EFFECTS OF TRAINING ON SERVICE DELIVERY IN SELECTED MEDICAL

LABORATORIES IN KENYA

BY

A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILMENT OF THE

COURSE REQUIREMENT OF …..AT THE SCHOOL OF BUSINESS AND

PUBLIC MANAGEMENT, KCA UNIVERSITY

© KCA University, 2020

 DECLARATION

I Emma Onyango, hereby submit my research proposal titled effects of training on

service delivery in selected medical laboratories in Kenya for examination and truthfully
declare that the research proposal is my original research work and has not been presented
for a degree or diploma award in any other institution.

Signed this day of ------------------------------------- at KCA University----------------------

APPROVAL

This research proposal prepared and submitted by Emma Onyango in partial fulfillment
of requirement of the degree of Master of Business Administration (Human Resource
Management) has been approved by us as University supervisors:

Dr. Asenath Onguso

Sign------------------------------------------------------ Date -----------------------------------------

Dean of faculty

Prof

Sign---------------------------------------------------------Date----------------------------------

ii
 ABSTRACT

The current study seeks to investigate the effects of training on service delivery in
selected medical laboratories in Kenya. Specifically, the study investigates how technical
training and soft skills training, digital skills training and cognitive skills training affects
service delivery in the selected medical laboratories. Likewise, the study seeks to find out
the moderating effect of regulatory bodies on the relationship between training and
service delivery in the selected medical laboratories. The study is grounded on the Theory
of Reasoned Action (TRA), Technology Acceptance Model (TAM) and the Social
Learning Theory. This study will be a descriptive cross-sectional design to understand the
effects of training on service delivery. The target population of this study will be the 4053
lab practitioners found in 18 accredited medical laboratories in Nairobi County. Simple
sampling in conjunction with convenience sampling will be used to obtain a sample from
the target population. Semi-structured questionnaires will form a primary mode of data
collection in the research. In order to ascertain how valid and reliable the questionnaires
are, a pilot study will be carried out. The study will use both qualitative and quantitative
methods which prior to analysis, data will be sorted to ensure completeness. Coding of
the responses will be done, in order to enable the data to be analyzed using SPSS
software. The quantitative information will be analyzed descriptively, and inferential
statistics will be drawn by the use of SPSS software (v.22.0). The results from the
descriptive analysis will be in the form of mean, standard deviations, and frequencies as
well as in percentages. Results will then be presented in tables, diagrams and charts.
Qualitative data collected from the open-ended questions in the questionnaire will be
analyzed using content analysis and a prose form of presentation will be derived.

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 TABLE OF CONTENT

DECLARATION...............................................................................................................ii

ABSTRACT......................................................................................................................iii

TABLE OF CONTENT...................................................................................................iv

LIST OF FIGURES.........................................................................................................vii

LIST OF TABLES..........................................................................................................viii

LIST OF ABBREVIATIONS..........................................................................................ix

CHAPTER ONE..............................................................................................................10

INTRODUCTION...........................................................................................................10

1.1 Background to the Study..........................................................................................10

1.2 Statement of the problem.........................................................................................12

1.3 Objectives of the study.............................................................................................13

1.3.1 General objective of the study...........................................................................13

1.3.2 Specific objectives.............................................................................................13

1.4 Research Questions..................................................................................................13

1.5 Significance of the study..........................................................................................14

1.5.1 Policy Makers....................................................................................................14

1.5.2 Laboratory Management...................................................................................14

1.5.3 Academicians and Scholars...............................................................................15

1.6 Scope of the Study...................................................................................................15

1.7 Limitations to the study............................................................................................15

1.8 Assumptions of the study.........................................................................................15

CHAPTER TWO.............................................................................................................17

iv
LITERATURE REVIEW...............................................................................................17

2.1 Introduction..............................................................................................................17

2.2 Theoretical Review..................................................................................................17

2.2.1 Theory of Reasoned Action (TRA)...................................................................17

2.2.2 Technology Acceptance Model (TAM)............................................................18

2.2.3 Social Learning Theory.....................................................................................19

2.3 Empirical Literature.................................................................................................20

2.3.1 Technical skills Training and Service Delivery................................................21

2.3.2 Soft Skills Training and Service Delivery.........................................................22

2.3.3 Digital Skills training and Service Delivery......................................................23

2.3.4 Cognitive skills training and Service Delivery..................................................26

2.3.5 Regulatory body and Service Delivery.............................................................27

2.4 Research Gap...........................................................................................................28

2.5 Conceptual Framework............................................................................................30

2.6 Operationalization of Variables...............................................................................31

2.7 Summary of the Chapter..........................................................................................32

RESEARCH METHODOLOGY...................................................................................33

3.1 Research design........................................................................................................33

3.2 Target population.....................................................................................................33

3.3 Sample and Sampling Techniques...........................................................................33

3.3.1 Sample Size Determination...............................................................................34

3.4 Research Instruments...............................................................................................35

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 3.5 Pilot Study................................................................................................................35

3.5.1 Validity..............................................................................................................35

3.5.2 Reliability..........................................................................................................36

3.6 Data Collection........................................................................................................36

3.7 Data analysis............................................................................................................36

3.7.1 Test for Moderation...........................................................................................38

3.8 Data Management and Ethical consideration...........................................................39

REFERENCES................................................................................................................40

APPENDICES..................................................................................................................46

Appendix I: Questionnaire.............................................................................................46

Part A: Respondents Information...............................................................................46

Part B: Service Delivery.............................................................................................46

Part C: Technical skills training.................................................................................47

Part D: Soft skills training..........................................................................................47

Part E: Digital skills training......................................................................................48

Part F: Cognitive skills training..................................................................................49

Appendix III: Work Plan................................................................................................51

Appendix IV: Budget.....................................................................................................52

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 LIST OF FIGURES

Figure 2.1: Conceptual Framework...................................................................................30

vii
 LIST OF TABLES

Table 2.1: Operationalization of Variables........................................................................31

viii
 LIST OF ABBREVIATIONS

ACT Assertive Community Treatment

CBSST Cognitive Behavioral Social Skills Training

CBT Cognitive Behavioural Therapy

CPD Continuing Professional Development

EBPs Evidence-Based Practices

HR Human Resource

ICT Information and Communications Technology

IT Information Technology

KMTTLB Kenya Medical Laboratory Technicians & Technologists Board

MTRH Moi Teaching and Referral Hospital

NACOSTI The National Council for Science Technology and Innovation

OECD The Organization for Economic Co-operation and Development

PEU Perceived Ease of Use

PU Perceived Utility

TAM Technology Acceptance Model

TRA Theory of Reasoned Action

UCD User-Centered Design

WHO World Health Organization

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 CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

The Organization for Economic Co-operation and Development (OECD) defines service
provision as any interaction with the public service in which consumers (that is, citizens,
communities or businesses) request or provide information, manage their activities or
perform their duties. Such services should be provided in a secure, consistent and
customer-friendly manner (OECD, 2016). Enhancing the quality of health care has been
identified as a priority of the Ministry of Health of Kenya. There is a need to look beyond
service coverage and financial security and to prioritize changes in the quality of service
delivery at the core of the country's acts. This is because quality of health services,
coupled with service coverage will play a critical role in strengthening national health
systems and improving health outcomes (World Health Organization, 2018).

World Health Organization (WHO), likewise states that besides quality health care,
human-centred and comprehensive health systems are essential to achieving universal
health coverage. People-centred care is a service that is centred and structured around
peoples’ and communities' health needs and desires, rather than diseases. While patient-
centred care is generally understood as concentrating on the person receiving treatment
(patient), human-centred treatment incorporates these clinical experiences and also
involves exposure to people's wellbeing in their communities and their central role in
influencing health policy and health services (World Health Organization, 2012).

The ideal condition of public hospitals is that of offering high-quality care to patients.
Quality in health coverage can be made up of newer technology, newer and more
effective medicines and a higher staff-to-patient ratio, professional staff, affordability,
efficiency and effectiveness of service provision. Such variables should be realized by
rapid patient care in terms of access to prescription medications, the provision of
specialized facilities inward; the willingness of medical personnel to set job goals, make
decisions and solve problems (Wavomba & Sikolia, 2015). Integrated health systems,

10
including the management and delivery of reliable and secure health services, have been
connected to the provision of quality services to ensure that patients access a continuum
of health promotion, disease prevention, diagnosis, treatment, disease management,
recovery and palliative care services, across the various levels and sites of care within the
health care system and across the board. Because of rapid expansion of the use of
information and communication technologies, the provision of electronic services is an
effective means of reducing costs, both in terms of time and money, for both the
customer and the government. The state has a vital role in the delivery of a wide array of
public health services.

