, workload, work relations, professional development, organisational commitment, and management (Ali Jadoo et al., 2016).

1.2 Statement of the problem

Uganda is one of the 57 countries identified by the World Health organization termed as experiencing a critical shortage of health workers (less than 2.3 physicians, midwives and nurses per 1000 population). Retention of Health workers in their respective Health facilities is one of the min challenges facing the government Health facilities in Uganda (Yagos et al., 2017). Since 2006, the national production of some cadres of health workers has steadily increased, with over 55 health training institutions opened, however despite the increment in the number of Health workers the government recruitment and retention of the health workers in specifically rural Health facilities like Kabale regional referral Hospital has been weak (Hobbs et al., 2021)

There is a currently increase in Brain drain in Uganda specifically among Health workers which is specifically intensified by the need to earn better salaries like those offered by advanced countries as a result many Health workers have shunned working in Government Health Facilities like Kabale regional referral Hospital and moved to western countries like united states and United Kingdom in such of better working conditions and better pay (Dohlman, et al., 2019). According to MOH, 2021) Records from the health professional councils show that 42 530 (52%) are currently employed in the public sector, at least 9798 (12%) are employed in the private-not-for- profit sector, while about one third (29 654) are private practitioners while in Kabale Regional Referral Hospital though the Hospital serves a population of 2 million people in over 5 districts in the area there is only a 280 capacity with less than 3 medical specialist and also 5 medical doctors though the hospital number of health professional its low there rarely complete more than 3 years of service in the hospital and as aresult the health workforce of the hospital is always fluctuating and this is coupled with the low recruitment capacity of the government. Its against this Background that this study intends to investigate into the influence of working conditions on retention of Health workers, with specific reference to Kabale regional referral Hospital (KRRH.).

1.3 General objectives of the study

The general objective of the study is to examine the influence of working conditions on retention and productivity of Health workers.

1.4 Specific objectives of the study

To establish the influence of working equipment on Health worker retention KRRH.
To examine the influence of motivation on Health worker retention KRRH.

To investigate the influence of personal protective equipment on Health worker retention in KRRH.

1.5 Research Questions

What is the influence of working equipment on Health worker retention KRRH?
What is the influence of motivation on Health worker retention KRRH?

What is the influence of personal protective equipment on Health worker retention in KRRH?

1.6 Scope of the study

This section includes the content scope, geographical scope and Time scope.

1.6.1 Geographical scope

The study will be carried out in Kabale Regional Referral Hospital is a 280 bed hospital located in Kabale Municipality in Southwestern Uganda, approximately 426 Kilometers from kampala. The hospital serves a population of about 2 million people in the districts of kabale, Kisoro, Rukungiri, Kanungu, and some parts of Ntungamo as well as people from neighboring countries of Rwanda and the Democratic Republic of Congo. Mission of the hospital is to provide quality and sustainable, general and specialised, health services to all people in Kigezi region.

1.6.2 Content scope

This will specifically include; the Influence of employee motivation on retention, the influence of payment terms on retention of employees and the influence of job satisfaction on employee retention?

1.6.3 Time scope

This study will use information for literature of the last 10 years while only the data which is 5 years old will be considered from the organization.

1.7 significance of the study

The study will provide data to future academicians in relation to influence of employee motivation on retention.

The study will also provide the policy makers with the information regarding the influence of payment terms on retention of employees.

The government will be able to have information on the influence of job satisfaction on employee retention.

1.8 Conceptual frame work

Working Conditions Retention

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter examines the related literature to the study, The actual literature will be reviewed objective by objective, and the sources of literature reviewed include; secondary sources especially text books, journal, newspapers, research dissertations, Government reports and publications.

2.1 Retention of Health workers

There was an unequal distribution of skilled public health workers across selected institutions in Georgia, with lack of professionals in rural district centers and overstaffing in urban centers. Survey respondents disagreed or were unsure that skilled public health workers possess sufficient skills and knowledge necessary for delivery of public health programs. The survey shed additional light on the findings that there is no clear vision and plans on human resource development. Limited budget, poor planning, and lack of knowledge of the local government were mentioned as main reasons for inadequate staffing. The study participants were concerned with lack of good training institutions and training programs, lack of adequate legislation for Human Resource issues, and lack of necessary resources for Human Resource development from the government (Mamuka, 2018).

