SciELO - Scientific Electronic Library Online

 
vol.59 issue4Attitudes towards male circumcision among attendees at a sexually transmitted Infection Clinic in Kingston, JamaicaFactors associated with pregnancies among HIV-positive women in a prevention of mother-to-child transmission programme author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Article

Indicators

  • Have no cited articlesCited by SciELO

Related links

  • Have no similar articlesSimilars in SciELO

Bookmark

West Indian Medical Journal

Print version ISSN 0043-3144

West Indian med. j. vol.59 no.4 Mona July 2010

 

ORIGINAL ARTICLES

 

HIV/AIDS: perceptions of the Grenadian faith-based community

 

VIH/SIDA: percepciones de la comunidad de fe Granadina

 

 

A Gomez; C Alexis-Thomas

Department of Public Health and Preventive Medicine, School of Medicine, Applied Anthropology, Grenada, West Indies

Correspondence

 

 


ABSTRACT

OBJECTIVE: This exploratory study conducted in 2008 aimed at gathering the views and opinions of leaders of the faith-based community (FBC) in Grenada about the increased incidence of HIV/AIDS in the Caribbean region including their beliefs and attitudes towards persons living with HIV/AIDS (PLHIV/AIDS).
DESIGN AND METHODS: The study followed a cross-sectional design and used a qualitative approach. Telephone surveys were conducted with all faith-based organizations and semi-structured interviews done with key leaders representing the faith-based community in Grenada.
RESULTS: Findings showed that perceptions of HIV/AIDS are embedded in a socio-political-cultural context where many risk behaviours and factors intertwine in complex ways. Religious beliefs are based on love, compassion and acceptance. The most prominent risk behaviours associated with the spread of HIV/AIDS identified by leaders are homosexuality, prostitution, promiscuity and substance abuse which are in direct contradiction to their beliefs and teachings. Leaders felt that these risk behaviours were exacerbated by changes in family structure and the absence of a common moral discourse shared by all sectors of society.
CONCLUSION: The faith-based community has a significant presence across Grenada and it can be an effective partner in helping communities understand and prevent HIV/AIDS and overcome the stigma and discrimination associated with this disease. Training and effective strategies are needed to engage them in the national response to HIV/AIDS without threatening their ideologies and practices.

Keywords: Beliefs, faith-based community, Grenada, HIV/AIDS


RESUMEN

OBJETIVO: Este estudio exploratorio realizado en 2008 tuvo por objetivo recoger los puntos de vistas y opiniones de líderes de la comunidad de fe en Granada, acerca del aumento de la incidencia de VIH/SIDA en la región caribena, incluyendo sus creencias y actitudes hacia personas que viven con VIH/SIDA (PLVIH/SIDA).
DISEÑO Y MÉTODOS: El estudio tuvo por base un diseno transversal y un enfoque cualitativo. Se llevaron a cabo encuestas telefónicas con todas las organizaciones de fe y se realizaron entrevistas semiestructuradas a líderes importantes, representantes de la comunidad defe en Granada.
RESULTADOS: Los hallazgos mostraron que las percepciones del VIH/SIDA se hallan embebidas en un contexto socio-político-cultural en el que múltiples comportamientos y factores de riesgo se entrelazan deformas complejas. Las creencias religiosas se basan en el amor, la compasión y la aceptación. Los comportamientos de riesgo más sobresalientes asociados con la diseminación del VIH/SIDA, identificados por los líderes fueron la homosexualidad, la prostitución, la promiscuidad, y el abuso de substancias que están en la contradicción directa con sus creencias y ensenanzas. Los líderes sentían que estas conductas de riesgo se hallaban exacerbadas por los cambios en la estructura de la familia y la ausencia de un discurso moral común compartido por todos los sectores de la sociedad.
CONCLUSIÓN: La comunidad de fe tiene una presencia significativa en toda Granada y puede ser un aliado eficaz a la hora de ayudar a las comunidades a entender y prevenir el VIH/SIDA, así como a superar el estigma y la discriminación asociados con esta enfermedad. Se necesitan entrenamiento y estrategias efectivas para comprometer a las comunidades de fe a una respuesta nacional frente al VIH/SIDA, sin amenazar sus prácticas e ideologías.

