HARAR HEALTH SCIENCE COLLEGE DEPARTMENT OF
MIDWIFERY
ASSESSMENT OF PREGNANT WOMEN SATISFACTION AND
ASSOCIATED FACTOR IN ANTENATAL CARE SERVICE AT
HARAMAYA GENERAL HOSPITAL , ESTEARN HARARGE
ZONE , OROMIA REGIONAL STATE , ETHIOPIA. JENEWARY
2023
A RESEARCH PROPOSAL SUBMITTED TO HARAR HEALTH
SCIENCE COLLEGE DEPARTMENT OF MIDWIFERY IN
PARTIAL FULLFILLEMANT FOR THE REQUIREMENT OF
BACHILER SCIENCE OF MIDWIFERY
BY:
1 . FIROMSA ZEYLAHI
2. TUJI DAWID
3. IMAN SHAMSHADIN
4. NADIYA KASIM
5 . AYANTU ABDI
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6. HIKMA HEYDAR
ADVISOR: Zelalam B. (BSc, MSc)
JANUARY 2023 HARAMAYA GENERAL,ETHIOPIA
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SUMMERY
.Introduction: Pregnancy is a very important event from both social and medical points of view.
Therefore, pregnant women should receive special care and attention from the family,
community and from the health care system. Pregnancy related causes are among the top reasons
for death in women of reproductive age in almost all developing countries. Antenatal care
(ANC), which is given to pregnant women, is widely used as one component as a preventive
health care for mother and fetus. Antenatal care is a key entry point for pregnant women to
receive abroad range of health promotion and preventive health service.
Objective: to assess client satisfaction and associated factor with the antenatal care service
at Haramaya general hospital, eastern hararge zone , oromia regional state , Ethiopia.
Metheds Institution based cross sectional study design will be used among
pregnant women in haramaya general hospital . The total of 386 woman will
be included in the study and the study subject will be selected using
systemic sampling method. Data will be collected by using structured
questionnaire by face -to -face interview by all students who are included in
this group after training is given for about half of a day. The returned
questionnaire will be checked for completeness, cleaned manually and
entered and processed by SPSS version 20 for further analysis.
Work plan: This study will be conducted from jenewary to febewary 2023
Budget-about 3600 birr will be needed to carry out the study.
ACKNOWLEDGMENT
First we wouid like to the almighty god ,for giving us strength and health to
accomplish this work , next we would like to forward our heart full gratitude
to harar health seance collegy for giving this chance to do research .we also
like to express our deepest heart full gratitude for our advisor zelalam and
for their tireless effort and support which has enabled us to finish this
work .
Table of Contents
TABLE OF CONTENT PAGE
ABSTRACT --------------------------------------------------------------------------------------------------I
ACKNOWLEDGEMENT ---------------------------------------------------------------------------------II
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TABLE OF CONTENT ------------------------------------------------------------------------------------III
LIST OF TABLE -------------------------------------------------------------------------------------------VI
LIST OF ACRONYMS AND ABBREVATION -------------------------------------------------------V
INTRODUCTION -------------------------------------------------------------------------------------------1
1.1 BACKGROUND ----------------------------------------------------------------------------------------2
1.2 STATEMENT OF THE PROBLEM -----------------------------------------------------------------3
1.3 SIGNIFICANCE OF THE STUDY -------------------------------------------------------------------4
2 LITERATURE REVIEW -------------------------------------------------------------------------------5
3 OBJECTIVE ----------------------------------------------------------------------------------------------6
3.1 GENERAL OBJECTIVE -------------------------------------------------------------------------------6
3.2 SPECFIC OBJECTIVE ---------------------------------------------------------------------------------6
4. METODS AND MATERIALS ---------------------------------------------------------------------7
4.1 Study area and period ------------------------------------------------------------------------------7
4.2 Study Design ----------------------------------------------------------------------------------------7
4.3 Population -------------------------------------------------------------------------------------------7
4.3.1 Source of population -----------------------------------------------------------------------------7
4.3.2 Study population ---------------------------------------------------------------------------------7
4, 3.3 study units ----------------------------------------------------------------------------------------7
4.4 Variables --------------------------------------------------------------------------------------------8
4.4.1 Dependent variable ------------------------------------------------------------------------------8
4.5.2 Independent variable -----------------------------------------------------------------------------8
4.6 Inclusion and exclusion criteria -------------------------------------------------------------------8
4.6.1 Inclusion criteria ----------------------------------------------------------------------------------8
4.6.2 Exclusion criteria ---------------------------------------------------------------------------------8
4.7 sample size Determination ------------------------------------------------------------------------8