A medical laboratory is a laboratory where tests are carried on clinical specimens to

obtain the required information about a patient to assist in diagnosis, treatment and
disease prevention (Omorodion, Achukwu & Umeh, 2017). Clinical Laboratory testing is
a highly complex process that entails numerous procedures. Due to the complexity
involved in the carrying out of tests in these laboratories, many countries through
organized bodies ensures that the medical laboratory standards have to be adhered to, to
the letter in order to realize the dream of quality healthcare in the country (KMTTLB,
2011).

Quality medical laboratory service provision is therefore, important in order to enhance

diagnostic value and save lives. This is because recognition of the disease is the
foundation of disease control and prevention (Saliki, 2000). Unfortunately, the
implementation of quality laboratory service in many resource-poor countries has been
unsystematic and is still questionable (Ishengoma et al., 2009; Kenya et al., 2012). In
Kenya, complaints about compensation have been raised from the public domain due to
malpractices like diagnostic errors by health practitioners in the medical laboratories
(Kibet, 2017). Such complaints put the reputation of these laboratories at stake. The
errors have been identified to emanate from inadequacy, incompetence, technological
know-how, and lagging in digitalization (Kimengech, Waithaka, Onyuka & Kigondu,
2017). It is expected that if more earnest heed is given to training the medical lab
practitioners, then service delivery will be of quality.

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Training is an effort initiated by an organization to foster learning among its workers, and
broaden an individual’s skills for future responsibility (George & Scott, 2012). Training
is a continuous effort designed to improve employees’ competence and organize
performance as a goal to improve on service delivery to customers. The relationship
between training and service delivery can be supported by the technical efficiency theory
which argues that the success of an organization can be measured by the optimal inputs
applied to get the desired outputs (Kaguta, & Iraki, 2017). Training is part of an optimal
input that a hospital can apply to improve the competence of medical lab practitioners
and in the long run improve on service delivery (George & Scott, 2012). Technical
efficiency theory entails the achievement of the highest output or best results by
combining the most suitable sets of inputs (Kaguta, & Iraki, 2017). This study selects soft
skills training, cognitive skills training, digital training and technical skills training, as the
sets of inputs that are expected to improve service delivery in medical laboratories in
Kenya.

Globally, in considering the role of the health sector in ensuring the health of the nation,
the Institute of Medicine (IOM) has mandated all health organizations, professional
groups and public and private buyers to continuously reduce the burden of disease, injury
and disabilities and to improve the health and functioning of the population of the United
States. The healthcare sector in the United States is made up of a variety of doctors,
hospitals and other healthcare facilities, insurance plans and health service buyers, all
operating in various independent groups, networks and practice contexts. Some are based
in the public sector; Others operate in the private sector as a for-profit or non-profit
entity. The health sector also includes regulators, some volunteers and other
governments. Although these various individuals and organizations are generally known
collectively as "the healthcare delivery system", the phrase suggests order, integration
and responsibility that does not exist. Communication, collaboration or planning of
systems between these various entities is limited and almost incidental to their operations.
However, for convenience, the committee uses common terminology from the healthcare
delivery system.

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The data survey of the Association of Public Health Laboratories (APHL) conducted
between 2010 and 2016 presents a picture of a highly educated and dynamic PHL
workforce, including an equitable distribution between three generational cohorts each
with slightly occupational values. different. It turned out that education was rewarded in
the workforce, while laboratory workers were mostly satisfied. However, some of the
setbacks in service delivery were due to the gender pay gap in which men earned more
than women. In addition, a large percentage of the workforce was not satisfied with their
salary.

In Santa Lucia, Gaspard and Yang (2016) reported that training programs on a needs-
based basis is critical, especially in developing countries. However, it is not clear exactly
how the health care professional can assess what tasks are critical and how well they see
the expected and actual results of the task in order to determine the need. The study noted
that needs varied from efficient communication, nursing skills, management, testing
techniques, computer training, health promotion, disaster management and time
management, to accurate documentation, among others. Based on the above observation,
the Sir Arthur Lewis Community College, Department of Health Science - General
Nursing was the only full-fledged health care teaching institution in Saint Lucia. This
proves that there is a clear gap in the training needs in bid to achieve the millennium
development goals to provide quality healthcare services to the citizens.

Regionally, access to CPD systems is a major challenge for laboratory staff in developing
countries, partially due to their limited availability. Laboratory professionals are therefore
under tremendous pressure to keep their awareness and competence on the most recent
advances in laboratory testing and continuing professional development (CPD) programs
that can meet this expectation (Alyaemni & Qassam, 2017; Kasvosve et al., 2014).
Laboratory facilities in the African region are vulnerable to many problems, including
poor infrastructure, insufficient human resource resources, and weak underlying health
systems (Birx, de Souza & Nkengasong, 2009).

13
As per Albert, Iragena, Kao, Erni, Mekonen & Onyebujoh (2017), providing access to
high quality is a problem in many sub-Saharan African countries. The introduction of a
good quality management system (QMS) and laboratory certification is crucial to
improving healthcare delivery. 3The report further stated that only about thirty-six
percent of the National Tuberculosis Reference Laboratories (NTRLs) in the African
Region had undergone a laboratory audit, a first step in quality improvement. Barriers for
certification, including lack of training and qualification programs, were also observed.
Just 28.6% of NTRLs had established comprehensive plans and budgets that included
certification.

in the context of NTRLs, only South Africa, Botswana, Mozambique and Uganda have
obtained accreditation. 54% of African countries reported having a standardized QMS to
obtain laboratory accreditation introduced at the NTRL in 2014. However, the level of
progress towards accreditation of individual laboratories remains uncertain (World
Health Organization, 2015).

As indicated by Kasvosve et al. (2014), The focus on continuing professional

development (CPD) is obligated to retain professionalism in view of an ever-changing
context of practice and technological advancements in the medical field. For instance,
involvement in CPD activities by lab physicians has been proven to increase the standard
patient healthcare offered to patients and the public. Studies have also revealed that
physicians participating in CPD have a higher probability to embrace innovative and
successful care approaches and to discontinue the use of current lower-benefit procedures
resulting in better patient outcomes (Goulet et al., 2013).

Kasvosve et al. (2014) assessed the CPD training needs and preferred modes of delivery
for CPD in Botswana, which demonstrated that there was no CPD formal programs, as in
so many other developing countries, to address the lifetime requirements of laboratory
specialists. The evaluation showed that CPD training and development needs are
inadequate. The Botswana Health Professionals Council (BHPC), the Licensing Board
for health professionals, is now requiring hospital lab scientists and specialists to build up
CPD credit points as part of their career-long teaching and to preserve professional

14
registration (Council, 2013). Similarly, in Ethiopia, Mesfin, Taye, Belay, Ashenafi &
Girma, 2017), indicates that the quality system in laboratories is poor due to several
factor such as a shortage of resources, incompetent management support, poor equipment
quality, high workload, a lack of equipment calibration and knowledge.

The unprecedented Ebola virus disease outbreak that occurred in west Africa exposed
severe weaknesses in national health systems, including laboratory networks and
infrastructure of the affected countries. This was attributed to the long neglected and
under-resourced laboratory networks, systems, and services that quickly became the
Achilles' heel to an effective response in Guinea, Liberia, and Sierra Leone (Nkengasong
et al., 2018).

Given the many challenges that African counties have encountered, there are also
occasions where positive stories have progressed. Nkengasong et al. (2018) outlines the
context of HIV laboratory medicine in Africa undergoing transition and increased
sophistication to the improvement of medical procedures, networks and institutions and
innovative quality improvement programs that have seen more than 1,100 research labs
enrolled and 44 accredited to international standards. Such enhanced HIV research labs
can now be used to battle emerging continental and global health threats over the coming

decades.

In 2009, after the WHO resolution and the Maputo Declaration, and as part of
implementation of the NLSPs, WHO AFRO and partners launched two innovative
initiatives in implementing quality management systems: Stepwise Laboratory Quality
Improvement Process Towards Accreditation (SLIPTA, a benchmarking framework used
to measure a laboratory's compliance with ISO 15189 through a graded system of zero to
five stars) (Ndihokubwayo et al., 2016). In Tanzania, with the support of the Abbott
Fund, 23 regional laboratories were refurbished which resulted from an estimated $200
million investment from the Abbott fund (Carter et al., (2012).