Palabras claves: Creencias, comunidad de fe, Granada, VIH/SIDA


 

 

INTRODUCTION

This paper presents the most salient findings of an applied research study commissioned by the National AIDS Directorate (NAD) in 2008. The purpose of the study was to gain a comprehensive understanding of the beliefs, perceptions and attitudes of the Grenadian faith-based community (FBC) regarding HIV/AIDS particularly in terms of stigma, discrimination and risk behaviours associated with this disease. The prevalence of HIV/AIDS in Grenada appears to be low compared to other Caribbean countries (1). The Grenadian AIDS Directorate believes current statistics only represent the cases that have been officially diagnosed and not the actual number of Grenadians living with HIV/AIDS.

Interest in this exploratory study emerged following the creation of the Faith-based Forum on Inclusion and Human Sexuality at the June, 2007 meeting of the Barbados Evangelical Association in Collaboration with the National HIV/AIDS Commission and the UNAIDS Country Coordinating Office for Barbados and the Eastern Caribbean. The Forum addressed many topics in addition to the regular conversation about condom use and abstinence including knowledge, attitudes, behaviours and discrimination. Guided by this experience, NAD believed that there was a need to broaden the perspective of the Grenadian FBC to help them be more effective in their community preventive efforts. This required NAD to have a solid understanding of the Grenadian FBC (Personal communication with NAD Director).

Although the aim of this study was to address a specific need and not to build on previous studies conducted with religious organizations, the literature provided ample evidence of the significance of using a more ecological approach in addressing the HIV/AIDS epidemic, which means expanding the focus from the individual to the larger community. This also means being mindful of the implicit messages sent through public attitudes and seeking ways of empowering communities through multi-sector collaborations.

A meta-analysis of risk behaviours associated with HIV/AIDS through a review of the social, psychological and medical literature available in AIDSLINE, MedLINE and PsychINFO from 1980 to June 2001 conducted by Crepaz and Marks (2) showed that not many studies looked at societal and cultural variables. Furthermore, the authors emphasized that individual level interventions do not occur in a vacuum and are shaped by societal attitudes toward discrimination, stereotyping, social status and social power based on gender. These are factors that hinder HIV/AIDS preventive efforts and require the construction of community-wide approaches to develop supportive attitudes and practices that benefit everyone (3).

Often illness-related stigma is symbolically expressed through public attitudes toward health policy (4). Responsibility and blame are central components in the social construction of disease, labelling those who are ill as "victims or patients, guilty or innocent, dangerous or benign, heroic or pitiable" (5). The social construction of HIV/AIDS has resulted in the stigmatization, discrimination, social ostracism and, in some cases, exposure to violence by those infected (6, 7). These attitudes respond not only to the fear of HIV infection but in some instances are used as a way of expressing disapproval of those infected if they happen to represent a disenfranchised sector of society (8). When such a climate exists, social risk - "the danger that an individual will be socially or economically penalized should he or she become identified with an expensive, disfavoured or feared medical condition" (9:122) - increases. Hence, the importance of considering the social climate when defining options available to those individuals with stigmatized conditions (9).

Public Health policy is created and implemented within a context where there are contested views about disease and its effect on communities. When stigmatization occurs, public health policies can help protect those who are ill from prejudice or it can promote discrimination against them (4). Building multi-sector and multi-agency collaborations that promote community empowerment help ensure that public health policies and efforts are equitable and inclusive of all. They also underline the notions of personal as well as collective responsibility.

Using a public health perspective, a broad definition of community empowerment encompasses the involvement of the community in the solution of problems, particularly considering the influence that environmental and community factors exert on health behaviours. As such, efforts to analyse and understand the effects of environmental and community factors on health behaviour must start with the recognition of their embeddedness in culture (10). The manner in which societies view people living with HIV/ AIDS (PLHIV/AIDS) determines how those infected exercise their personal responsibility to protect others. If a society's message of personal responsibility is framed in a way that blames the victim, its outcome may be increased stigmatization of the infected and less motivation on their part to protect others. Furthermore, the perception of social hostility could also polarize the political environment in which prevention messages are offered. Thus, the importance of promoting collective responsibility to create conditions that are conducive to healthy behaviour and that identify structural factors that deter individuals in their attempts to living healthy lives (3).

Community empowerment has been identified as a positive prevention and intervention framework in countries where the HIV/AIDS epidemic has touched significant numbers of people (11-13). In Brazil, community empowerment was achieved through a massive social mobilization that included religious organizations. As a result of those efforts, religious organizations positioned themselves as advocates for PLHIV/AIDS through the provision of educational programmes, the establishment of homes for patients excluded from society and for children orphaned as a result of HIV/AIDS (12). Similarly, Botswana created the National AIDS Coordinating Agency as the coordinating channel for the implementation of a multi-sector national response to the HIV/AIDS epidemic (10).