4.8 Data collection tool and procedure ---------------------------------------------------------------9
4.9 Data quality control ---------------------------------------------------------------------------------9
4.10 Data processing and analysis -------------------------------------------------------------------9
4.11 ethical considerations ---------------------------------------------------------------------------10
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4.12 operation definition -------------------------------------------------------------------------------10
4.13 Dissemination of the result ---------------------------------------------------------------------11
5. Work plan and budget -------------------------------------------------------------------------------12
5.1 work plan -------------------------------------------------------------------------------------------12
5.2 budget break down --------------------------------------------------------------------------------13
5.2.1 Stationary -----------------------------------------------------------------------------------------13
Table 2 material ---------------------------------------------------------------------------------------13
Table 3 personal cost ----------------------------------------------------------------------------------14
REFERNCE ---------------------------------------------------------------------------------------------15
ANNEX: I Information sheet AND Informed consent ------------------------------------------18
ANNEX: II QUESTIONAIRE {ENGLISH VERSION} -----------------------------------------20
ACRONYMS
ANC-Antenal care
FP-Family Planning
MCH-Maternal and Child Health
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MMR-Maternal Mortality Rate
OPD-Out Patient Department
TT-Tetanus Toxoid
WHO-World Health Organization
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CHAPTER ONE: INTRODUCTION
1.1 Backgrounds
Worldwide there were 295000 maternal deaths in 2017. The global
maternal mortality ratio is 211 per 100,000 live births. Half, 50%, of all
maternal deaths were in only six countries (India, Nigeria, Afghanistan,
Ethiopia and Democratic Republic of Congo) (1).
Maternal mortality ratio in Ethiopia is 401/100,000 live births. This level of
maternal mortality is highest by any developing country’s country standard
(2).
Antenatal care is considered one of the most effective health intervention
for prevention of maternal mortality and morbidity, particularly where the
general health status of women is poor (3).
Although systemic ANC was first introduced early in the 20 th century in
Europe and North America and is now almost universal in developed
countries, question related to its effectiveness have only began to be tackled
comparatively recently(4).
Approach to the evaluation of health and medical care commonly classified
in to three categories; structure, process, and outcome. The model
presupposed that structure affects process which in turn affect outcome (5).
The two mechanisms through which quality of care affects the decisions to
seek care are satisfaction or dissatisfaction with the outcome (example
effectiveness of treatment and remedies prescribed) and satisfaction and
dissatisfaction with the care received (example satisfaction long waiting
time hospital procedure, availabilities of supplies and efficiency). These
factors
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will affect as inhibitors of future utilization, thus affecting decision to seek
care (6).
Client satisfaction with the health care services largely determines their
compliance with the treatment and thus contributes to positive influence on
health (7).
The major goal of focused antenatal care is to help women maintain normal
pregnancies through: Health promotion and disease prevention, early
detection and treatment of complications and existing diseases, Birth
preparedness and complication readiness planning.
The Focused ANC Protocol is intended to assist ANC providers in their
work. It includes updated forms and checklists for identifying women who
can receive basic care and those who have special health conditions or are
at risk of developing complications and require more attention (3,4,5). As it
is emphasized in the new world health organization (WHO) ANC model,
women are evaluated in their first visit to the clinic to see if they required
especial care for existing medical condition. According to this model,
pregnant women are segregated in to two groups, those eligible to receive
routine antenatal care (basic component) and those who need special care
based on their specific health condition or risk factors. The newly proposed
ANC model recognizes that every pregnant woman is at risk for
complications and four ANC visits are recommended for most pregnant
women. Ideally, the first visit during first trimester; the second, close to
week 26; the third around week 32; and the fourth and final visit between
weeks 36 and 38 (5).The standard of care when evaluating a woman with a
potentially complicated first trimester pregnancy is to take a detailed
history of risk factors and ascertain the clinical course(10). Because it will
help to have enough time for essential diagnosis and treatment regimen
(7))ANC refers to pregnancy related health care provided
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by health worker in a health facility or home and it is the key entry point of
a pregnant woman to receive broad range of health promotion and
preventive services that promote the health of the mother and the baby
(14).