Aggressive external recruitment drives, particularly targeting nurses, were of great concern as they were a contributing factor for the increasing trends in nurse migration. The main factors in the migration of SHP were consistent with those found in other studies elsewhere in the world. These included low remuneration; poor working conditions, such as inflexible working hours, shortages of supplies and equipment and a poor working environment especially in rural and remote areas where health needs are least well served; limited continuing educational opportunities for professional development and career advancement; having trained and obtained a higher qualification abroad; the desire for better income and family well-being, including children’s education and remittances; the aggressive recruitment drives by external agencies; and the presence of relatives and friends abroad. While the decision to migrate or to leave the public health sector and seek employment elsewhere was primarily a personal decision, the study also revealed that structural and societal issues affected the migration of SHP. Some examples included the globalized labour markets in health care, small-scale economies, fiscal policies leading to downsizing of an already inadequate labor force, bureaucratic and governance weaknesses, limited capacity in labor force planning and management (the lack of comprehensive and reliable information and database of health personnel, particularly on the distribution of the health labor force, attritions and migration flows), and political and civil instability (WHO, 2016).

A study of health systems challenges in Nigeria showed that, with the many challenges facing the health system in Nigeria, is acute shortage of competent health care providers. As a result of poor infrastructure and inadequate compensation packages, a significant number of physicians, nurses and other medical professionals are lured away to developed countries in search of rewarding and lucrative positions. In fact, some of these countries have recognized recruiting agencies and examination protocols targeting the best and brightest medical brains in Nigeria, forcing the government to require that these agencies register with the Federal Ministry of Health and function within an established framework. Nigeria is a major health workforce exporting nation, accounting for 347 (recently revised upward to 432) out of a total of 2000 nurses that emigrated out of Africa between April 2000 and March 2001. This numbers appears to be underreported as it fails to take into account the vast number of nurses who move abroad under different pretexts. The efflux has resulted to severe shortages in local health facilities and drastically impacted access (Uneke, 2018).

The major challenge facing developed and developing countries is inequalities and imbalance of health care workers densities in urban compared with rural areas. For example, in Bangladesh, thirty per cent (30%) of nurses are located in four metropolitan districts where only 15% of the population lives. In South Africa rural areas are inhabited by forty six per cent (46%) of the total population, but only twelve per cent (12%) of doctors and nineteen per cent (19%) of nurses are working there. Rural and urban areas in South Africa face a critical shortage of health workers, as these health workers prefer to work in areas with better opportunities for income generation and professional development and better living and working conditions (WHO, 2019).

Shortages in the health labor force represent a major challenge for health policy-makers. There are various approaches to defining shortages. From an economic perspective, a shortage occurs when the quantity of a given skill supplied by the labor force and the quantity demanded by employers deviate at the existing market conditions. Non-economic definitions are generally normative, i.e. there is a shortage of labor relative to defined norms. In the case of skilled health personnel, these definitions are based either on a value judgment– for instance, how much care people should get – or on a professional determination – such as deciding what is the correct number of physicians for the general population. On the basis of those criteria, staff shortages are reported in most countries of the world, although the severity varies. The shortage seems most severe in Africa. For instance, serious staff shortages in all health professions categories are reported in Zimbabwe, including 2,000 vacancies for nurses. In Asia, Vietnam experienced a 57% decline in the number of nurses between 1986 and 1996. Shortages appear to have been accentuated by the migration of health personnel (Pascal, 2015).

The low number of health workers across Africa is a significant bottleneck to the provision of health care. This is most apparent in remote, hard to reach parts of the continent. The geographical imbalance of health workers within countries and the lack of appropriate skills, training and support for existing workers are at the crux of the health worker crisis in Africa. In many countries the skills of limited and expensive professionals such as doctors are not well matched to local health needs. In almost all sub-Saharan countries there are far higher concentrations of workers situated in urban areas than in rural areas. In Uganda about 70% of medical doctors and 40% of nurses are based in urban areas, serving only 12% of the population, meaning that many rural facilities are served by untrained or less skilled workers. There is no escaping the fact that the absolute numbers of skilled workers needs to increase. However, addressing the appropriate skills mix for African countries and ways to train, motivate and retain lower to middle-cadres of workers, including CHW, should be an immediate priority. This briefing therefore focuses on the importance of training and deploying health workers where they are needed most, at community level, and the ways in which proven models can be scaled up to address the health worker crisis (Sarah, 2017).