A premise for this research was the notion that religion and religious organizations represent a significant element of the Grenadian culture that not only help sustain existing social norms and policies but also help shape them. Heterosexual communities are nested within the larger society and their sexual norms "reflect the culture as a whole and the social policies that sustain it", and in a broad perspective, "gender, poverty, race and homophobia represent 'fundamental social causes of disease', which need to be recognized" (3:301). The FBC is a segment within the larger community and is comprised of groups of individuals who share their religious beliefs and values. Viewing the FBC as a social force through which the meanings and perceptions of HIV/AIDS are mediated emphasizes the importance of understanding the extent to which these meanings may enhance or hinder efforts to prevent this epidemic.

 

SUBJECTS AND METHOD

The study followed a cross-sectional exploratory design aimed at capturing the perceptions and beliefs of leaders of the FBC regarding HIV/AIDS. The study was implemented from March to July 2008. Given the nature of this exploration, the study used a qualitative approach. The methods utilized were telephone surveys and semi-structured interviews. Telephone surveys had two purposes: (a) completing an inventory of the FBC and their religious and social activities and (b) identifying key leaders for the interviews. Semi-structured interviewing followed an interview guide to ensure that all interviewers cover the same topics while allowing interviewers the necessary flexibility to probe interviewees in order to clarify and enhance the data collection process (14). In order to maintain consistency throughout the data collection process, new topics that emerged during interviews were added to the questioning route for continuous exploration. Through this process, interviewers were able to determine the extent to which emerging topics were shared by other key leaders or represented individual concerns.

Sample selection

Combining a list of faith-based organizations provided by NAD, the Grenadian telephone book and word of mouth information, the research team compiled a list of 34 FBCs. Through telephone surveys, information about the size, location, services offered and the leadership structure of these congregations was gathered. Thirty-six key informants (leaders and administrators) from the various religious organizations across all Grenadian parishes (St Andrew, St David, St George, St John, St Mark and St Patrick) and from its only dependency (Carriacou and Petit Martinique) were identified for interviewing.

Two trained anthropologists (male and female) conducted the interviews. The interviews were digitally recorded with the consent of the interviewee. Only a couple of interviewees refused the use of the recorder. The interviewers debriefed on a regular basis to discuss the process, verify the relevance of the data being collected, identify new trends in the content of the interviews and ensure that both incorporated emerging themes into their continuous exploration.

Data Analysis

Interviews were analysed following a qualitative data analysis process that includes: transcription, organization of data, coding, identification of emerging patterns and trends, and interpretation (14-16). The software Atlas.ti® (17) was used to facilitate data management and analysis. A preliminary narrative analysis guided the development of a code scheme that included both categorical and explanatory codes which once implemented allowed the identification of response patterns and trends. Both interviewers reviewed the coding and the data reduction processes. Given that the purpose of this exploratory research was to capture the perceptions of the leaders of the FBC, limited effort was placed in interpreting the findings. Instead, the findings were organized into categories that allowed the various views and their grounding to come through. Upon review of the findings, NAD organized a workshop with the FBC (all interviewees were invited) to share the findings with them not only for validation purposes but also to continue building their collaborative efforts.

 

RESULTS

From the onset of the data collection process it became evident that beliefs and perceptions about HIV/AIDS cannot be explored in a vacuum where the contextual factors that imbue them with meaning are absent. The findings presented in this section speak about context-related perceptions and to preserve this contextual richness they are organized into three categories: (a) knowledge and stigma; (b) risk behaviours associated with HIV/AIDS and (c) factors associated with risk behaviours. In addition, direct quotes reflecting the sentiment of the respondents are included throughout the findings. In keeping with confidentiality rules and Institutional Review Board guidelines, interviewee's identities were replaced by codes.

Knowledge and stigma

Key leaders provided their perspectives about HIV/AIDS according to their own religious perspectives and beliefs. One respondent alluded to religious cosmology as the departing point of the interview: "We believe this disease comes from God because it is a judgment against sin. Before this disease arrived God [had] given us guidelines to live by. However, sometimes we forget about these teachings or are distracted from what we are supposed to be doing. Therefore, HIV/AIDS is an ailment from God to those who believe in Him".