1.2 Statement of the problem
Worldwide it’s estimated that more than 50 million women suffer from poor
reproductive health and serious pregnancy related complication and
disability. Annually 600,000women die from complications of pregnancy and
child birth (8).
Globally, an estimated 295,000 maternal deaths occurred worldwide in 201
17. Among these maternal deaths, 56% occurred in Sub-Saharan Africa (9).
The maternal mortality ratio in Ethiopia is strikingly high and has stagnated
at 401 per 100,000 live births (10). The majority of maternal deaths could
be avoided if women had access to quality medical care during pregnancy,
childbirth, and postpartum (11).
Life risk of death related to pregnancy and child bearing estimated to be 50
times as high for women in Africa as for those in developed countries. In
Ethiopia, maternal mortality is relatively high accounting 23% of all deaths
to women aged 15-49. Reduction in MMR has been found for mother who
attends ANC when compared to those who didn’t (13).
ANC is more beneficial in preventing adverse pregnancy when its sought
early in pregnancy and is continued throughout depending on the
recommendation which states that a pregnant women should attend a
minimum of four visits and the first visit should occur in the first three
month of pregnancy (6) our country, Ethiopia although adopted the WHO
guided ANC package, the overall ANC coverage still remains low i.e. about
34% (15). Thus in developing countries like us
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the problem related to ANC coverage appears to be two fold (16). Coverage
of ANC attendance in Ethiopia is generally low, (38%) minimam first visits
are conducted (17).
Maternal and prenatal morbidity remain a big challenge in developing
countries, including South Africa were the figures are among the highest in
the world. Ethiopia MMR of 401 per 100,000 live births, however, remain
among the highest in the world, has fallen at all since 2017. Maternal
mortality in Ethiopia is likely linked both to extremely low utilization of
skilled birth attendants and facility delivery to even low use of emergency
obstetric care (18).
Patient satisfaction is a multidimensional health care constant affected by
many variables. Health care quality affects patient satisfaction which in
turns influences positive patient’s behaviour such as loyalty, patient
satisfaction and health care service quality; through difficult to measure,
can be operationalized using multidisciplinary approach that combines
patient input as well as expert judgement(20). Client satisfaction is an
important and desired outcome measure of the quality of care and need to
be addressed in order to improve utilization of service (21). Optimal
utilization of service is hampered by the relationship between the provider
and client (22). Satisfied patients are likely to comply with the prescribed
treatment and may be more willing to pay service thereby increasing
revenue (23) client satisfaction with the health care service s largely
determines their compliance with treatment and thus contribute to positive
influence on health (8). Improvement of ANC ethiopian healthy develop 4
visit to 8 visit during preganacy these is used quality of ANC is major
strategy used by hospitals and health care facilities to reduce maternal
death and morbidity so, the aim of this study identifying gaps and barriers
in the provision of quality of ANC in public MCH facilities, which when
addressed will go a long way in strengthen
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the capacity and credibility of public ANC. This will result in improved
client satisfaction, sustained use of services and improved outcome of care.
Women presenting themselves for ANC service will be empowered to make
informed decision on their heath and that of their infants. So the study will
be conducted to explore the level of satisfaction on ANC and determinant
for dissatisfaction using different factors to be relevant to client
satisfaction. (14)
1.3 Significance of study
According to the new focused ANC model, every pregnant woman is at risk
of pregnancy related complication to minimize this risk, pregnant woman
should start first ANC visit early in first trimester so that they will have
enough time for essential diagnosis and treatment of the cases.
Since model is now being applied in our country, and to be effective with
this approach, pregnant women need to be encouraged to come early for
ANC (as much as possible in the first trimester).
But there is gap in timing of first ANC visit in our country. EDHS 2016
reported that only 32% of ANC client started first visit in the recommended
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time. Study in Addis Ababa showed that, even if 40 % of pregnant women
started first ANC within first trimester, the timing ranges from first month
to ninth months of gestation.
Since model is now being applied in our country, and to be effective with
this approach, pregnant women need to be encouraged to come early for
ANC (as much as possible in the first trimester).
But there is gap in timing of first ANC visit in our country. EDHS 2016
reported that only 32% of ANC client started first visit in the recommended
time. Study in Addis Ababa showed that, even if 40 % of pregnant women
started first ANC within first trimester, the timing ranges from first month
to ninth months of gestation.
