Use of Critical Ethnography to Study the PMTCT Program

Background: Despite the efforts at establishing Prevention of Mother to Child Transmission (PMTCT) programs in Rwanda, there are still children who are becoming infected through mother-to-child transmission of HIV. The purpose of our research study was to explore the experiences of HIV positive women using PMTCT program to prevent HIV transmission in Rwanda. Methodology: In this study, a qualitative approach using a critical ethnographic design was used to answer to our research question and with the aim to discover the meaning, process, and context of the studied phenomenon. In this paper, we discussed ethnography, critical ethnography, and its related philosophical assumptions as well as illustrating the rational for the use of critical ethnography to study the PMTCT program. Critical ethnography ultimately will contribute to raising awareness on how we can prevent new infections among children born from HIV positive mothers who are using the PMTCT program. The findings suggested a wide range of challenging factors that are shaped by social, political, cultural, economic, ethnic, and gender values, and that directly and indirectly affect the uptake of the PMTCT program. While using the critical realist ontology, we discovered multiple truths about the challenging factors for HIV+ mothers experience to uptake the PMTCT program. We triangulated their experiences with the findings gathered from healthcare providers, PMTCT leaders and policy-makers, field observation, and document analysis. No previous studies on this phenomenon used a critical lens to explore the reality behind a wide range of experiences of mothers using the PMTCT program to prevent HIV


Introduction
Inquiry is driven by philosophical assumptions within research that are divided into two main approaches: quantitative and qualitative [1]. The difference between these approaches stands from contrasting ontological beliefs [2]. Ontological beliefs have an influence on the type of questions that are of interest to researchers [3] [4]. Researchers orient their research based on the objectives and the goal they need to achieve, and the research questions they want to answer. In choosing the design of the study, researchers are guided by epistemology, ontology, ideology, and ethics.
Quantitative research focuses on quantities and numbers and is concerned with discovering facts regarding social phenomena. In contrast, qualitative research is directed at the discovery of meaning, rather than cause and effect, and typically focuses on process and context [5]. In qualitative studies, researchers conduct research projects in a natural setting and data analysis is inductive; moreover, researchers pay attention to discourse and to the behavior of the participants. There are various types of qualitative research designs, such as ethnography, case study, content analysis, phenomenology, historical study, action research, and grounded theory [6].
Despite the efforts at establishing the Prevention Mother-to-Child Transmission (PMTCT) programs in Rwanda, there are still a number of children who are becoming newly infected through mother-to-child transmission of HIV. We recently conducted an ethnographic study to explore the experiences of HIV positive women using the PMTCT program to prevent HIV transmission in Rwanda. In this paper we discuss critical ethnography and its related philosophical assumptions as well as illustrate the rationale for using critical ethnography to study the PMTCT program.
Our intention in the research we conducted was to increase knowledge around the PMTCT program to prevent HIV transmission to the infants. Critical ethnography was an appropriate exploratory and descriptive method that helped not only identify factors that influence and challenge the uptake of PMTCT but also to critically examine the experience of mothers using PMTCT program to prevent HIV transmission and how it could be implemented effectively.

Ethnographic Designs
Ethnography is one of the qualitative research designs which has been traditionally used and developed in anthropology and sociology [7]. Disciplines interested in the culture and social interactions of groups have adopted ethnography [8].
It has become a more predominant design used to study phenomenon related of health [9], and it is now commonly used in nursing [10]. Brewer defines ethnography as a study of people in a naturally occurring setting or field where the researcher spends time with research participants in their setting and participates directly in their activities [7]. Ethnography is considered to be a methodology that helps the researcher develop a better understanding of the meaning of a phenomenon by getting closer to the participants [11] [12] [13] [14] [15]. It is a suitable design for examining and resolving sociocultural problems in health institutions by trying to find out how and why of behaviors or actions [16].
Ethnographers use multiple sources of data collection that allow them to examine the behaviors of participants in a specific social situation and understand the meaning through the interpretation of such behavior [17] [18]. Moreover, ethnography has the potential to offer data that are considered beneficial in terms of validity through cross-checking from different sources such as artefacts, documents, interviews, and observation [19].
Ethnography appears to nurse as a holistic way of obtaining knowledge around a phenomenon of interest that fits well with long held professional values. Similarly, to the nursing process it includes a brief history and analysis of the terrain, the climate, and the habitat. In addition, ethnography facilitates rigor and trustworthiness in qualitative research [19] [20]. Because of its aspects in relation of cultural sensitivity, fieldwork, and prolonged time in the field, ethnography can further increase rigor [21]. Hence, the main characteristics of ethnography, include participants' interaction with researchers, research in a natural setting, inductive data interpretation, accurate reflection of the participants' perspectives and behaviors, recursive data collection, and analytic strategies framed within a socio-political context [22] [23]. Ethnography is a recommended design for researchers whose intent is to provide in-depth description of the phenomena of interest. Ethnography may take several forms, depending on the types of the research question, its scope, and the researcher's perspective. Those ethnography forms include autoethnography, traditional, focused, critical, participant action research, visual, ethnomethodology, ethnoscience, evaluation research, and experiential description.