Key leaders demonstrated their knowledge of HIV/AIDS in terms of the aetiology and transmission of the disease. They were well informed about the medical/clinical aspects of HIV/AIDS (ie, symptoms, incubation period, transmission, etc.). However, some respondents highlighted that more education is needed in order to reach members of society who continue to obtain their information from unreliable sources. Particular emphasis was placed on the need to transmit a stronger message regarding the incubation period of the disease. The concern is that the absence of immediate symptoms provides those at risk with a false sense of security.

A very small number of respondents reported knowing or having known PLHIV/AIDS. In general, key leaders credit the absence of HIV/AIDS among members of their congregations to people's willingness to adhere to religious teachings and the application of such to their lives. Some leaders were of the opinion that prevalence rates are higher than currently reported simply because people are afraid to find out their status and are not getting tested. A condition that is exacerbated by people's fear of being ostracized in their communities and of losing their jobs in the event that their tests results are positive.

While the great majority of respondents reported not having PLHIV/AIDS among their congregations, all of them considered their organizations to be all-inclusive in their membership regardless of the HIV status of a person. This attitude is in line with their religious teachings and human values. They recognized that the type of stigma that was pervasive with the onset of HIV/AIDS does not exist anymore.

Several respondents added that while they would have no reservations in welcoming and supporting PLHIV/AIDS as active members of their congregations they could not guarantee that all members of their congregations would share this feeling because the stigma associated with HIV/AIDS still remains among some members of the general community. They believe that this is mostly due to people's lack of education and misperceptions regarding HIV/AIDS. As a result, "people do not have a clear understanding of how they can maintain a relationship or friendship with someone who has HIV/AIDS".

Risk behaviours associated with HIV/AIDS

Certain behaviours are considered to increase people's risk of contracting HIV/AIDS. The most common risk behaviours associated with HIV/AIDS are homosexuality, prostitution, substance abuse and promiscuity/unfaithfulness. Key leaders viewed these behaviours as risks factors having a direct association with HIV/AIDS and shared their perceptions about their prevalence among their congregations and the wider Grenadian population.

Homosexuality

All respondents recognized homosexuality as a risk factor for HIV/AIDS. As stated by a respondent, "Because it does exist, the transfer of infection exists and in fact there are a lot of homosexuals in Grenada". From their religious perspective and teachings, respondents do not approve of the practice, they try to make a distinction between the act and the person. Many of them mentioned that they would not discriminate against people based on sexual orientation but rather they would attempt to counsel individuals into changing such behaviours: "We must not take what is abnormal and make it normal". Homosexuality as a health-related risk was viewed by some of the respondents as having a stronger impact on young people. Some respondents emphasized young males while others emphasized young females. Respondents could not ascertain the prevalence of homosexuality among the Grenadian population but the majority concurred that it was a growing trend and whereas before people had managed to keep it hidden, this no longer seems to be the case in many instances.

Prostitution

Prostitution runs against all religious teachings and it is discouraged by the FBC. While most key leaders recognized that prostitution has a long history in Grenada, there are some aspects of it that are becoming more evident. A respondent's description summarizes many of the comments made: "In more recent times, we have been hearing a lot about the whole idea of prostitution in a global sense. In the local community, prostitution is still considered a very taboo thing and as such we would make every effort and would do as much as we can to discourage this whole idea ofprostitution. Sometimes you hear of prostitution because of need, or prostitution because of persons in position abusing their privileges on the younger and vulnerable and so forth and we try as much as possible to teach that this is illegal, it is wrong and sinful".

Respondents identified the various sectors of society that, in their view, are at risk of engaging in this behaviour: a) young girls looking for financial stability, b) unemployed women, c) middle age men with financial stability and d) professional women unable to find suitable partners. While all respondents concurred that prostitution is not new in Grenada, most of them felt that it was increasing and becoming more public and easily accessible. And "...the fact that it exists creates opportunity for [HIV/AIDS] transmission, because no matter how many checks and balances you have in a system there will always be loopholes".

Substance abuse

There was consensus among all respondents that substance abuse is a precursor to unsafe sexual practices which may lead to the contraction of HIV/AIDS. Further exploration as to the FBC's attitude towards the consumption of alcohol and other substances showed that there are distinct postures within the FBC in terms of their acceptance of alcohol consumption. For some denominations, alcohol consumption is totally forbidden while others accept it with moderation. Regardless of their stand, all respondents concurred that alcohol consumption is a problem in Grenada. The prevalence of this behaviour is such that many people are blinded to its negative effects on society.