Data on service utilization are incomplete and little is known about health
seeking behaviour of clients. Studies are in a short which favour deal with
satisfaction of health service consumers, especially on ANC attendants both
locally and nationally. Thus this study will try to explore client degree of
satisfaction on ANC since at local level so that responsible bodies will use
the evidence for making improvement decisions.
Therefore this study tried to found some information and enables targeting
of ANC services to improve health of mothers and fetus and this show that
the timing of their when the mother the first ANC visit, matter for early
identification of risk factor and act accordingly
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2 CHAPTER TWO:
2.1 leteracur revew
ANC is expected to have positive impact on the development of the foetus
and infant. It was reported that with the maternal health hold constant, low
birth weight, neonatal and infant mortality were 1.5-5 time higher with the
late and less frequent antenatal care. Some danger of child birth can be
avoided if the pregnant women attend ANC clinic (15).
In study done in Bangladesh, the most powerful predictor of client
satisfaction with the government service was provider behaviour especially
respect and politeness. For client, those aspects were much more important
than the technical competence of the provider. Farther more, a reduction of
waiting time was more important for clients than a prolongation of the quit
short consultation time with 75% of clients being satisfied (19).
A study done in western Uganda forwarded that by educational status ANC
utilization improved higher levels (2.1 more likely) and satisfaction is also
more by higher level. Overall this study found 65% of clients satisfied with
the ANC services provided (19).
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In contrast to this, study done in India shows that irrespective of
educational status cost and occupation 7.7% of clients were most satisfied
from reproductive and child health services provided (11).
Study done in Kenya shows that the relationship between clients and
provider as an aspect of quality of care, influenced by the time spent in
service, interpersonal communication between provider and clients provider
attitude, improvement in service provision and client options about the
provider which was stated as <<although some provider were good, most of
them were negligent while on study and often biased>> (12).
A study done in Malawi stated that client satisfaction is state of being
contented or pleased with an event. These studies found that majority,
(97.3%) of clients were satisfied with the care they received from admission
through labor and delivery. The satisfaction is mainly due to the frequent
reviews of patient by nurse and doctors in the unit (20).
A study done in South East Nigeria showed that 94.3% of respondents were
satisfied with ANC services and 95.8% of respondents were satisfied in child
birth services. Over all 90.6% of respondents reported that the service to be
at least good (21).
A study done in India showed that 64.6% of patient are satisfied with
duration of outpatient department services and 100% satisfied for presence
of sign boards. 60% of patient is satisfied regarding doctor-patient
communication at all level of health care facility. But consultation on and
examination is <60% at primary level as compared to more than 80%else
were (8).
Client satisfaction was higher in reformed primary health care unit
compared to non-reformed primary health care unit. In all aspects
cleanness, doctors, nurse, waiting area and waiting time. Patient in
reformed PHC satisfied with those all aspects while those in non-reformed
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PHC are opposite. The overall satisfaction was 95% in reformed primary
health care units compared to 72%in non-reformed PHC unit (23).
A study done in Tanzania in Amana and Muhimbil Hospital reported that
patient at Amana hospital were either very satisfied (44.3%) or satisfied
(55.78%) and none were unsatisfied. While at hospital 1.1% of patients were
very satisfied while 94.7% were satisfied and 4.2% were unsatisfied with the
health care service provided. Lack of privacy when consulting with doctors
and dispenser contribute to patients’ dissatisfaction with services (24).
A critical aspect in the measurement of patient satisfaction is that models
and instruments sometime reflect the provider perspective rather than the
patient one. For example the patient capability to evaluate health service
provider and professionals skill is frequently questioned even when those
items receive high satisfaction rate (25).
In a study done in Egypt, Elmina city clients from rural area more satisfied
than those from urban in waiting time and environment while client in
urban are more satisfied than those from rural area in doctor-client
interaction and nurse-client interaction. 47% of urban HC and 69.5% of
rural HC satisfied in waiting time. 95% from urban HC and 89% from rural
HC satisfied in doctor (nurse)-client interaction. 68% from urban and 84.5%
from rural satisfied with the environment. Client satisfied faction
undoubtedly useful measure and the extent that it is based on client
accurate assessment; it may provide a direct indicator of quality of care.