A review conducted by the Africa Region of the World Bank in collaboration with the African Regional Office of the World Health Organization at a consultative summit in 2002 in Addas-Ababa in some low income countries found that in the previous few years increasing attention has been paid to the development of health policies. But side by side with the supposed benefits of policy, many analysts share the opinion that a major weakness of health policies is their failure to create room for issues of human resources. The lack of explicit policies for Human Resource Health development has created, in most countries, imbalances that threaten the capacity of health care systems to attain their objectives. The labor force in the health sector has specific features that cannot be ignored. Health institutions are faced with external pressures that cannot be effectively met without appropriate adjustments to the labor force. The development of the labor force thus appears to be a crucial part of the health policy development process. Putting employees problems on the political agenda and developing clear Human Resource Health policies is a way to clarify goals and priorities in this area, to rally all sectors concerned around these goals, and to promote a more comprehensive and systematic approach to Human Resource Management. In the long run, this opens the prospect of developing health care systems that is more responsive to the expectations and needs of populations (Gilles & Dubois, 2018).

Human resources for health in Mozambique pose a major challenge for various reasons. Mozambique is a poor developing country; its epidemiological profile is dominated by communicable diseases, especially malaria, tuberculosis, cholera and HIV/AIDS among the population in general; acute respiratory infections, diarrhoeal diseases, malnutrition, anaemia and measles among the infant population; and high infant mortality and maternal mortality. Average prevalence of HIV/AIDS is 16.2%. Despite efforts by the government to improve the health status of the population, much remains to be done to increase accessibility to health services, improve the quality of services and provide drugs. The main source of human resources supply to the national health system (NHS) is recruitment of the graduates of Ministry of Health training institutions. However, staff placement in health services is still characterized by imbalance in staff distribution among the different regions and provinces and between urban areas and rural areas where 80 % of them live characterized by imbalance in staff distribution (Samuel, 2017).

According to the study carried out in South Africa one strategy to maximize the effectiveness of the program in increasing the supply of health workforce to rural areas is to choose candidates based on characteristics observed to be associated with a low chance of defaulting on the service obligation and a high chance of remaining in a rural area after completion of the obligation. There is evidence from both developing countries and developed countries that medical graduates from rural background are more likely to choose rural practice than their peers from urban areas. For example, a 2003 study in South Africa found that ten (10) years after graduating from medical school, doctors of rural origin were 3.5 times more likely than doctors of urban origin to practice in rural areas (Till & David, 2019).

2.2 Working equipment on Health worker retention

Medical equipment represents a substantial asset in the health care delivery system and needs to be managed efficiently. Moreover, the way in which it is purchased, managed and used can influence the quality of health care delivered to patients. Medical equipment can pose a risk to patients and staff, particularly if used improperly. Appropriate daily, periodic and corrective maintenance of medical equipment is key to achieving safe and cost-effective management of medical equipment. Adequate operation and daily maintenance budgets should be allocated to Health Facilities. In order to guide investments, sufficient advisory and supervisory capacity needs to be developed by Health Infrastructure Division (HID) and in all the health facilities operated by PnFPs. operation and maintenance capacity development should be systematically in line with the increasing demand. It is difficult for low income countries to procure cost-effective equipment for their health care sectors, the challenge therefore is for the country to incorporate the experiences gained over the years into this Medical Equipment Policy, and this is the fourth edition of the national Medical Equipment Policy. The first edition containing a summary of the work of the national Advisory committee on Medical Equipment and its various subcommittees was issued in March 1991.

Doctor’s ability to work depends notably on the availability of medical equipment and facilities, without which, doctors are unable to practice what they were trained, A survey of doctors sampled from 10 hospitals in the Limpopo district in South Africa demonstrated that the availability of equipment which assisted them to save peoples’ lives was an important factor for attraction and retention of doctors in rural areas , Similar findings reports from four Discrete Choice Experiment (DCE) studies in Liberia, Ethiopia , Ghana and and a survey in Ghana Availability of equipment attracts and retains health workers at the same time increase the community responsiveness to health services (Cutumisu et al., 2019).

Behera et al., (2019), conducted a DCE study of 300 COs finalist in rural Tanzania which reported that, availability of equipment and supplies in health facility was among the factors influencing COs to take job in rural areas. Another study conducted by Songstad (2022) in FBO rural areas in Tanzania revealed availability of equipment and medicine supported health workers to serve the poor in rural areas.

The availability of an operating theatre, water, electricity or solar power system, sanitation, roads and communication can make health facility to be more attractive (WHO, 2020). A study conducted by Ditlopo (2017) among 302 medical students in South Africa observed that doctors who have poor hospital accommodation leave rural areas as soon as they completed mandatory services, but for those who have good accommodation stay longer”. Another study in Ghana reported the types of house preferred by doctors to be “a free housing with three bedrooms and internet access.