Key leaders described a range of activities in which alcohol consumption is promoted that expand from the little neighbourhood rum shack where men spend all day drinking to community activities involving all members of society. "...We find that there is a lot of drinking by our young people, that is a disturbing issue and probably that is why there is the escalation of violence; the sooner they have a get-together then comes the chopping because the alcohol gets into their heads".

All key leaders also recognized the use of marijuana as a practice that has been part of Grenadian life from time immemorial. Just as with alcohol consumption, marijuana consumption cuts across all sectors of society, from government officials to young people and it is implicitly accepted. Some respondents felt this practice is also on the rise and is also becoming more public. In the past "people used to go to the bush to smoke, now you find people smoking it at the beach." Some respondents also expressed their concern about other substances, such as crack and cocaine that are making inroads in the community and are accessible, in terms of price, to all socio-economic levels. In their opinions, the effects these substances have on communities are noticeable.

Infidelity

All religious doctrines speak against infidelity. It is considered a violation of religious and moral laws. As such the FBC promotes "abstinence before marriage and fidelity in marriage" as the way to remain true to religious teachings and prevent sexually transmitted diseases. Overall, key leaders acknowledged that infidelity is common in Grenada, but it is kept private. This behaviour is described as cutting across all segments of society. Emphasis was made on the burden infidelity places on women. Women are under an enormous amount of stress because men move from relationship to relationship leaving their seed around. As a result "80% of children are born out of wedlock" and in many cases fathers are not assuming their financial obligation towards their children.

Many key leaders felt that the media influences promote promiscuous behaviour. This influence can be seen in TV commercials that rely on sexual overtones to catch the attention of the public, on TV shows and soap operas and through the proliferation of pornography through DVDs and the internet. As the adults engage in these behaviours, the younger generation is following suit. Adults "have no respect for the youth and the youths have no respect for them". Children know what the adults are doing and they say: "If you are doing it, then I can do it too".

Factors associated with risk behaviours

The risk behaviours previously discussed are closely linked to factors that, depending on the circumstances, may contribute to their prevention or exacerbation. Two factors were identified through this study: family and country values. These values are significant because they represent the bedrock that defines the moral character of societies. These factors emerged as key leaders attempted to reconcile the prevalence of the listed risk behaviours within a religious society. Many key leaders viewed this lack of balance as a reflection of the erosion taking place in the Grenadian value system.

At the family level, respondents identified the changing roles of males and females within the households and the transitions families are making from an extended family to the nuclear family model, as factors that threaten the social foundation of communities. As families transit through these changing times, behavioural patterns previously maintained and dealt with within the confines of the family, such as domestic violence and teen pregnancy, are becoming public concerns that have both positive and negative effects in society.

As family values guide the behaviours of family members, a country's values help shape the behaviours of its citizens. In this regard, many of the key leaders mentioned the absence of a public discourse emphasizing moral values. This coupled with the lack of enforcement of laws and regulations associated with domestic violence, statutory rape, incest, and child support contribute to the moral deterioration of society.

 

DISCUSSION

This study explored the beliefs and perceptions of the FBC about HIV/AIDS. Findings of the study showed that addressing HIV/AIDS requires confronting a wide range of issues that render the Grenadian population vulnerable to the spread of this epidemic. For the FBC, certain behaviours and lifestyles, such as prostitution and homosexuality, are considered to be in direct contradiction to their beliefs and teachings, however, their beliefs do not translate into discriminatory attitudes towards people engaged in these activities. Rather, in their role as religious leaders, they make efforts to help these individuals see the value in choosing lifestyles that are congruent with religious principles. As such, the FBC is an excellent resource in health promotion efforts given that the risk behaviours and factors associated with HIV/AIDS showed that moral and socio-economic factors not only underlie, but also cut across all sectors of Grenadian life. Some members of the FBC were already involved with NAD in the implementation of HIV/AIDS preventive efforts; however, there is great potential for a much wider involvement aimed at educating entire communities rather than groups of individuals, given the significant presence of the FBC throughout Grenada. Launching such an effort would require providing training to members of the FBC on the basic knowledge about HIV/AIDS, ways to prevent, identify and address discrimination and stigmatization and issues related to confidentiality. With proper training, the FBC could be one of many partners in a multi-sector approach to educate the citizenry, reduce the stigmatization of PLHIV/AIDS and provide the moral and economic support required by PLHIV/AIDS.