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has likewise, supported
the establishment of state-of-the-art laboratories in Botswana, Cameroon, CÔte d'Ivoire,
Ethiopia, Kenya, Mozambique, Tanzania, and Uganda. In Ethiopia, PEPFAR helped to
15
establish the National Public Health Laboratory in Addis Ababa and six regional
laboratories around the country. The Uganda National Laboratory Services was expected
to address crucial gaps in new emerging diseases such as Ebola virus disease, Marburg
virus disease, Crimean–Congo haemorrhagic fever, and swine flu among others. The
laboratory was set to give priority to viral load monitoring capacity, EID, quality
assurance, and other aspects of laboratory services coordination.

Locally, like any other African country, Kenya is experiencing health workforce shortage
particularly in specialized healthcare workers to cater for the rapidly growing need for
specialized health care. This greatly and negatively impacts on the service delivery in
Kenya (MOH, 2015; MOH, 2018). Efficient use of the existing health workforce
including task shifting is under consideration as a short-term stop gap measure while
deliberate efforts are being put on retention policies and increased production of HRH.
The Ministry of Health defines the supply of health workforce as the number of qualified
health workers willing to work at a given wage rate in the health care sector (physicians,
nurses and other care providers). The number of trained health workers depends on that
of training institutions, the number of years of training, the education level, the cost of
training, the individual interest in working in that field and the expected probability of
getting a job after training among others (MOH, 2018).

According to the data received from the Oral/Dental Health Division of Ministry of
Health, there are 100 dental specialists and 339 dental officers in-post in the public
sector. However, the requirements are 1,340 and 7,400 dental specialists and dental
officers, respectively. The data from Community Health Services unit indicate that there
are 2,100 community health personnel working in Community Health Units. The total
number required is 46,470 leading to a shortfall of 44,370. Likewise, the report reveals
that there are no graduate laboratory technologists in the cadres in public health.
However, the staffing norm is 3,196 leaving a gap of the same which the Division of
Medical Laboratory forecasts to fill by 2030. There are 2,067 medical laboratory
technologists (diploma) but the requirement is 13,678 in public sector, this leaves a gap

16
of 11,647. The division also forecasts to fill this gap by 2030. During the plan period, the
gaps existing in the two cadres will not be filled (MOH, 2014; MOH, 2015).

According to a survey of County Health Records Information Officers (CHRIOs) by

Muinga et al. (2020), public hospitals in Kenya are increasingly purchasing systems to
support administrative functions. However, several challenges were highlighted such as
system usability, adequate training, availability of adequate infrastructure and system
support. For instance, some users of the electronic health records felt that the training and
system support provided by the system vendors was still inadequate despite receiving
training on general computer and system use. Adequate support provision was also
constrained by the availability of funds.

Therefore, based on the above backdrops, the current study noted that there is an existing
challenge in the training needs that results in the poor health service delivery by
laboratory technicians both locally and across borders. It therefore offers a basis for the
current study to fill this gap by investigating the various training needs such as technical
training, soft skills training, digital skills training as well as cognitive skills training
which have been noted to be a problem in many contexts.

This has further been supported by the ministry of health reports that indicated capacity
building and training to be the key gap in Kenyan health facilities which hinder effective
health care waste management of health care and sound chemical waste management.
The health facilities require provision of color-coded bins, liners and posters to
streamline segregation (MOH, 2015). The WHO Blue Book recommends that hospital
personnel, including senior medical staff and managers, be prepared to undertake training
and be convinced of the health, occupational safety, economic, environmental and
regulatory advantages. Achieving this outcome strengthens the participation and
collaboration of other personnel in training activities. The Ministry of Health also
proposed to establish Kenya Institute of Health System Management (KIHSM) to
harmonize leadership, management, HRM and governance for improvement of
performance and to facilitate the implementation of a comprehensive induction training
program, with specific milestones for all leaders and lab practitioners (MOH, 2018).

17
1.2 Statement of the problem

The quality of laboratory services is important in achieving the national goal of improved
health care (Shrivastava, Gadde, & Nkengasong, 2016; MOH, 2018). Service quality is
influenced by the competence of the laboratory service providers who are the
practitioners. However, in Kenya complaints about compensation have been raised from
the public domain due to malpractices like diagnostic errors by health practitioners in the
medical laboratories that have led to the loss of lives (Kibet, 2017). These malpractices
are still thriving in some hospitals despite the fact that accreditation was established in
some of the hospitals to help in minimizing diagnostic errors.

According to the Oral/Dental Health Division of Ministry of Health, there are 100 dental
specialists and 339 dental officers in-post in the public sector; a shortage down from
1,340 and 7,400 dental specialists and dental officers, respectively. Likewise, the report
reveals that there are no graduate laboratory technologists in the cadres in public health.
However, the staffing norm is 3,196 leaving a gap of the same which the Division of
Medical Laboratory forecasts to fill by 2030 (MOH, 2014). For instance, a study
Kimengech et al. (2017) established that in Kenyan medical laboratories, preanalytical
errors are the most common with a frequency of 148(42.8%), followed by analytical
errors 114 (32.9%) and post-analytical errors 84 (24.3%). All these errors have negatively
affected the patients in terms of service. Whereby, most of the patients 40 (27.0%) did
not get back their results due to request forms lacking address i.e. ward or clinic. Further,
the lack of address prolonged the turnaround time for the results due to wasted time in
tracing the address. It is also reported that the errors have led to unnecessary medical
procedures, repeated testing, extra clinician appointments, and therapy, disability, and
death (Kimengech et al, 2017).

Several studies have been conducted on the subject of medical laboratories in Kenya but
the studies did not focus on the effect of training on service delivery in the medical
laboratories. For instance, Kimengech et al. (2017) determined the errors that
compromise the quality of laboratory service in a tertiary hospital but failed to link how
the errors can be solved through competence enhancement, therefore leaving a conceptual

18
gap. Similarly, Njoroge (2014) on his study focuses on the assessment of the quality of
medical laboratory service provision in Kenya but he fails to establish how the different
types of training can be used to mitigate the challenges being faced in the sector of
medical laboratories in terms of service delivery. This study, therefore, aims to fill the
conceptual gap that exists by determining the effect of training on service delivery in
medical laboratories in Kenya.

1.3 Objectives of the study

1.3.1 General objective of the study

To establish the effect of training on service delivery in the selected medical laboratories.

1.3.2 Specific objectives

i. To establish the effect of technical training on service delivery in the selected

medical laboratories.
ii. To establish the effect of soft skills training on service delivery in the selected
medical laboratories.

iii. To establish the effect of digital skills training on service delivery in the
selected medical laboratories.

iv. To establish the effect of Cognitive skills training on service delivery in the
selected medical laboratories.

v. To establish the moderating effect of the regulatory body on the relationship

between training and service delivery in the selected medical laboratories.

1.4 Research Questions

i. What is the effect of technical training on service delivery in the selected medical
laboratories?
ii. What is the effect of soft skills training on service delivery in the selected medical
laboratories?

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 iii. What is the effect of digital skills training on service delivery in the selected
medical laboratories?

iv. What is the effect of Cognitive skills training on service delivery in the selected
medical laboratories?

v. What is the moderating effect of Regulatory body on the relationship between

training and service delivery in the selected medical laboratories?

1.5 Significance of the study

1.5.1 Policy Makers

The agenda of the health sector is to provide the public with the most appropriate and
quality healthcare services and along the same vein, the study seeks to look into the
training effects on service delivery. Therefore, the policymakers in the health docket are
informed on the practical issues that affect the Kenyan laboratories which are beyond the
control of the management. The Ministry of Health based on the recommendations
provided herein will be in a better position to analyse and understand the training needs
that are specific to laboratories in Kenya and be able to set/amend the necessary policies
to offer an umbrella for the benefit of the service delivery to the public.

1.5.2 Laboratory Management

Since the study focuses on how competence improves professionalism in the laboratories,
the findings of the study would help the lab management of Kenya laboratories to address
the deficiencies that exist in the health sector. This will be done by the recommendations that
the study will provide for practice in the lab sector. As such the information can be trickled
down to the lower level management and other related staff so that the element of training
and competence can be upheld to higher standards.

1.5.3 Academicians and Scholars

This study will also contribute to the wells of knowledge concerning the public health
sector which can be used as reference material by future researchers. The study will also

20
identify gaps and seek to fill them and more so areas for further studies related to service
delivery in the Kenyan medical laboratories where other scholars are able to advance and
improve on the existing literature.