Better understanding of determinants of clients’ satisfaction should help
decision makers to implement programs important to patients need as a
perceived by clients and service providers (27)
In Ethiopia ANC clinic are expected to provide the pregnant mother with
vital health care messages. Among other things health facilities should
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provide minimum basic care such as TT Immunization and Iron and Folic
acid supplementation. They are also expected to identify high risk group
and give them special care. According to response of health clinics they
were less efficient than that was expected even in areas with adequate
human resource and good facilities (16).
One of the significant trends in the development of modern heath care is the
involvement of clients in the management of their care and treatment
person concerned health care respond dignity and value of each person. It
is entirely desirable and proper that the view of patients should be sought
on their experience and expects (17).
The indicator of quality of ANC services were assessment, treatment,
counselling and client satisfaction according to study done in Pakistan. This
study also found that 46% clients were satisfied on being directly
questioned about satisfaction with the reviewed ANC service (18).
In a research done in central Ethiopia Health centres, majority (62.6%) of
respondents reported that they have been satisfied with their visit (9.9% are
highly satisfied and 52.5% are moderately satisfied with health care
provider interaction (26).
In study conducted in Addis Ababa, it was showed that selectivity in
satisfaction level may be attributed to many factors including women’s
expectation of care as a result of knowledge gained from health educations,
radio and other sources (16).
A cross-sectional study done in Jimma University specialized Hospital
reported that clients’ satisfaction was positively associated with increased
training level of the provider and short waiting time at the health unit.
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Source of dissatisfaction was found to be inadequate physical examination
by provider and failure to obtain prescribed medication. Declining of the
client satisfaction with increased level of education and revers with age also
been observed (14).
Conceptual frame work
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Socio-demographic
characteristics
Age
Obstetric characteristic
Religion
Pregnant mothers’ Number of visit
Ethnicity
satisfaction in ANC
Parity
Educational status service
Type of pregnancy
Marital status
History of abortionHistory of
Occupation still birth
Income History of FANC
Figure1 Conceptual frame work for assessment of pregnant women satisfaction and
associated factor in antenatal care service at Haramaya general hospital ,
estern harerghe zone, oromia regional state , Ethiopia.(Source from literature
review).
CHAPTER THREE: OBJECTIVE OF THE STUDY
3.1 general objective
To assess pregnant mothers’ satisfaction and associated factor in ANC
service at Haramaya general hospital during the study period, January
2023 .
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3.2 specific objectives
To determine the prevalence of pregnant mothers’ satisfaction in ANC
service at haramaya general hospital, January ,2023
To identify factors affecting pregnant mothers’ satisfaction in ANC
service at Haramaya general hospital ,January 2023.
CHAPTER FOUR: METHODS AND MATERIALS
4.1 Study area and period
The study will be conducted in haramaya general hospital from january to
february 2023 . this study will be conducted in haramaya general hospital at
antenatal care ward . haramaya general hospital is located 516 km from
addis ababa the capital city of ethiopia and away from harar city 16 km . it
is only hospital in haramaya warada with a total of 450 beds that provides
surgical , gynecological and obstetrical , medical and pediatrics wards . it is
referal center for surrounding health center .about more than 450 pregnant
women use antenatal service per month
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4.2 Study design
Institution based cross sectional study design will be used.
4.3 Population
4.3.1 Source population
All Women of reproductive age group (15-49) who visit in haramaya general
hospital
4.3.2 Study population
All pregnant women visiting the antenatal care clinic at Haramaya general
hospital during data collection period.
4.3.3 Sample size and sampling technique
Sample Size Determination.
• The sample size required to the study will be calculated using a single
population proportion formula. Jimma university study done is
Prevalence of pregnant mothers’ satisfaction in ANC service is taken
to be 34.5 %, which is taken from the study conducted in haramaya
general hospital (37).
n= (zα/2)2p (1-p)/d2
P = Proportion of pregnant mothers’ satisfaction (0.345)
z( α / 2 2 = Confidence level 95 % ( 1.96 )
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d = Margin of error (0.05)
n= (zα/2)2p (1-p)/d2
n=(1.96)2×(0.345) (0.655) = 347
(0.05)2
By adding 10% non-response rate the final sample size will be= 347+ 34 =
381
Then the total sample sizes for this study Will be = 381
4.3.3 Sampling technique
In this study, a provide ANC service. A preganat mother who attending ANC flow up selecting
by using will be selected by using lottery method, which haramaya general hospital. The total
sample size will be divided to those institutions proportional to the number of clients attending
ANC. The sampling interval by using: K=N/n, where K is sampling interval, N is number of
women( 945 ) and n is the required sample size (381). Then participants will be selected by using
systemic sampling method until the required sample size obtained.