Kolstad, (2021)conducted a DCE study of 320 COs in Tanzania, reported provision of decent housing was among the factors for attraction of clinical officers working in rural areas. Furthermore, MoHSW and BMAF (2022) tracking of new health workers posted and reported in a new station in Tanzania found that provision of house in rural and remote areas increased likelihood of health workers to take job and stay in rural areas. The shortage of health workers in rural area is a global issue. Globally the shortage is estimated to be approximately 4.3 million health workers. According to WHO (2017) half of the world population live in rural and estimated 1 billion people do not have access to health workers (WHO,2020), 57 countries reported to have critical shortage of health workers and 36 of them are from SSA countries. Rural dwellers are facing more critical shortage of health workforce than urban.

(Kruk et al, 2010). Two DCEs studies of 107 nurses in Malawi (Mangham, 2008) and a sample of 642 Ethiopian nurses have similar findings (Hanson et al, 2010). The availability of house in rural area can change the mindset of health workers to attract and retain in rural. Moreover, availability of housing for health workers near the health facilities reduces costs and make provision of health services easier. Rockers (2012) conducted a DCE study of 665 health workers in Uganda, the findings observed 426 doctors out of all participants reported good quality of health facility to be important determinant for them to accept rural job.

The shortage of health workforce became more severe because of the policy and employment freezes which occurred in 1993 and 1999. The implementation affected much of the health system when the heath posts were frozen (Munga et al, 2018). There is evidence that in rural and remote areas one can find a clinical officer or medical attendant running a dispensary because of shortage of respective staffs, for which the standard norm of staffing is a minimum of nine health workers to cater for 10,000 people (MoHSW, 2020). Willingness of health workers to serve in a rural area is also related to their attitude and good will to work for the poor. A study conducted in Ghana with a sample of 238 final year nursing students observed that their willingness to serve the rural communities mainly depend on humanitarian reasons as well as their desire to save lives of poor people (Lori et al ,2021).

Religious or ideological belief towards serving the poor, influence the decision of health workers to practice in rural areas. A survey conducted in Ghana among 84 doctors observed the willingness of doctors to work in remote and rural areas because of religious belief. “Christians spoke passionately about service to poor while socialist ideology of those who trained in Cuba expressed their strong commitment to work in rural areas to bring equity in health” (Snow et al, 2021). The implication is that health workers’ decisions to practice in rural can be influenced by different beliefs which aim to improve health status of the poor.

A study conducted in Kenya, South Africa and Thailand indicated 30% of the a sample of 1,064 final year nursing students showed a greater generosity to patients and poor people in rural areas, and they were likely to remain in rural areas. But, the results varied between the three countries: Thailand indicated harmony to be the core value while in the other two countries nurses showed less solidarity, the reasons for variation were not presented but may be because of difference in settings or educational background (Smith et al, 2021). Prytherch (2018) conducted study in Tanzania; reported health workers expressed their main drive for joining the medical field were not for salaries but to serve poor people. The implication is that health workers are willing and committed to practice in remote and rural areas if their expectations are met especially the necessary equipment’s to work.

2.3 Motivation on Health worker retention.

The health care system is established with mandate of ensuring that health care services are provided to citizens. For the health sector to meet its obligations, among others, requires adequate number of healthcare professionals. According to Alam (2019), the healthcare profession is regarded as one of the noblest professions across the globe. It is only nat- ural that this profession is expected to demonstrate the highest standard of professionalism and quality health care services even under unfavorable conditions. This notion is supported by Alam and Haque (2017), who indicate that health care professionals are expected to adhere to the required standard even in the face of such adversity as unfavorable job environment, poor working conditions and low salaries. These factors are seen as impediment towards attracting and retaining healthcare professionals, particularly, critical scarce skills of clinicians, for instance medical specialists and medical officers.

Shawn Abraham (2017) argues that reward and recognition is a crucial component to the success of organizational retention programs. He suggests that one of the easiest and best ways to reward employees is to simply congratulate them on a job well done. Companies might consider a systematic compensation/ bonus program designed to establish milestones and reward top performers , The lack of recognition from superiors for a job well done is one of the most avoidable reasons to lose a good employee. Employee development; In the 21st century according to (Simonsen, 2019) Development is considered as gaining new skills and taking advantage of many different methods of learning that benefit employees and organization alike. He argues that employee benefit from experiencing greater satisfaction about their ability to achieve results on the job and by taking responsibility for their career; the organization benefits by having employees with more skills who are more productive.

Logan (2019) argues that giving employees the opportunity to learn, try new things, and grow as individuals are some of the most critical factors for retaining employees. Jane, Steven and Chris (2019) say that people do not leave organization but leave people; they suggest that organization should practice in-house training to allow employees show their expertise to others throughout the firm while promote networking among personnel who work in different locations.