1.6 Scope of the Study

The study seeks to establish the effects of training on service delivery in the selected
medical laboratories. This study will be a descriptive cross-sectional design to understand
the effects of training on service delivery. The target population of this study will be the
4053 lab practitioners found in 18 accredited medical laboratories in Nairobi County in
the laboratories. Simple sampling in conjunction with convenience sampling will be used
to obtain a sample from the target population. The study will be conducted in 2020.

1.7 Limitations to the study

Due to the confidentiality of the sensitive information being sought by the study, the
researcher anticipates the lack of willingness by the institution to access some of their
financial information. In addition, the institutions are either private or state-owned and
might be placed under strict policy restrictions to safeguard confidentiality. The
researcher, however, plans to mitigate this limitation by presenting an introduction letter
obtained from the university to the respective respondents with a supplement
accreditation letter from the National Council for Science Technology and Innovation
(NACOSTI) as well as from the University (KCA) in order to avoid suspicion and enable
the management/s to disclose the information that is sought.

1.8 Assumptions of the study

The researcher assumes that the data being sought will be available online for
convenience and time management. The researcher also assumes that he will be granted
the authority to collect data from the targeted institutions. The researcher assumes that
she will have the necessary resources to carry out the study and that the data gathered will
be applicable for generalization to the whole population.

21
 CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This chapter discusses the relevant literature that the study draws from in order to justify
the study. This is done by a review on the theoretical review and the frameworks that
explain how various studies have attempted to evaluate the effect of training on service
delivery in the selected medical laboratories in Kenya and other contexts. The empirical
studies are also reviewed in depth in order to identify the gaps that the study will seek to
fill. Finally, a conceptual framework is developed from a review of existing studies.

2.2 Theoretical Review

The study is grounded on the Theory of Reasoned Action (TRA), Technology

Acceptance Model (TAM) and the Social Learning Theory.

2.2.1 Theory of Reasoned Action (TRA)

TRA was developed by Ajzen and Fishbein (1980). It consists of three constructs known
as the intention of behaviour, attitude and subjective norm. According to this theory, the
intention of a person's behaviour is a component of the person's disposition regarding
subjective behaviour and norms. The intention of behaviour is characterized by a person's
motivation or expectation to behave in a certain way. The attitude, on the other hand,
includes the different beliefs about the results of the execution of the behaviour, while the

22
subjective norm is connected to the apparent social expectations of the different people
and to the enthusiasm to satisfy these expectations. To put it plainly, a person's
disposition towards a certain behaviour is anticipated by the mood towards the behaviour
to which it is referred and how other people are expected to see them if the behaviour is
performed (Ajzen & Fishbein, 1980).

TRA is still widely known as a general model that does not specifically establish beliefs
that are operational for a given behaviour but suggests that a person's behaviour is
determined by the intention to perform a certain action. Ajzen and Fishbein (1980)
recommended using exceptional modal beliefs for the population obtained by taking the
beliefs most frequently drawn from a representative sample of the population. Reasoned
action theory has also been successfully applied a reasonable number of times to predict
performance and intentions of behaviour. A good example is when TRA was used to
predict education in a study by Fredricks and Dossett (1983) that predicted the behaviour
and intentions of people who used different types of technology. This theory has
therefore been found to be instrumental in the study since it predicts the attitudes and
behavioural intentions of the employees in the hospitals towards training and
development. The theory specifically looks into how the employees see training as it is in
the organizations.

2.2.2 Technology Acceptance Model (TAM)

Fred Davis (1986) introduced this model specially designed to model user acceptance of
information systems or technologies. Davis' principle in this model is based on previous
works such as the Theory of Reasoned Action by Fishbein and Ajzen (1975). Since then,
the theory has evolved to explain different aspects of events in the technological
environment. Lee, Kozan and Larsen (2003) have also been able to synergistically
establish the importance of the model to explain the long-term problem that exists in
terms of acceptance of a given technology. The Technology Acceptance Model has
become a predominant model for examining user acceptance factors especially given the
technological needs in the current era (Davis, 1989).

23
Venkatesh and Davis (2000) brings to perspective the perceived utility derived by the
user and thus, the subjective norm that influences other people on the user's decision.
That is, the theory is used to explain the general context of computer acceptance which
leads to explaining user behaviour in a wide range of end-user information technologies
and user populations. The basic TAM model included and tested two specific beliefs:
Perceived Utility (PU) and Perceived Ease of Use (PEU). This model is widely used to
study user acceptance of the technology. According to TAM, perceived utility (PU) and
perceived ease of use (PEU) influence one's attitude towards the use of the system, which
influences the behavioural intention to use a system which, in turn, determines the actual
use of the system (Venkatesh & Davis, 2000).

Perceived Profit (PU) is "the degree to which a person believes that the use of a given
system would improve their job performance (Davis, 1989) and PEU as" the degree to
which a person believes that the use of a certain system would be effortless. Perceived
ease of use is expected to affect the perceived utility, as the easier, it is to use a system,
the more useful it can be. These constructions reflect the subjective assessments of users
of a system, which may or may not be representative of objective reality. Acceptance of
the system will be affected if users do not perceive a system as useful and easy to use
(Lai, 2017). Therefore, as proposed by Surendran (2012), individual behaviour is
motivated by behavioural goals and these are a function of an individual's attitude
towards behaviour and the subjective norms that surround him. Given the emphasis
placed on the need for information technology in the health sector, the theory, therefore,
informs the employee acceptance of the training with respect to soft skills and/or digital
skills.

2.2.3 Social Learning Theory

Developed by Bandura (1971), social learning theory states that popularized personality
doctrines depicted behaviour as impelled by inner forces in the form of needs, drives and
impulses often operating below the level of consciousness. In this theory, new patterns
can be learned by experiencing phenomena directly or by observing others’ experiences.
These experiences often occur from the environment through the process of observational

24
learning, i.e. between stimuli & responses. Social Learning Theory by Bandura and
Walters in 1963 acknowledge that behaviour and cognition are integrated towards
learning thus proving a detailed framework to account for learning experiences (Bandura
& Walters, 1963). In developing the theory along Gerbner’s lines, Bandura (1988)
reinforces the behaviour of an individual by stating that it is commonly moderated by
internal factors rather than the external factors.

It is the nature of people to both influence and be influenced by the environment they are
surrounded with. This is, thus, the main principle of social learning which is applied to
almost any social and behaviour change communication program. According to Gerbner
(1973) and Bandura (1971), direct reinforcement (training and development programs
organized to enhance the skills) cannot address all types of learning. Such services do not
cover all aspects of learning since certain social aspects are not available. These learning
by an individual are from his setting. This learning is referred to as observational learning
and is related to the understanding of specific human conducts. Observation is the first
kind of learning described in this theory. The climate and the atmosphere play a very
important role in an organization. The atmosphere should be very professional, and
people (employees) should learn from the atmosphere (Zhou & Brown, 2015). This
theory also suggests that the behaviour doesn't need to be changed after learning
something. It is expected that a person’s behaviour changes after learning something, but
it is not in all cases. In addition, the theory discusses the states of mind that play a
significant role in the learning process. When the individual's psychological state is
pessimistic in terms of learning behaviour, he does not engage in this learning experience
and, while he is required to do so, there will be no positive impact. The mental state will
be beneficial for leadership and improvement activities in the corporate training
programmes, by integrating the rewards and benefits with other activities, which inspire
staff and help in developing a positive mental state. The case company also supports this
principle as it allows staff to know about the world and offers an atmosphere and
provides an environment where they can learn from their supervisors/managers and
coworkers (Kay & Kibble, 2016).

25
Thus, typical stimulus-response relies entirely upon direct experience (of the stimulus) to
inform behaviour. Knowledge is best constructed when learners collaborate together
(Keen, Brown & Dyball, 2005). Learners in an organization, support one another and
encourage new ways to form, construct and reflect on new material. The social learning
theory of Bandura by placing emphasis on the importance of observing and modelling the
behaviour, attitudes, and emotional reactions of others, is thus viewed in this study as
pertinent (Mosharafa & Mosharafa, 2015).

2.3 Empirical Literature

The review of the literature is relevant as it explains how the research project relates to
past studies. It demonstrates the uniqueness and significance of the research question and
particularly, how this study varies from other studies. This explains the suggested
approach and shows the readiness to conduct the study. This review is a vital overview
and description of statistical literature of general and specialized importance to the field
and subject of the research issue (Long, 2014).

