When embarking on social research, it is important to consider and recognise the role that underlying philosophical foundations play in defining the trajectory of the study as well as the overall decision-making process. When reflecting on the phenomenon of social research and its precepts, Martyn (2010) argues that it is vital to grasp the philosophical foundations that underpin each research investigation and how these manifest themselves in developing social research. Considering the above assertions, this exploratory study was executed using the transformative paradigm. The transformative paradigm is a framework of belief systems that unswervingly engage members from groups that are culturally diverse with an intent focus on enhancing social justice (Mertens, 2009).
This study explores the communicative practices, attitudes and perceptions of BMSM, a population that is disproportionately affected by the HIV epidemic and is underserved by the national and local response to HIV. What is particularly relevant to this study is the inaccessibility of PrEP by BMSM in Msunduzi, KwaZulu- Natal. Therefore, the transformative paradigm selected for this study aims to address and respond to the social inequalities that affect BMSM in non-metropole areas, considering preventative methods in the age of the biggest health epidemic in the history of humankind.
As Luke and Kurz (2002: 1) suggest that:
Addressing inequalities is not a choice—it’s a moral and practical necessity. A moral necessity that speaks directly to our conscience... our sense of fairness and justice... our conviction that all people must have a fair opportunity to live full, healthy lives, no matter where they live, no matter what barriers they face. That is their right. And a practical necessity, because a focus on equity in our work saves more lives.
The transformative paradigm asserts that the role of the researcher is reframed as one who possesses a shared sense of responsibility and recognises the inequalities and injustices in society and strives to challenge the status quo (Mertens, 2007). Therefore, for this research, the subject matter of inquiry is explored through the transformative paradigm lens. The study aims to give a voice to previously relegated BMSM, regarding the adoption of PrEP as a strategy to mitigate HIV incidence. This is especially important for this key population that has not been included in very few implementation programmes.
By giving voice to BMSM, this study explores the feasibility of PrEP and makes suggestions on effective communication strategies that can help increase and enhance access to this new biomedical preventative method by BMSM.
A characteristic of the transformative paradigm is to place central importance on the lives and experiences of individuals that have been relegated to the margins of society. As well as to interrogate unequal power relations and to connect the results of the research into social action (Mertens, 2009). These are the philosophical considerations of the study at hand; I am interested in studying BMSM, a social grouping that has been relegated to the margins of society due to the intersection of their race and same-sex desire. This relegation has resulted in these BMSM being underserved and not accessing the necessary preventative tools against HIV incidence. Furthermore, this population has been further relegated due to their geographic location which has translated in a dearth in research on BMSM in non-metropole areas.
This research on the attitudes and perceptions of BMSM and their acceptance levels of PrEP as an HIV prevention method addresses issues of relegation and erasure in preventative health care. Therefore, this dissertation is concerned with the preferences of BMSM and what informs them. The study explores how BMSM can inform the implementation of PrEP. By exploring the saliency of sexual health communication among this key population, this dissertation further addresses the subject in question and makes suggestions of how best to communicate accessibility and knowledge of PrEP to this population.
For Mertens (2008) the ontological assumptions of the transformative paradigm necessitate the examination of undeserved privileges based on social dimensions of socio-economic status, age, religion, gender, race and ethnicity, (dis)ability, as well as sexual orientation. These are not the only dimensions of diversity that are used as a basis for discrimination and oppression, as the bases of social inequities and injustices are dependent on the context that individuals find themselves in. This discussion ties with one of the theoretical foundations [Intersectionality] of this dissertation. This foundation seeks to not only determine the awareness, attitudes and perceptions of BMSM towards PrEP but also to appreciate how contextual factors influence these perceptions. This is done by interrogating the multiple constructs that reinforce inequality or
marginalisation and how these compound on the lived experiences of BMSM vis-à-vis the power relations that exist in society.
To best achieve the study objectives, this study used a mixed-methods approach. Uwe Flick (2014) defines this approach as, a type of research which combines elements of qualitative and quantitative research approaches with the intention of understanding a specific phenomena. A mixed methods approach has the potential to increase the reliability and validity of a study by merging more than one method to provide a comprehensive view of the phenomenon under scrutiny. The transformative paradigm provides a mixed methods framework for examiningassumptions that overtly address power complications, social justice, and cultural complications throughout the research process. Mertens (2007) argues that transformative mixed methods research is needed because previous research had not served the needs of those who had traditionally been excluded from power in the research landscape. Mixed methods research has the potential to mitigate the above power dynamics and provide a basis for social change (Mertens, 2007).
As she argues:
Hence, the reason we need good mixed methods research is that there are real lives at stake that are being determined by those in power. The voices of those who are disenfranchised on the basis of gender, race/ethnicity, disability, or other characteristics remind us of the issues of power that surround so much in the public sphere, even that supposedly neutral and objective world of research (Mertens, 2007:214).
The above description best encapsulates the positive elements of using a mixed-methods approach within the transformative paradigm. For this study, a mixed methods approach was crucial to give voice to those disenfranchised by racial, gender, economic and sexual orientation inequalities especially in the context of health care and preventative health. This study used a sequential mixed methods approach which involved using quantitative and qualitative data collection and analysis techniques. There was no weighting of strength between the two methods and both were used to fulfil separate methodological intentions. On the one hand, a quantitative method (questionnaires) was selected for its ability to collect data that when analysed, would be more generalisable to the broader population of BMSM in Msunduzi Local Municipality. Whereas, qualitative methods were used to obtain greater depth on the results emergent from the quantitative
component of the study. Ideally, the two methods were combined to leverage the strength and weaknesses of each method, namely (depth and nuance) – in qualitative research against (objectivity and generalisability) of the quantitative.
Furthermore, there is an array of literature dedicated to the mixed methodological approach (Creswell, 2007;
Flick, 2014). One of the significant benefits of using this approach as emphasised by these studies is that it provides an optimal opportunity for triangulation which allows for more robust analysis of the phenomena.
Consequently, using a mixed-method approach was based on the intention to obtain optimal results and to translate in writing what the topic entails, which is to give voice to the disenfranchised and under-researched population on BMSM in the broader Msunduzi Local Municipality.
Another valuable consideration that informed the decision to adopt a mixed-method approach for this study was a reflection on similar studies that have been conducted across the world. This includes studies by Brooks et al. (2011), Eisingerich et al. (2012), Hugo et al. (2016) and Karuga et al. (2016), which explore the perceptions, attitudes and acceptability of PrEP amongst men having sex with men (MSM). Most of these studies used a mixed-methods approach to elicit comprehensive responses to their research questions, which resulted in credible research that added to knowledge production around MSM and PrEP. Therefore, an assessment of these studies influenced this study’s methodological approach.