They point out that with this kind of training new employee will integrate more quickly within the firm, when given the opportunity to interact with other firm employees in this type of environment. They argue that the training received reinforces the employee‘s sense of value to the firm (Tax adviser march 2019). The opportunity for a personal development is one of the more important variables in personnel selection and retention today Suzan (2019). She argues that training and education, in what the employees is interested in learning, is one of the key factors in retention and motivation. Employers who pay for classes, conferences, and professional associations encourage staff growth and ensure staff motivation. She adds.

Human resources are vital for delivering health services, and health systems cannot function effectively without sufficient numbers of skilled, motivated, and well-supported health workers. Job satisfaction of health workers is important for motivation and efficiency, as higher job satisfaction improves both employee performance and patient satisfaction. Even though several studies have addressed job satisfaction among healthcare professionals in different part of the world, there are relatively few studies on healthcare professionals’ retention in Kabale regional referral hospitals.

It is important for companies to make sure that their employees can access new information and knowledge as quickly as possible and to ensure to secure an order of succession (Garger 219), he further notes that states that many employers believe that training boosts morale, enhances motivation, and improves personnel retention, a powerful motivator to stay or to go. Employees who find their jobs becoming routine tend to lose interest in their work and by extension in their employer. The desire to learn and grow, to push into uncharted waters and be excited about one’s work again is a positive force for an employer to harness.

When people feel that they have reached the limits of career growth and there is no more challenge, it is natural to seek change and the excitement of new experiences. Wheeler suggests that every employer should encourage employees to transfer to different positions frequently and institute rewards for managers who let their people go to other departments and who focus on developing their staff. Many employees who leave organizations are simply looking for a bigger challenge or the opportunity to use a new skills or degree. However, Smart organizations will encourage this and motivate managers to source and hire internally whenever possible or even if it will require a bit of training. Education and development are the cheapest retention tools in your arsenal, adds wheeler Kabbash et al., 2021)..

Every person has different reasons for working but everyone works because he/she obtains something from work. The something obtained from work impacts on individual‘s morale and

motivation and the quality of one‘s life. Most people think that money is what people want from work (Kabbash et al., 2021).

According to Suzan (2019) in her article Work is about Money, she points out that people work for love; others for personal fulfillment. Others like to accomplish goals and feel as if they are contributing to something larger than themselves, something important. She suggests that whatever one‘s personal reasons for working, almost every one works for money. She also stresses that fair benefits and pay are the cornerstone of a successful company that recruits and retain committed workers. Without the fair, living wage, organizations risk losing their best people to better paying employer she adds.

The research carried out by the Infosurv in 2012 at Maritz Inc, about how Maritz motivates its employees found that when employees are offered more benefits financial or non-financial they will work harder to achieve a specific goal and their overall attitudes and habits will change. They‘ll become more engaged, which correlates not only with better performance, but also with increased retention, improved customer experience and other desirable factors. Your employees will stay with your company longer, provide better service to customers, and report more attachment and more pleasure in their work.

2.4 Personal protective equipment on Health worker retention

Retention Management is a critical aspect to successful organizations. With the high costs associated with replacing the outgoing workers, employers must deliberately engage in retention activities. Kaye and Sharon Jordan (2019) found that losing employees is expensive in terms of replacing lost talent which is 70 to 200% of that employee‘s annual salary. There are advertising and recruiting expenses, orientation and training of the new employees, decreased productivity until the new employee is up to speed and loss of customers who were loyal to the departing employee.

PPE is a physical barrier worn by HCWs to prevent spreading of a pathogen from either a suspected or confirmed case or a pathologic specimen. It serves the dual role of preventing disease spread from patients to HCWs and vice versa. These physical barriers include goggles, face shields, fluid-resistant medical or surgical masks, particulate respirators , gloves, disposable gowns, disposable coveralls, waterproof or heavy duty aprons, waterproof boots, and hoods or headcovers in conjunction with other IPC methods. Wu et al. (2019) and the National Hospital Infection Management and Quality Control Centre recently reported a large-scale infection of HCWs from the Hubei province in China that was mainly due to underutilization of PPE. Similarly, the Henry Ford Health System recently confirmed that 46.6% of its workers had been infected with SARS-CoV-2 , The consequence of these reports is fear among HCWs in the setting of a lack of definitive treatment or a vaccine for SARS-CoV-2. This situation necessitates critical observation of occupational hazards and workplace safety during the COVID-19 pandemic. HCWs in low-resource settings need adequate PPE skill (including appropriately selection, donning, removal, decontamination, and disposal of PPE) at the backdrop of good theoretical knowledge of the indications and procedures, for effective protection in clinical areas. They should also have the right attitudes towards, training on, approaches to, and beliefs on and the requisite skills for PPE in practice in addition to other interventions to successfully fight and win the battle against SARS-CoV-2.