2.3.1 Technical skills Training and Service Delivery

Mpofu and Hlatywayo (2015) sought to investigate the influence of training and
development on basic service delivery with data collected from 150 employees. The
results indicated the need for effective employee training and development systems and
processes to achieve improved employee performance thus improved provision of basic
services to the communities. Therefore, the study acknowledges that quality employee
training and development programs are significant for improved employee performance
in organizations. In boosting employee professional development in the municipality and
enhance efficiency and service delivery, managers ought to increase the number of
workers involved in training and development. This can be done by providing incentives
that may motivate employees to participate in training and development programmes.
Rewards that could motivate employees to participate in training and development of
employees include the prospect of promotion or the provision of clear hierarchies within
the organization to indicate where performance is rewarded.

26
Kasvosve et al. (2014) analyzed the role of continuing professional development training
needs of medical laboratory personnel in Botswana. A self-administered questionnaire
was disseminated to medical laboratory scientists and technicians registered with the
Botswana Health Professions Council. The findings revealed that the most frequently
selected topics for training in rank order according to key themes were quality
management systems; pathophysiology, data interpretation, and research; technical
competence and laboratory management, leadership, and coaching. The study, therefore,
noted that continuing professional development (CPD) programs to be developed should
focus on topics that address quality management systems, case studies, competence
assessment, and customer care. The findings from this survey can also inform the medical
laboratory pre-service education curriculum

Rastgoo (2016) likewise looked into the responsibility played by the competence of
human capital/asset in promoting the overall performance of employees. The strategy
utilized in this examination was descriptive where the outcomes demonstrated that
Human Resource (HR) skills represented an affirmative association with the execution of
the chiefs of HR. Also, the connection between every one of the components of abilities
and execution of the supervisors of HR was critical. The results showed that there was a
positive and significant relationship between the two structures of human resource skills
and competences and the performance of human resource department. In addition, there
was a strong relationship between all the dimensions of the competencies (knowledge,
attitude, skills and characteristics) and the success of human resource managers.

Diab and Ajlouni (2015) conducted a research to test the influence of training on the
employee's performance and the quality of medical services on Jordanian private
hospitals. The study relied on 380 responses from surveys where the results indicated that
there’s a significant and positive relationship between training process, training programs
diversity, and used modern technology in training programs, and the performance of
workers, quality of medical services, and organizational commitment. The most
influential factor is the quality of medical services while the lowest influential one is the
organizational commitments.

27
2.3.2 Soft Skills Training and Service Delivery

Opiyo and English (2015) aimed to assess the effects of in‐service emergency care
training on health professionals' treatment of seriously ill newborns and children in low‐
income countries. Randomized trials, non‐randomized trials, controlled before and after
studies and interrupted‐time‐series studies that compared the effects of in‐service
emergency care training versus usual care were eligible for inclusion. In the first trial,
newborn resuscitation training compared with usual care improved provider performance
of appropriate resuscitation and reduced inappropriate resuscitation. Effect on neonatal
mortality was inconclusive. Findings from the second trial suggested that essential
newborn care training compared with usual care probably slightly improves delivery
room newborn care practices (assessment of breathing, preparedness for resuscitation)
(moderate certainty evidence).

Adeleke et al. (2015) sought to discover the influence of information and

communications technology (ICT) knowledge, utilization and perception among
healthcare providers at National Hospital Abuja, Nigeria. By use of a stratified random
sampling, it was found that profession, possession of a laptop computer, age and sex were
associated with knowledge, utilization and perception of ICT. Most participants were
advanced in the use of electronic mail and the Internet mostly acquired through self-
efforts. However, a greater portion of the participants exhibited poor knowledge of
database management and statistical analysis package. The study therefore opined that
ICT will improve medical care quality but some anticipated concerns over medical
confidentiality as ICT becomes widely adopted in the country’s healthcare systems.

Baridam and Govender (2019) investigated the perceived influence of information and
communication technology on clinical service delivery among caregivers and patients in
Makurdi metropolis. This study was purely quantitative and focused on growth within the
health sector, identifying the extent of ICT application, the application of appropriate ICT
policy in the sector, and the influence of related policy. By use of a survey method the
results obtained indicated low-level adoption rates of ICT application in healthcare
delivery and a need for an enabling policy. This study confirmed the low levels of

28
healthcare delivery in the region and the importance of an ICT policy in the healthcare
sector to improve efficiency.

2.3.3 Digital Skills training and Service Delivery

Slovensky, Malvey and Neigel (2017) sought to describe the current state of the
acquisition of mHealth skills, education and training available for clinical professionals in
educational programs (digital communication skills, technological literacy and user skills,
product implementation and telemedicine services, regulation and compliance) and
telemedicine business problems). The study discussed how telemedicine experienced
exponential growth largely due to the ubiquity of the cell phone. The emergence of the
need for technology skills training programs for doctors to fill existing curricular gaps
cannot be emphasized. The study noted that technology alone will not transform
healthcare and although digital literacy is important, it is not enough. To maximize the
potential of telemedicine tools, suppliers need to know how and when to use them for
specific purposes. Trainee doctors are often experts in various digital technologies, but
the current practice of telemedicine as an integrated delivery approach is not necessarily
intuitive just because the individual technological components can be managed correctly.
However, Slovensky, Malvey and Neigel (2017) indicated that current medical
professionals (as a collective) have had minimal exposure to the concepts of telemedicine
delivery during their education and training. Similarly, as regards continuous innovation
and the spread of telemedicine, foresee the skills of the health workforce and the training
needs in the context of integrated delivery models that involve the provision of virtual
services and the implementation of reactive planning it could be a challenge.

Owino (2017) also discovered that integration of Information technology (IT) and the
action or process of innovating had the greatest impact on the performance of various
firms, trailed by association structure, at that point irregular advancement, and after that
human capital while operational procedures viability had minimal impact to the execution
of protection business firms. The investigation likewise discovered that investigation of
new ideal models, quest for new procedures and investigation of new information all
influences execution of protection business as it were. The examination found that

29
aptitudes and state of mind, staff involvement, representative capabilities, collaboration
with providers and clients being parts of the human capital have a critical impact over the
execution of protection business firms. It was in this way prescribed administration staff
be permitted to experiment with new thoughts in their particular firms.

By use of a non-systematic qualitative review Ajami and Mohammadi-Bertiani (2012)

sought to assess the impact on training in meeting Hospital Information Systems (HISs)’s
success. HIS was found to play a pivotal role in providing quality healthcare services and
reduce cost. There are however, many barriers to implement the HIS such as; rejection of
new technology by users, lack of involvement and participation user during the design
and implementation of the system (this is commonly known as User-Centered Design,
UCD), integration with healthcare workflow, and non-trained users. The results
emphasize that training is one of the key factors to achieve HIS success. Non-trained
users fear they would not be able to cope with the HIS and lose their job, and then they
resist the change.

Thus, Fadhil, Jusop and Abdullah (2012) recommends that in order to decrease barriers to
fulfill the HIS leaders ought to train employees to make more familiar with the function
and benefits of it, second, to involve more users in the implementation and facilitate the
HIS needs, act as a protection against future complaints. So, hospital must have regular
training programs to educate people on how to use the system, plus address attitudes and
build enthusiasm for doing so. Appropriate techniques, training and high-quality training
materials are required for successful system implementation and usage.

Kim et al. (2012) implied that users generally attain a high level of understanding of a
computer system from either effective training or experience or both and also expressed
the user’s perception of the shared involvement and commitment to the operation of the
computer system is beneficial to the success of a computer system. It is notable that
raising users understanding of the system requirements and benefits are important to
ensure success. In essence, computer literacy, system training, clinical specialty,
occupation and job satisfaction were found to have a positive and significant relationship
with attitudes of the employees. System complexity has been found to be negatively

30
correlated with attitudes and gender traditionally has not impacted physician attitudes
toward computer use.

Martha (2016) sought to investigate the effects of electronic information on provision of

medical services at Moi Teaching and Referral Hospital. Descriptive survey design was
used to elicit data from 3144 employees of Moi Teaching and Referral Hospital. The
sample size comprised of 175 staff who were targeted by structured questionnaires
implying that the study utilized quantitative data. The study findings indicated that there
is a strong positive correlation between electronic information and service delivery. The
study thus concluded that in order to predict provision of medical services at Moi
Teaching and Referral Hospital (MTRH) such factors as infrastructure facilities, social
structure and skills and expertise are required to motivate the staff motivation.

