Data Analysis

Qualitative data analysis is a continuous and iterative process. It begins in the early stages of the study where analysis of newly acquired information influences future data acquisition methodology, and/or participant selection, as well as the refinement of research questions. Traditionally individuals use the techniques like “coding” [123 (p. 76-77)] and “comparative analysis” [126 (p. 339)]. I however decided to use another, more thematic/iterative based approach. This thematic approach to qualitative analysis is very

cyclical and incorporates writing fieldnotes, and reading and re-reading the fieldnotes, and interview transcripts, while using the data analysis theories described below. The process continues with the writing of theoretical memos (described in the previous section), as fieldnotes and interview transcripts continue to be reread, and the audio of the interviews listened to. The analysis continues with the writing of the dissertation. According to Ely et al (1997), “writing can be alive” because our “understanding is informed through writing” and rewriting ^[127]. As each section is written a better understanding of the data emerges. In addition, as new sections are written, older sections are rewritten for clarity and deeper understanding. This then informs the writing of new sections of the dissertation. In the end qualitative analysis identifies the major themes, constructs and relationships that influence human behavior ^[128]. In this study two theories are used to guide the analysis of the data, and a third theory is used to inform the development of prevention programs. These theories and how they are utilized are discussed below.

(a) Data Analysis Theories

PEN – 3 Model

The PEN-3 model was developed to be used in the planning, development and implementation of culturally appropriate health education programs in Nigeria ^[129]. It emphasizes the use of the concept of

“cultural empowerment” which focuses on both the micro (individual, family, and community) and the macro (national and international) development, instead of just “self empowerment” which focuses on individual development ^[129]. PEN-3 consists of three dimensions of health belief and behavior, which are interrelated and interdependent – “health education, educational diagnosis of health behavior and cultural appropriateness of health behavior”[129 (p. 29)]. Within each of these dimensions, there are sets of categories that are represented in the PEN acronym.

The health education dimension refers to the specific issues that health education should focus on. The categories include Person, Extended family, and Neighborhoods. Educational diagnosis of health behavior, the second dimension of the model, is used to identify or determine the “factors that influence individual, family, and/or community health actions”. At the core of this dimension is the central role of culture, and its influence of “health actions”. The categories include Perception, Enablers, and Nurturers. The third dimension of the PEN-3 model refers to the cultural appropriateness of the health behavior. The categories include Positive behaviors, Existential behaviors, and Negative behaviors. The inclusion of this dimension ensures that the intervention developed is culturally

appropriate by reinforcing the positive behaviors, creating programs that address the negative behaviors, while leaving the existential behaviors alone since they neither help nor harm the health of the

participants. In this study the third construct of PEN-3, the cultural appropriateness of health behaviors was used to identify the social and cultural aspects of health behaviors in Tobago that were either

Positive, Existential, or Negative as they relate to HIV infections risks. The Negative behaviors were highlighted for behavior change intervention.

Theory of Gender and Power

In 1987, Connell developed the theory of gender and power (TGP), after a review of the literature and existing theories connecting gender, power imbalances and sexual inequality. This theory identifies three constructs that influence the relationship between men and women. These constructs include the sexual division of labor (specific jobs for men and women), the sexual division of power (gendered power given to men by society and taken away from women) and the structure of cathexis (“social norms that govern appropriate sexual behavior for women and encompasses the emotional attachments involved in social relationships” [130 (p. 33)]). According to Connell, the interconnection of these constructs “explain the cultural bound gender roles assumed by men and women” [131 (p. 540)]. These constructs exist at two levels, the larger societal level (social norms that govern appropriate sexual behavior for women and encompass the emotional attachments involved in social relationships), and the lower institutional level. In this study, the factors that perpetuate gender imbalances, and therefore follow the Theory of Gender and Power were also identified.

(b) Triangulation

In this study, triangulation is the method used for substantiating the data. Triangulation is the process of looking at a problem using “as many different methodological perspectives as possible”. This process crosschecks the information gathered, and identifies and then allows further investigation to explain gaps and discrepancies. In addition to triangulating using different methods (participant observation,

ethnographic interviews and in-depth interviews), a researcher can triangulate using different data sources. For example, using both method and source triangulation, if interviews with physicians in the Caribbean identify their belief that adequate information about HIV/AIDS is present in the community, however participant observations involving young girls indicate that they lack basic information about HIV transmission, the combination or triangulation of the data gathered from these two methods and sources might lead to the understanding that more group-specific information is needed in the community. In addition, using the different methods allows the same question to be answered from different angles, thereby enriching the response. It must be noted however, that in qualitative research, information gathered from one method is neither correct nor incorrect. This information highlights the emic perspective of the participants being interviewed and therefore the utilization of several methods insures that valued information isn’t neglected ^{[11, 132]}.

(c) Program Development and Implementation Theory The Socio-Cultural Theory of Learning (SCTL)

Lev Semyonovich Vygotsky developed the SCTL in the field of education. It is part of a larger socio-ecologic model that does not view the individual as an isolated entity but as part of a larger context, and is therefore heavily influenced by the characteristics of that larger context. The SCTL specifically identifies this “larger context” as the Zone of Proximal Development (ZPD), which is where the individual lives and therefore where learning occurs. Learning is defined as a two-step process where individuals (1) acquire knowledge (knowledge-in-waiting) and then (2) apply that knowledge (knowledge-in-use). The agents of change or “instructors” are individuals with greater cultural capital and memberships, who pass information and skills to other individuals within the zone. Information flows in both directions,

therefore, there is “cultural reciprocity” ^[133] which ensures that all participants are attuned to the context within which the other resonates. Finally, in the SCTL, learning is most influenced by the available resources (accuracy and availability of information for example) and the social environment (which includes social relations, cultural ideas, economics resources, etc) ^[134].

(d) Use of SCTL In Program Development and Implementation

The SCTL identifies at least six (6) factors that must be considered in learning. In this study, these six factors are identified and recommendations for their application in the Tobago setting are discussed:

(1) Zone of Proximal Development (ZPD) – places where learning can take place (2) Knowledge-in-waiting – what information is needed

(3) Knowledge-in-use – what skills are needed

(4) Instructors - who are the most appropriate people to impart this knowledge, teach skills, and provide examples

(5) Available resources – what is already available, and what needs to be added to increase the likelihood of behavior change

(6) Social environment – what social and cultural factors (including policies) influence the behavior change and methods of altering these factors.

Age group Male Female Total

18 – 24 0 1 1

25 – 34 2 2 4

35 – 44 3 3 6

45 – 54 1 2 3

Total 6 8 14