Health professionals need personal protective equipment when dealing with parties of all types of illness for example airborne diseases like Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogen that causes coronavirus disease 2019 (COVID-19), is one of the most contagious viruses in human history , Following the declaration by the World Health Organization (WHO) on 11 March that COVID-19 is a pandemic disease, COVID-19 has rapidly spread across 212 countries with an estimated 4,248,389 cases and 294,046 mortalities within the five months from the start of the outbreak to 14 May 2020 , Over a period of five weeks, the number of COVID-19 cases in Nigeria rose from 38 cases on 24 March to 4,791 cases by 14 May 2020 , This ravaging infection has spread beyond boundaries and race and has a predilection for senior citizens, Containment of this disease has been a major problem despite the numerous protocols advanced by various regulatory bodies. These guidelines and protocols include those by the WHO, the Centers for Disease Control, the International Labour Organization, and the European Agency for Safety and Health to prevent infections among healthcare and nonhealthcare workers, They include facility cleaning, regular and proper handwashing, respiratory hygiene and etiquette, advice on national travel, emphasis on staying at home for infection containment, events and meeting arrangement rules, case notification and management, and proper use of face mask, Among the critical components of infection and prevention control (IPC) during the management of COVID-19 is the mandatory use of PPE by healthcare workers (HCWs) (Chan et al., 2020), This component is a safeguard, as HCWs are at greater risk of contracting the disease, In Nigeria as on the 1st of May, approximately 113 HCWs have been infected with SARS-CoV-2 during their duties (Sohrabi et al., 2020).

Many organizations assess the cost of staff turnover by working on the principle that replacement of a staff member costs the equivalent of that person‘s annual salary, with the proviso that high level staff may cost up to two year‘s salary to replace, (Australian Institute of Management‘s Salary survey 2013). According to this survey 38.4% of organization surveyed estimated a cost up to $ 20.000 and 28.4% indicated that the turnover of each position costs up to $50.000. On keeping with other research on employee retention and motivation, the survey found that remuneration is not the main contributing factor in staff retention. Out of 50 identified retention factors Kaye and Sharon (2019) found that pay is the least important. Benjamin (2006) agrees with them on the idea that money is the least important in employee retention.

Retention management has been a hot topic for many researchers and it is a major concern for many organizations. Employee retention programs connect professional achievement with personal rewards, helping a company‘s people to do more and inspiring them to stay longer (Infosurv at Maritz Inc 2018). According to Wayne Reschke (2019), the central to successful retention is to know the dreams, aspirations, interests, and needs of employees and translating this knowledge into responsive organizational practices. Retention doesn‘t just happen; therefore keeping people must become a significant element of a business strategy he continues.

Retention cannot be accomplished purely through money. A host of on the job and off the job factors must be considered when developing a retention plan Mitchell, Halton, &Lee (2019). According to these authors, voluntary turnover is huge problems for many organizations today and there are many reasons why people voluntarily leave organizations. Some reasons are personal and others are influenced by the employing organization. According to Mike (2013), staff retention topic is very important to any organization and managers should not ignore it. This is because it is very expensive to replace departing staff in terms of recruitment, hiring, and retaining, orienting and staffs. There are also other related costs that go with replacing employees and appear in terms of time, money and energy spent by managers in replacing departing staffs. However, under this section, voluntary turnover and problems associated with it will be discussed together with recruitment and selection as key factors to staff retention.

CHAPTER THREE

METHODOLOGY

3.1 Introduction

This chapter presents the research methods that will be used to carry out the study. It covers the research design, Area of study, target population, sample design, sample size, research instrument, and measurement of variables, Data Collection Procedure, data analysis and Ethical considerations of the study.

3.2 Research Design

The study will adopt a cross-sectional survey research design because of the nature of the variables that will be at hand; to produce data required for quantitative and qualitative analysis and to allow simultaneous description of views, perceptions and opinions at any single point in time. The study will also use qualitative and quantitative methodologies for data analysis. Quantitative and qualitative methodologies will be used in examining the influence of working conditions on retention and productivity of Health workers. Quantitative research will consist of those studies in which the data concerned could be analyzed in terms of numbers while qualitative described events, persons and so forth scientifically without the use of numerical data. Quantitative research is based more directly on its original plans and its results are more readily analyzed and interpreted. Qualitative research is more open and responsive to its subject. (Hennink et al., 2020).