2.3.4 Cognitive skills training and Service Delivery

Medalia, Saperstein, Huang, Lee and Ronan (2017) examined the feasibility and efficacy
of cognitive interventions provided to 18–22-year-old homeless youth living in urban
supportive housing. Ninety-one homeless youth were randomized to receive either
targeted cognitive training (cognitive remediation) or general cognitive activation
(computer skills training). Cognitive and psychological outcomes were assessed at
baseline, after 13 and 26 sessions, and one-month post-intervention. A high drop-out rate
highlighted the feasibility challenges of treating this population. The study found
significant improvements across groups in specific and global measures of cognition and
psychological distress, with no significant group differences. Transition-age homeless
youth show improvements in cognitive and psychological functioning when engaged in
interventions that address their cognitive development. This speaks to the malleability of
cognitive skills in this cohort and lays the groundwork for future research to address their
cognitive health.

Granholm et al. (2015) sought to investigate ways of enhancing assertive community

treatment with cognitive behavioral social skills training for schizophrenia. For the

31
effectiveness study component, persons with schizophrenia were recruited from existing
publicly funded ACT teams operating in community settings. Respondents were
randomly distributed to one of the treatment groups; Assertive Community Treatment
(ACT) and Adapted Cognitive Behavioral Social Skills Training (CBSST) accompanied
for 18 months with evaluations every 18 weeks after baseline (5 in total). From the study,
adapting CBSST to fit into the framework of ACT care delivery in the United States
offers an opportunity to substantially increase the number of individuals with
schizophrenia who may have access to and benefit from evidence-based interventions
(EBPs). That is, psychosocial evidence-based practices (EBPs) improve functioning,
although these EBPs are not available to most people with schizophrenia.

Likewise, according to Hadden, Groom and Waddington (2018) who focused on one
Welsh Health Board's plan to improve access to cognitive behavioural therapy (CBT),
training in general plays a pivotal role in enhancing delivery of services to the public.
Mental health workers supported by the Health Board to undertake approved CBT
training were requested to answer an online survey asking about their qualifications,
certification, use of cognitive behavioural therapy and experience in promoting the
provision of cognitive behavioural therapy at the workplace. Standards have been taken
from the Health Competence Framework for CBT, the NICE Guidelines and the
Cognitive Behavioural Therapist Safety and Privacy Criteria. The Health Board has
achieved well across seven levels of job support for the implementation of evidence-
based CBT. Staff sponsored to undergo approved CBT training continued to learn and
use CBT in their regular clinical practice. The study shows that the Health Board has
succeeded in providing decent requirements of assistance for CBT in the place of work,
such as access to certified CBT training.

2.3.5 Regulatory body and Service Delivery

Government regulation is known as the ability of the government to formulate and

implement sound policies and regulations that permit and promote developments in the
public sector. At its most basic level, OECD defines regulation as law. In other words,
regulations are rules or norms adopted by government and backed up by some threat of

32
consequences, usually negative ones in the form of penalties. These regulations are
mostly directed at businesses; also take aim at nonprofit organizations, other
governmental entities, and even individuals (Coglianese, 2012; OECD, 2014). Therefore,
this study has used County government intervention as the constructs, procedures and
guidelines that are developed by the National government/county government to create
an enabling environment for the adoption of financial innovations.

Regulation seeks to make such improvement by changing individual or organizational

behaviour in ways that generate positive impacts in terms of solving societal and
economic problems (Coglianese, 2012). Thus, for the regulations to work, it means that
the environment is well conditioned where the public entities find it smooth to make
sustainable business. One important factor in regulation is the regulatory policy which
encompasses transparency and consultation rules, such as requirements for public notice
of proposed regulations, public access to key meetings, or disclosure of relevant
information relied upon by governmental decision makers. Regulatory policy also
includes processes for certain types of planning and analysis to be conducted prior to a
regulatory decision, such as regulatory impact analysis, cost-benefit analysis, impacts on
small businesses or local governments, or paperwork burden analysis (OECD, 2009). In a
study by Obadeyi (2014) government regulations were measured by the capital account
policy while Momanyi (2018) used licenses as the measure of government regulations.
To affect the introduction of new solutions in response to problems, challenges, or
opportunities that arise in the economic environment, policies have been seen to play a
major role in the game (Mowery, 2011 ; Mazzucato, 2013; Mazzucato & Semieniuk,
2017).

Government regulation is one amongst the macro economic variables that individual
firms, governmental as well as non-governmental bodies and households rely on for the
control of the economic conditions in order to operate efficiently. The control of these
conditions is way beyond the control of the management of the company management.
For instance, in the case of a government owned bank which suffers frequent changes in
board membership and many appointments made based on political affiliation rather than

33
expertise consideration. Such a bank will have instability and also the appointed board
members can see themselves as representatives of certain political parties.

2.4 Research Gap

The study finds considerable literature of evidence showing a wide range of factors that
affect training and service delivery. In addition, the study after the in-depth review has
come across a number of effects training has on service delivery in selected medical
laboratories in Kenya and across border. However, the study reviewed and critiqued some
of the aforementioned studies and found that most of them presented weaknesses in terms
of the concepts, methods, theoretical grounds, contextual settings as well as variations in
findings.

For instance, Mpofu and Hlatywayo (2015) looked into training and development as a
tool for improving basic service delivery and the relationship between training and
development and improvements in the provision of quality services was found to be
positive. However, the study was purely quantitative by using a survey questionnaire and
thus, ignored the reinforcement of a qualitative approach in the study. This presents a
methodological gap.

Findings by the Association of Public Health Laboratories (APHL) (2016) are subject to
at least the following limitations. The survey respondents were self-selected and therefore
may not be representative of the entire PHL workforce. This presents a methodological
gap where the current study seeks to fill the gap by carrying out a representative random
sampling technique for objectivity and generalization purposes.

The study by Adeleke et al. (2015) on ICT knowledge, utilization and perception among
healthcare providers was done at the National Hospital Abuja, Nigeria. There was an
industrial action at National Hospital Abuja during data collection. Therefore, the study
contended with various setbacks when collecting the primary data. In spite of the attrition
rate, the study could not retrieve all completed questionnaire from the nurses this presents
a limitation in the methodology which limits the generalizability of the findings.

34
According to Ajami and Mohammadi-Bertiani (2012), one of the solutions to decrease
barriers to fulfill the HIS is to train users to make more familiar with the function and
benefits of it; and to involve more users in the implementation and facilitate the HIS
needs, act as a protection against future complaints. However, the study was only
concentrated on the success of Hospital Information System (HIS) given training and
skills and ignored the impact of training on service delivery. Medalia, Saperstein, Huang,
Lee and Ronan (2017) examined the feasibility and efficacy of cognitive interventions
provided to 18–22-year-old homeless youth living in urban supportive housing. The study
only focused on18–22-year-old homeless youth. The current study however extends the
scope to lab practitioners in order for a comparison approach to the findings. The studies,
therefore, presented a conceptual gap.

These among other research gaps that have been noted in the empirical review, presents
the current study with the basis of the argument to conduct a study on the effect training
has on service delivery in selected medical laboratories in Kenya in bid to fill the
presented research gaps.

2.5 Conceptual Framework

Independent Variable Dependent Variable

Technical skills Training

 Database
knowledge
 Knowledge of
networking

Soft Skills Training

 Motivation
Service Delivery
 Integrity
 Interpersonal  Patient Satisfaction
interaction  Disease Prevention
Digital Skills training
 iSkills
 IT

Cognitive skills training

 Decision Making
 Reasoning
35
 Regulatory
Discerning Body
 Kenya Medical Laboratory
Technicians & Technologists
Board (KMTTLB)
 Moderating Variable

Moderating Variable

Figure 2.1: Conceptual Framework

Source: Author (2019)

2.6 Operationalization of Variables

Table 2.1: Operationalization of Variables

Variable Category Objective Measurement Statistical Hypothesize

test d
Relationship
Service Dependent - Patient p- values, Poor
Delivery Satisfaction F-tests and
t statistic
Disease
Prevention
Technical Independent To establish the Database p- values, Negative
skills effect of technical knowledge F-tests and
Training training on t statistic
Knowledge of
service delivery in
networking
the selected
medical
laboratories
Soft Skills Independent To establish the Motivation p- values, Negative
Training effect of soft F-tests and
Integrity
skills training on t statistic
service delivery in Interpersonal
the selected
medical

36
 laboratories
Digital Independent To establish the Internet Skills p- values, Negative
Skills effect of digital F-tests and
Computing
training skills training on t statistic
Skills
service delivery in
the selected
medical
laboratories
Cognitive
Independent To establish the Decision p- values, Negative
skills
effect of Making F-tests and
training
Cognitive skills t statistic
Reasoning
training on
service delivery in Discerning
the selected
medical
laboratories
Regulatory
Moderator To establish the Kenya Medical p- values, Negative
body
moderating effect Laboratory F-tests and
of Regulatory Technicians & t statistic
body on the Technologists
relationship Board
between training (KMTTLB)
and service
delivery in the
selected medical
laboratories

Source, Author (2019)

2.7 Summary of the Chapter

This chapter discusses the relevant literature that the study draws from in order to justify
the study. This is done by a review on the theoretical review and the frameworks that
explain how various studies have attempted to evaluate the effect of training on service
delivery in the selected medical laboratories in Kenya and other contexts. The empirical
studies also be reviewed in deep in order to identify the gaps that the study will seek to
fill. Finally, a conceptual framework is developed from a review of existing studies.