Where; N =Total woman= N1+ N2
n = Total sample size = n1 + n2
K = N/n = 2.48 approximately = 2.5
4.4 Inclusion and Exclusion criteria
4.4.1 Inclusion criteria
Pregnant mother who come for ANC service.
4.4.2 Exclusion criteria
Those who refuse to participate.
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Those who are unable to communicate for different reasons.
4.5 Data collection measurements
.Primary data from reproductive age women in haramaya genaral hospital will be used in this
study and data on socio demographic and economic characteristics follow up history,
awarenessof antenatal care satistfication and reproductive health characteristics will be collected
using a self-administered questioner which is adopted from studies done on similar topics. And
this tool will be used as a data collection tool from the study participants for this study.
Finally, data will be collected after consent will be taken from each participant.
4.5.2 Study variables
Dependent variables
Pregnant mothers’ satisfaction in ANC service
Independent variables
Age
Marital status
Occupation
Distance from house to the health institution
Waiting time to get the service
Providers’ behaviour
Privacy during examination
Comprehensiveness of physical examination
4.5.3 Operational definition and definition of terms
Maternal satisfaction: Is the extent to which a mothers need or desire are met[13].
Very satisfactory: Above one’s expectation (the mothers were happy 6 and above from the seven
satisfaction assessment questions).
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Satisfactory: Just one’s expectation (when the mothers were happy with 4-5 satisfaction
assessment questions).
Dissatisfactory: Below one’s expectation (when the mothers were happy only with 1-3
satisfaction assessment questions).
Very dissatisfactory: Fail to meet one’ expectation usually leading to disappointment.
4.6 Data quality assurance
The data collection tool is first prepared in English version and it will be translated to Oromic
and Amharic language during interview. Edited final version of questionnaire will be used to
collect data from respondents.
Face-to-face Interview will be administered by using a structured interview.
The exit interview technique will be used to collect data with semi-
structured and pretested questionnaires. The completeness and consistency
of data will be established through direct supervision by the advisors.
4.7 Data quality control
Training will be given for data collectors and supervisor about research
objectives, data collection tools and procedures and interview techniques
for one day. The principal investigators together with one supervisor (health
officer) were supervised technique of data collection and completeness of
tools on the daily basis.
4.9. Data processing and analysis
The returned data will be entered and processed by Statistical Package for Social Science
[SPSS] version 2020 soft ware for analysis. Descriptive and summary statistics will be carried
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out. The dependent (outcome) variable is , or of ANC vist . Association will be done by chi-
square with p-value less than or equal 0.05 in the considered as significant association with time
in ANC.
The collected data will be cleaned, checked for quality, coded and analysed.
Independent variable will be described by using single descriptive statics
and determined at a level of significance of 95%and p-value was used to
decide whether the observed difference is statically significant or not. A
table and graph will be used to present the results and online chi square
calculator used to get the association of dependent and independent
variables.
4.9 Ethical consideration
Formal letters of cooperation will obtain from harar health science college
Department of Midwifery. The objective of the study was explained in detail
and pregnant mother was interviewed after oral consent. The privacy of the
pregnant mother was kept confidentially.
4.10 dissemination plan
• After writing the report, final result of this paper will be submitted
and presented to harar health science college Department of
Midwifery. The study findings will be disseminated through
presentation, hard copy and soft copy to relevant authorities who
deserve the result of the finding. And also it will be disseminated to
harar health science college and department of midwifery, haramaya
general hospital offices and other concerned bodies.
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5, WORK-PLAN
Work Plan of activities for a study on the assessmentof pregnant women satisfaction associated factors in antenatal care
service in haramaya general hospital estearn hararge zone Oromia riginal state , Ethiopia, 2023
Number Activity Carried out Nevem December January Februar March May Jule
ber y
1 Topic selection
2 Literature review
3 Proposal
Writing
4 Data collection
5 Data processing
and analysis
6 Report writing
7 Submission and
presentation
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