3.3 Study Population

Study population is defined as the entire group of people that a researcher wishes to investigate. Kabale Regional referral hospital is comprised of 60 employees, 1 medical superintendent and assistant, 2 pharmacist, 3 specialists, 5 medical doctors, 5 clinicians, 2 chemists, records officer, 2 laboratory assistants 20 nurses, and 20 midwives.

3.4 Determination of the sample size

It is impossible to study the whole targeted population of the study and therefore the researcher will take a sample of the population this is also further supported by Mugenda and Mugenda (2003) who notes that a research should choose a sample out of the whole targeted population. A sample is a subset of the population that comprises members selected from the population. Using Krejcie and Morgan’s (1970) table for sample size determination approach, a sample size of 52 respondents will be selected from the total population of 60 employees.

Table 1: Showing Population and Sample size of respondents

Category	Population size	Sample size	Sampling Technique
Medical superintendent and assistant	2	2	Purposive sampling
Medical specialist and medical doctors	8	7	Purposive sampling
Pharmacists	2	2	Purposive sampling
Clinicians and chemist	7	6	Simple Random sampling
Records officer	1	1	Purposive sampling
Nurses and midwives	40	34	Random sampling
Total	60	52

Source: Kabbale Regional Referral Hospital

3.5 Sampling techniques and procedure

Purposive sampling, also known as judgmental, selective or subjective sampling, is a type of non-probability sampling technique where the researcher chooses a sample based on what they think in other words they use their personal judgement (Palys, 2008). The study will use Purposive sampling technique because it saves time and also enables the researcher to get information from the right people who have knowledge and skills regarding the subject topic. This technique will use in selecting, Managers, managers, Unit heads, the researcher will use this technique because these respondents hold enough knowledge and skills regarding the study topic.

The researcher will use simple random sampling technique, According to Amin, (2010) a simple random sample is a subset of individuals chosen from a larger set (a population). Each individual will be chosen randomly and entirely by chance, such that each individual has the same probability of being chosen at any stage during the sampling process, and each subset of individuals has the same probability of being chosen for the sample. The technique will be used to select from the other staff members.

3.6 Data collection methods

The section presents data collection methods which will include questionnaire survey, interview and documentary review.

3.6.1Questionnaire Survey

Questionnaire Survey method will be used to obtain the opinion of the respondents regarding the topic under study, according to (Johnson, Adkins, & Chauvin,(2020) states that questionnaires are important in research because the respondents are given time to think and they don’t feel intimidated. Questionnaire gives the respondents ample time to respond to the questions when ready and they can be kept for future references. This method will be deployed to capture information from Staff Members, unit heads and managers.

3.6.2 Interview

Face-to-face interview is a data collection method when the interviewer directly communicates with the respondent in accordance with the prepared questionnaire (Polak & Green, 2015).

This method enables to acquire factual information, consumer evaluations, attitudes, preferences and other information coming out during the conversation with the respondent. Thus, face-to-face interview method ensures the quality of the obtained data and increases the response rate.

Interviews will be used because they fetch a variety of ideas needed for the study and give a deeper understanding of the topic. The method will be used to generate information from Executive Director.

3.6.3 Documentary review

This will be used to supplement the data that is acquired from the interviews and questionnaires. The researcher will analyze the documents and publications related to the study topic. Documents that are expected to be reviewed include; Kabale regional referral Hospital reports, Journals, and Newspapers.

3.7 Data collection instruments

For each deployed data collection method, there is a corresponding data collection instrument that will be used. The study will use Questionnaire Guides, Interview Guide and Document review checklist as described in the sub-sections below.

3.7.1 Self-administered Questionnaire

The questionnaire shall be designed in a manner that motivates respondents with simple structured questions with the option of providing any addition information to the structured questionnaire as an option to obtain relevant data from them. The questionnaire is structured with both close-ended and open-ended questions. It has aLikert scale 1-5 indicating the level of a respondents’ agreement or disagreement, where 1 represents Strongly Disagree and 5 stronglyAgree.

3.7.2 Interview Guide

The researcher will use an interview guide to collect data in order to find out the vivid picture of the participants’ perspective of the topic. Interviews are an effective qualitative method for getting people to talk about their feelings, opinions and experiences. They are also an opportunity for us to gain insight into how people interpret the study topic. The views of the respondents is a personal reflection of their personal experience relating to the study topic. Open ended questions will be allowed to ease of expression and capture of vast information from study participants.

3.8 Data quality control of instruments

The data collection tools will be pre-tested on a smaller number of respondents from each category of the population to ensure that the questions are accurate.