37
 RESEARCH METHODOLOGY

This section describes the procedures used for the research paper to illustrate the research
design, selected area of study, targeted population, sample+ size and sample techniques,
the methods of collecting data, tools to be used for data collection, methods of data
analysis and ethical considerations.

3.1 Research design

Sileyew (2019) as well as Tobi and Kampen (2018). characterizes a research design as a
framework or technique used by a particular study to gather, measure and analyze the
research data. That is, a plan that provides the aggregate platform for data collection. The
decision of a study design is grounded on the its benefits for the achievement of the
study's objectives. The proposed choice of research design will be a descriptive cross-
sectional design as it seeks to explain the situation through a data collection process in

38
order to describe the situation as it is. A descriptive analysis is aimed at producing facts
regarding the nature and condition of the research phenomena. This means that in a
descriptive survey as stated, quality and standing facts are given meaning (Nassaji, 2015).
Several studies such as the Association of Public Health Laboratories (APHL) (2016),
Kasvosve et al. (2014), Granholm et al. (2015), Hailu et al. (2020), Genet Akal &
Andualem (2018), Desale, Taye, Belay & Nigatu (2013) and Lee et al. (2017) have used
the descriptive cross-sectional design successfully

3.2 Target population

The study seeks to establish the effect of training on service delivery in the selected
medical laboratories. The target population of this study will be the 4053 lab practitioners
found in 18 accredited medical laboratories in Nairobi County (Ministry of Health, 2019).
Stratified sampling in conjunction with simple random sampling will be used to obtain a
sample from the target population.

3.3 Sample and Sampling Techniques

The general rule when computing a sample requires the sample to be as large as possible
or else it will not provide a good representation (Gentles, Charles, Ploeg & McKibbon,
2015). The sample of the current study will be selected using a simple random style. The
participants in this technique possess an equal and representative chance of being
selected. Opiyo and English (2015), Desale, Taye, Belay & Nigatu (2013), Diab and
Ajlouni (2015), Oladeinde, Omoregie, Odia and Osakue (2014), Kothari 2004 and
Mugenda 2013 have acknowledged that the choice of a representative and random sample
is appropriate in obtaining generalizable findings.

3.3.1 Sample Size Determination

The selection will be scientifically guided using Fishers’ formula (Fisher, 1956, Fisher,
1962). The Fisher formula is as follows:
2
z p ( 1−p )
n=
d2
Where;

39
 n= sample size
z= the standard normal deviate value for the level of confidence, for instance 95%
level of confidence =1.96.
d= margin of error or level of precision at 0.1 for CI at 95%
p= proportion to be estimated, Israel and Duffy (2009) recommends that if you
don’t know the value of p then you should assume p=0.5.
Substituted as in:
( 1.96 )2 ( 0.50 )( 0 .50 )
n= 2
( 0.50 )
Therefore:
n = 384 respondents
Where: n = the desired sample size if the target population is greater than 10,000.
However, when the target population less than 10,000, final estimate (nƒ) is calculated as;
n
nƒ=
1+ ( Nn )
Where: nƒ = the desired sample size (if the target population is less than 10,000)
n = the desired sample size (when the target population is greater than 10,000)
N= the estimate of the population size
Substituted in:
384
nƒ=
1+ (
384
4053 )
= 350.77

Therefore, the study will target 351 lab practitioners who will be conveniently and
randomly selected from the target population, that is those that are ready and willing to
respond to the questionnaires.

3.4 Research Instruments

The information in the present analysis is primary; where the it will be gathered from 351
lab practitioners using self-administered semi-structured questionnaires. While semi-

40
structured questionnaires commonly consist of open-ended questions, they have the same
attributes as interview guides. They aim to provide both quantitative and qualitative data
that will help to collect more evidence regarding individuals (analysis unit) under study.
Persons can easily and widely share their unique piece of truth regarding the study
phenomenon. An added benefit of these type of data is that they allow the interviewee to
react independently that is providing expansive and in-depth rationalizations. They are
also easier to build, as the researcher does not suggestive solutions, however their use
often lead to unnecessary data and may be time consuming (Zohrabi, 2013). The Adeleke
et al. (2015), Slovensky, Malvey and Neigel (2017), Owino (2017), Martha (2016),
Granholm et al. (2015), Njoroge (2014) and Blandford (2013) have acknowledged the use
of questionnaires in gathering objective and unbiased information for both qualitative and
quantitative studies.

3.5 Pilot Study

A pilot research will be conducted to determine how valid and reliable the
research instrument is. This is going to be done before starting an actual scientific
study to detect and correct any possible errors that might be present in the questionnaires
(Janghorban, 2014). One to ten per cent is regarded as an adequate sample during a pilot
research (Mugenda & Mugenda, 2003). The respondents included in the pilot study will
not be incorporated into the real research process to rid the study of biasness. The
instruments will be fine-tuned and refined rigorously to achieve reliable and valid results.
The pilot study will cover 35 respondents representing 10% of the target population
(Kistin & Silverstein, 2015). Pilot Study will be conducted on 35 (that is 0.1*351) lab
practitioners in the laboratories in Nairobi County. Therefore, the actual study will
consist of 316 respondents (351-35).

3.5.1 Validity

Validity is the degree to which the results of the research inform the populace as a whole
(Schonhaut et al., 2013). The construct validity analysis will be done using Kaiser-
Meyer-Olkin (KMO). The KMO scores are as follows: wonderful (1.00- 0.90),

41
meritorious (0.80-0.90), middling (0.70-0.80), mediocre (0.60-0.70), miserable (0.50-
0.60) while any value below 0.50 are unacceptable.

3.5.2 Reliability

Reliability refers to the measure of the pertinence and accuracy of the research tools
(Cronbach, 1951; Mugenda, 2013). In the current study, the reliability tests will be
carried out by use of the Cronbach Alpha Coefficient as a measure with a cut-off value of
0.7; below which the values represent unreliable statements while the higher the value
the better the alpha. Trizano-Hermosilla and Alvarado (2016). Best alternatives to
Cronbach's alpha reliability in realistic conditions: Congeneric and asymmetrical
measurements. Frontiers in psychology, 7, 769.) acknowledge that the Cronbach’s alpha
is useful when analyzing responses that have a scale response. The study’s questionnaire
is mainly a Likert scale thus the method is ideal. Cronbach’s alpha value of 0.7 and above
is accepted and thus anything below the threshold will be left out (Rushton, Miller, Kirby
& Eng, 2013).

3.6 Data Collection

The researcher after receiving the authoritative consent from the KCAU Graduate school,
the National Commission for science technology and innovation (NACOSTI), Nairobi
City County Ministry of Health and from individual respondents will set out to conduct
the actual research. Secondary data will be collected by reviewing previous documents
while self-administered questionnaires will be utilized for primary data. Three research
assistants will be recruited to help in the data collection. Where necessary, interpretation
will be required in order to make the respondent understand the questions.

3.7 Data analysis

The information from the surveys will be formatted, classified and organized into themes
where quantitative data will be compiled and displayed in descriptive statistics (that is,
frequencies, means, standard deviations, median and percentages, etc.). Inferential
statistics will likewise, be used to link the independent variables and the dependent
variable. Qualitative data will be processed and analyzed thematically and the results will

42
be presented in prose/thematic form, figures and tables. The whole analysis will be
carried out by use of Excel and SPSS software v22.0. To measure the cause and effect
between the predictor and the predicted variables, the study will use the following: R
squared, F statistic, regression coefficients at 0.05 (95 % confidence interval). Statistical
the model is represented as follows:

Υ=β0+ β1Х1 + β2Х2 + β3Х3 + β4Х4 + e

Where;

Υ= the dependent variable (service delivery)

β= Regression constant (the value of Υ when Х1=Х2=Х3=Х4= 0)

βί is the coefficient for Хί (where ί= 1, 2, 3, 4)

β1, β2, β3, β4= Change in Υ with respect to a unit change in Х1, Х2, Х3, Х4
respectively.