While there was consensus among the FBC about the risk factors associated with HIV/AIDS, there was variance on their levels of tolerance and comfort with certain behaviours and practices. These are factors that would require further discussion and exploration when seeking the inclusion of the FBC in future public health campaigns. The FBC is an integral part of the Grenadian cultural, political and socioeconomic landscape, which is constantly changing and reshaping itself in order to adapt to current pressures and circumstances. As part of this never-ending process, some religious organizations are better able to accommodate and respond to these changes without jeopardizing their moral integrity while others consider that any accommodation effort would result in the dilution of their religious teachings. These varying perspectives within the FBC do not stand as insurmountable differences but as concerns worth addressing as part of their interest in sending a consistent message to society. This would be in line with a quality shared by all key leaders: their love for people.

 

ACKNOWLEDGEMENT

We are grateful to the reviewers of this article for helping us refine our work.

 

REFERENCES

1. Macro International Inc. Grenada Caribbean Region HIV and AIDS. Service Provision Assessment Survey. Draft of the Measure Evaluation Project, Maryland, USA: Macro International Inc., 2006.

2. Crepaz N, Marks G. Towards and understanding of sexual risk behaviour in people living with HIV: a review of social, psychological, and medical findings. AIDS 2002;16:135-49.

3. Marks G, Burris S, Peterman TA. Reducing sexual transmission of HIV from those who know they are infected: the need for personal and collective responsibility. AIDS 1999;13:297-06.

4. Herek GM, Capitanio JP, Widaman KF. Stigma, Social Risk, and Health Policy: Public Attitudes Toward HIV Surveillance Policies and the Social Construction of Illness. Health Psychology 2003;22:553-40.

5. Herek GM. Illness, stigma and AIDS. In PT Costa Jr. and GR VandeBos (eds). Psychological Aspects of Serious Illness: Chronic conditions, fatal diseases, and clinical care (pp. 107-150). Washington, DC: American Psychological Association; 1990.

6. Gostin LO, Webber D. The AIDS litigation project: HIV/AIDS in the courts in the 1990s, part 2. AIDS and Public Policy Journal 1998;13:3-19.

7. Zieler S, Cunningham WE, Andersen L, Shapiro MF, Bozzette SA, Nakazono T et al. Violence victimization after HIV infection in a US probability sample of adult patients in primary care. Am J Public Health 2000;90:208-15.

8. Capitanio JP, Herek GM. AIDS-related stigma and attitudes toward injecting drug users among black and white Americans. American Behavioural Scientists 1999;42:1148-61.

9. Burris S. Surveillance, social risk, and symbolism: framing the analysis for research and policy. J Acquir Immune Defic Syndr 2000:25(Suppl.2):S120-7.

10. Beeker C, Guenther-Grey C, Raj A. Community Empowerment Paradigm Drift and the Primary Prevention of HIV/AIDS. Soc Sci Med 1998;7:831-42.

11. Letamo G. Prevalence of and Factors Associated with, HIV/AIDS-related Stigma and Discriminatory Attitudes in Botswana. J Health Pop Nutri 2003;4:347-57.

12. Levia GC, Vito' riab, M.A.A. Fighting against AIDS: the Brazilian experience. AIDS 2002;16:2373-83.

13. Parker R, Aggleton P. with Attawell K, Pulerwits J, Brown L. HIV/AIDS-related Stigma and Discrimination: A Conceptual Framework and an Agenda for Action. USA: The Population Council Inc.; 2002.

14. Bernard R. Research Methods in Cultural Anthropology. Newbury Park, CA: Sage; 1994.

15. Coffey A, Atkinson P. Making Sense of Qualitative Data: Complementary Research Strategies. Thousand Oaks, CA: Sage; 1996.

16. Morse JM, Field PA. Qualitative Research Methods for Health Professionals. Second edition. Thousand Oaks, CA: Sage; 1995.

17. Muhr T. ATLAS/TI: The Knowledge Workbench. Vers. 4.2. [Computer Software]. Berlin: Scientific Software Development; 1997.

 

 

Correspondence:
Dr A Gomez
Department of Public Health and Preventive Medicine, School of Medicine, St Georges University
Grenada, West Indies
E-mail: angelagomez16@yahoo.com