3.8.1 Validity

Validity is defined as the extent to which results can be accurately interpreted and generalized to other populations (Oso & Onen, 2008). While Borg & Gall, 1989 as cited in Onyinkwa, (2013) validity is defined as the degree to which results obtained by the research instrument correctly represented to the phenomenon understudy and Mugenda & Mugenda, (1999) as the accuracy and meaningfulness of inferences which are based on the research results.

Amin, (2005) recommended minimum CVI of 0.7 to be used. Validity will be tested using content validity index which involves judges scoring the relevancy of the questions in the instruments in relation to the study variables.

The formula for Content Validity Index will be;

CVI =

Where CVI = content validity

n= number of items indicated relevant.

N = total no. of items in the instrument

In this study, validity will be achieved by establishing content validity. The researcher will achieve content validity by using the experts to assess the validity of the research instrument. The experts especially research supervisors and consultants from UMI will be given data collection tools to assess whether the items in the instruments are valid in relation to research topic, objectives, and questions. From the instruments they will declare some items valid and others invalid. Those declared invalid will be dropped, others adjusted, while the valid ones will be maintained. Then content validity index (CVI) will be computed by dividing the number of items declared valid by total number of items/questions in the data collection instrument.

3.8.2 Reliability

According to Mugenda and Mugenda, (2003) reliability is the measure of the extent to which research instruments are able to provide the same results upon being tested repeatedly. Crobach’s coefficient alpha (a) as recommended by Amin, (2005, P.302) will be used to test the reliability of the research instrument. The instrument is deemed reliable if chronbach’s alpha of 0.7 and above is obtained and therefore, it will be adopted for use in the data collection.

Formula for reliability is

= ()

Where = alpha reliability co efficiency.

K=Number of items included4 in the questionnaire

= sum of variance of individual items

= variance of all items in the instrument.

To ensure credibility and trust worthiness of qualitative data the researcher will ensure that only the officials who are employees of Kabale regional referral Hospital will be interviewed.

3.9 Procedure of data collection

The researcher will obtain an introductory letter from Uganda management institute to seek permission and enable easy access of information by the researcher from Kabale regional referral Hospital, after the permission is granted from Kabale regional referral Hospital the researcher will go ahead and administer questionnaires and interviews selected respondents however the consent of the respondents will be sought before being given questionnaire and the respondents will be informed that the study is strictly for academic purposes.

3.10 Data analysis

Mugenda and Mugenda (1999) and Mbaaga (2000) both defined data analysis as a process of bringing order, structure and meaning to the data gathered to create information out of it. Data analysis will therefore be done with quantitative and qualitative methods. The quantitative (Questionnaires) and qualitative (interviews) will be analyzed separately and then combined during discussion of the findings.

3.10.1 Quantitative Data Analysis

Data processing will be done by entering the data into a statistics package for social sciences (SPSS) version 24.0 in line with the research questions. Data analysis will be done by also using this statistics package for social sciences (SPSS) to formulate frequency tables will the percentages, frequency, mean, variance and standard deviation will be obtained.

Under quantitative analysis, process includes; editing, classification, coding and presentation. Data will be summarized in frequency tables, percentage; data will be analyzed with the use of statistical package for social scientist (SPSS). Quantitative data will be collected through structured questionnaires and it will be cantered into a computer, tabulated and analyzed.

Spearman’s correlation coefficient and regression analysis is recommended by Amin (2005, P.378) will be used during data analysis in order to test the strength, degree and direction of the study topic. The formula will be used for this study because it is compatible with SPSS program in addition to being appreciated in analyzing data under which the data is arranged.

3.10.2 Qualitative Analysis

Qualitative data will be analyzed using content analysis.it involved gathering and analyzing data based on the content, where by the raw data collected from the field will be read through to enable the researcher to get familiar with the data. At this process the study will use noted cards to organize the available data to accelerate further analysis. Data will then be evaluated and analyzed to determine its accuracy, credibility, usefulness and consistency which will aide acceptance or rejection of the research hypothesis.

3.11Measurements of variables

A five point Likert ordinal scales ranging from; strongly agree which will be assigned 5, strongly Agree, 4 agree, Not Sure assigned 3, Disagree allocated 2 and strongly disagree allotted 1 to obtain responses on the variables. The Likert ordinal scale has been used by numerous scholars who have conducted similar studies such as Bowling, (1997).

3.12Ethical considerations

The researcher will ensure that before giving questionnaires to the respondents their consent is sought and when they accepted to participate in the study, they will be given questionnaires.

Confidentiality of the respondents ‘information will be assured and the researcher also informed that the study is strictly for academic purposes and therefore, they should not fear giving information.

Only respondents who are selected will be given questionnaires and only those meant to be interviewed will actually be interviewed.

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