Independent variables are:

Х1 = technical training

Х2 = soft skills training

Х3= digital skills training

Х4= cognitive skills training

βί (where = 0, 1, 2, 3, 4) are coefficients

e = Error term assumed to be normal in distribution (mean zero and variance σ 2)

The inclusion of a random error, e, is important because other unspecified variables may
also affect service delivery.

43
3.7.1 Test for Moderation

A moderator is a variable that specifies conditions under which a given predictor is

related to an outcome. The moderator explains ‘when’ a dependent variable (DV) and
independent variables (IVs) are related. Moderation implies an interaction effect,
where introducing a moderating variable changes the direction or magnitude of the
relationship between two variables. In general, moderator effects are one of two types:
ordinal or dis-ordinal interactions (Mcfadden, 2013). A moderation effect could be
enhancing, where increasing the moderator would increase the effect of the predictor
(IV) on the outcome (DV); buffering, where increasing the moderator would decrease
the effect of the predictor on the outcome; or antagonistic, where increasing the
moderator would reverse the effect of the predictor on the outcome (Mcfadden, 2013).

In order to confirm a third variable making a moderation effect on the relationship

between the two variables X and Y, we must show that the nature of this relationship
changes as the values of the moderating variable M change. This is in turn done by
including an interaction effect in the model and checking to see if indeed such an
interaction is significant and helps explain the variation in the response variable better
than before. The moderating approach that will be used for moderation in this study will
be the baron & Kenny (1986) approach which was advanced by MacKinnon, Lockwood,
Hoffman, West and Sheets (2002). The study will use a significance alpha level of 0.05
for all the statistical tests.

The moderating approach that will be used for moderation in this study will be the Baron
& Kenny (1986) approach which was advanced by MacKinnon, Lockwood, Hoffman,
West and Sheets (2002). The study will use a significance alpha level of 0.05 for all the
statistical tests.

The model is presented as follows:

Y= β0 + β1M + β2 A + β3A.M

Where;

44
 Υ= the dependent variable (service delivery)

M = Moderating variable (Regulatory body)

A= variable composite {(Х1+Х2+Х3+Х4)/4}

A.M = Interaction term

β1, β2, β3 = Change in Υ with respect to a unit change in M.

3.8 Data Management and Ethical consideration

Ethical approval will ibex sought from KCA university graduate school, ethical review
committee, and NACOSTI. additional clearance will ibex obtained from target hospital(s)
and the constituency/county commissioner and health officer. Confidentiality and
anonymity of the respondents will always ibex insured, and participants will be informed
of the freedom into withdraw it any stage of the study.

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APPENDICES

Appendix I: Letter of Introduction

Dear (Respondent)

RE: VOLUNTARY PARTICIPATION IN DATA COLLECTION

I am a student pursuing a master’s degree in business administration at the KCA

University, currently undertaking a research project on, “Effects of Training on Service
Delivery in Selected Medical Laboratories in Kenya”. You have been selected for this
study to fill the questionnaire. Kindly respond to the questions in the attached
questionnaire. The information provided will exclusively and solely be used for academic
54
purposes and will be treated with utmost confidentiality. Upon request, you will be
furnished with a copy of the final report.

Your cooperation will be highly appreciated.

Yours Faithfully,

Emma Anyango

Appendix II: Questionnaire

Part A: Respondents Information

1. Name……………………………………………………………………….
2. Age of the respondent
20 to 25years [] 26 to 30 years [] 31 to 35 years []
36 to 40 years [] 41 to 45 years [] 46 to 50 years []
Above 50 years []
3. Gender
Male Female
4. What is your highest level of education?

55
 Postgraduate Degree Diploma Form four

Part B: Service Delivery

5. Indicate your level of agreement with following statements relating to the delivery of
services at the medical laboratories in Nairobi County. Tick your answer in the box
provided. Note: 5=Strongly Agree 4=Agree 3=Not Sure 2=Disagree, 1=Strongly
Disagree

Service Delivery 1 2 3 4 5
The services are delivered professionally
Services offered meet health standards of the Ministry of Health
The responsiveness is prompt and on time
The bed capacity is sufficient for admission of more patients
There are no delays in the delivery of services to patients
Waiting time is reduced significantly
6. How else does cognitive skills training influence the delivery of services at the
medical laboratories in Nairobi County?

................................................................................................................................................
................................................................................................................................................

Part C: Technical skills training

7. Does technical skills training influence the delivery of services at the medical
laboratories in Nairobi County?

Yes ( ) No ( )

8. Indicate your level of agreement with following statements relating to the technical
skills training and delivery of services at the medical laboratories in Nairobi County.
Tick your answer in the box provided. Note: 1= Great extent 2= Moderate extent
3=No extent

Technical skills training 1 2 3

Database management skills and competence
Knowledge of networking
Professionalism
Competence in physical and electronic record keeping

56
Safety and presentable measures in the lab
Ability to work under minimum supervision
9. How else does technical skills training influence the delivery of services at the
medical laboratories in Nairobi County?

................................................................................................................................................
................................................................................................................................................

Part D: Soft skills training

10. Does soft skills training influence the delivery of services at the medical laboratories
in Nairobi County?

Yes ( ) No ( )

11. Indicate your level of agreement with following statements relating to soft skills
training and delivery of services at the medical laboratories in Nairobi County. Tick
your answer in the box provided. Note: 1= Great extent 2= Moderate extent 3=No
extent

Soft skills training 1 2 3

Motivation of employees by the leaders
Adaptability of new employees
Integrity among senior and junior employees
Interpersonal interaction
Teamwork among all levels of employment
Creative Problem-Solving
Time Management
Amicable conflict management
12. How else does soft skills training influence the delivery of services at the medical
laboratories in Nairobi County?

................................................................................................................................................
................................................................................................................................................

57
Part E: Digital skills training

13. Does digital skills training influence the delivery of services at the medical
laboratories in Nairobi County?

Yes ( ) No ( )

14. Indicate your level of agreement with following statements relating to digital skills
training and the delivery of services at the medical laboratories in Nairobi County.
Tick your answer in the box provided. Note: 1= Great extent 2= Moderate extent
3=No extent

Digital skills training 1 2 3

Social Media communication
Information technology update
Laboratory data analytics
Digital Marketing and selling
Computer literacy
Mobile/online coordination for instance online appointments
15. How else does digital skills training influence the delivery of services at the medical
laboratories in Nairobi County?

................................................................................................................................................
................................................................................................................................................

Part F: Cognitive skills training

16. Does cognitive skills training influence the delivery of services at the medical
laboratories in Nairobi County?

Yes ( ) No ( )

17. Indicate your level of agreement with following statements relating to cognitive skills
training and the delivery of services at the medical laboratories in Nairobi County.
Tick your answer in the box provided. Note: 1= Great extent 2= Moderate extent
3=No extent

Cognitive skills training 1 2 3

Sustained attention

58
Working under pressure
Undivided attention
Long-term working memory in the laboratory
Logic and reasoning
Processing and decision-making speed
18. How else does cognitive skills training influence the delivery of services at the
medical laboratories in Nairobi County?

................................................................................................................................................
................................................................................................................................................

Part G: Regulatory body

19. Does the regulatory body influence the delivery of services at the medical laboratories
in Nairobi County?

Yes ( ) No ( )

20. Indicate your level of agreement with following statements relating to the regulatory
body and the delivery of services at the medical laboratories in Nairobi County. Tick
your answer in the box provided. Note: 1= Great extent 2= Moderate extent 3=No
extent

Regulatory body 1 2 3
KMLTTB internal by laws strictness
Flexibility of KMLTTB laws and policies
KMLTTB recruitment procedures and guidelines
KMLTTB remuneration and pay guidelines
KMLTTB training guidelines and policies
21. How else does the regulatory body influence the delivery of services at the medical
laboratories in Nairobi County, Kenya?

................................................................................................................................................
................................................................................................................................................

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Thank you for your cooperation

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Appendix III: Work Plan

Month /Activity 1st 1st 2nd 2nd 3rd 4th

Mont Month Month Month Month Month

h

Proposal Writing

Corrections

Data Collection

Data Analysis

Project Writing

Submission of
Project

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Appendix IV: Budget

Item Cost (KShs)

Traveling expenses (inclusive of research assistants) 15,000.00

Printing and Photocopying of proposal 15,000.00

Binding of proposal 10,000.00

Data analysis 30,000.00

Printing and Photocopying of Project 10,000.00

Contingencies 10,000.00

Total 60,000.00

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