Critical Ethnography Methodology
Critical ethnography is a design that studies people in naturally occurring settings referred to as fields. A researcher using critical ethnography needs to do intensive field work that involves the participation of the researcher in the setting to capture the social meanings and ordinary activities [16]. The researcher keeps monitoring, reflecting upon, and reporting her/his role as a mechanism for reflexivity which is an integral part of critical ethnography. This reflexivity helps the researcher gain a better understanding of the data and avoid misinterpretation of the findings [24] [25].
In our study on the PMTCT program, the findings suggested a wide range of challenging factors that are shaped by social, political, cultural, economic, ethnic, and gender values, and that directly and indirectly affect the uptake of the program [26] [27]. While using the critical realist ontology [28], we discovered multiple truths about the challenging factors for HIV+ mothers to uptake the PMTCT program by gaining access to their experiences and triangulating those experiences with data gathered from health care providers (HCP), PMTCT leaders and policy-makers interviews, field observation, and document analysis.
None of the previous studies that had been conducted about the PMTCT program had used a critical lens to explore the reality behind the wide range of experiences of mothers using the PMTCT program to prevent HIV transmission in Rwanda. The critical nature of this inquiry contributed to the depth and breadth of knowledge related to the delivery of the PMTCT program to prevent MTCT of HIV.

Philosophical Assumptions in Critical Ethnography
There are a number of philosophical terms that need to be understood when

Ontological Assumptions of Critical Ethnography
Ontology refers to beliefs about the nature of reality [30]. In philosophical terms, it refers to the study of our existence and the nature of reality or being [6]. Beliefs about the nature of reality determine what can be known about it [31].
Critical ethnography is one of the qualitative research designs that assume meaning and reality are socially constructed [2]. Ontologically, critical ethnographers assume that individuals make sense of their own reality and that there are multiple truths [2] [26]. As well, critical ethnography reveals underling issues that produce reality are grounded in historical realism. This historical realism embraces the view that reality is shaped by social, political, cultural, economic, ethnic, and gender values [27] [32]. Critical ethnographers embrace an ontology based on the understanding that often organizations are historically born in conditions of struggle and domination [33]. Critical ethnographers adopt a political purpose to change, they believe there is something better out there, and the aim must be to work toward it [33].

Epistemological Assumptions of Critical Ethnography
Epistemology examines the relationship between knowledge and researcher during discovery. It is defined as the nature of knowledge and addresses the questions how do we know what we know, what is the relationship between the knower and what is known, and what accounts as knowledge [30]? Knowledge in critical ethnography is both socially constructed and influenced by power relations from within society [26]. Critical ethnographers start to explore a phenomenon having their own preconceived ideas while seeking to expose underlying meaning(s) with an aim for change [33]. In critical ethnography research, the knowledge is both socially constructed and is created through a dynamic interaction between the participants and researchers, the emancipation of both, and the transformation of the lived reality [34]. The aim of the research is to discover what is distorted and through the praxis the process tries to transform reality. Critical ethnographers assume reality can be transformed through a critical review that may bring about an emancipatory function of knowledge and human activity beginning with consciousness-raising, which addresses matters of social justice [26].

Positionality: Emic and Etic Perspective
Critical ethnography is subjective, using the researcher as a key instrument [35]. It is not the aim of critical ethnography research to be neutral or value-free; it is essential for researchers to acknowledge their own power, privilege, and biases that surround their subjects [17]. Any interaction between participant and researcher is influenced by the researcher's beliefs, biases, values, gender, age, sexual orientation, ethnicity, culture, nationality, language, class, privilege, education, professional, status, and life experiences [36]. Researchers using critical ethnography must similarly address how subjectivity informs and influences reality or is informed by the researchers' engagement and representation of others. The terms emic and etic help understand how ethnographic researchers position themselves within the research as an insider or an outsider. Emic and etic are two constructs that are well tied to the epistemological principles and address issue on how knowledge is acquired and to what degree a particular topic can be known [37]. The researcher's insider (the emic) or the outsider (the etic) role is to acknowledge that the interpretations of participant interactions and observations are shaped by the researcher's norms, cultural values, and social locations [37] [38]. Likewise, participants have their personal values, norms, biases, and beliefs that will influence their interaction with the researcher. In short, these factors shape the research questions and the participants' answers; and determine the interaction and relationship between the researcher and participants [39] [40].
As a researcher using critical ethnography, it is important to reflect on your personal background, experiences, values, beliefs, and social locations to determine your perceptions and interpretations of the participants and their experiences. For example, in this study, I (first author) considered myself as an insider because I am Rwandese, female, married, and a mother who shares the same cultural values, taboos and misconceptions or perceptions that shape the community, and the participants. However, I consider myself also as the outsider because I am not HIV positive and have never experienced having an HIV positive infant. I am also an educated woman, and I have studied at a North American University.
Having an emic view has multiple benefits including better knowledge and understanding of the context and language, which will positively influence participants' interaction and connection. However, the researcher must be vigilant and be as objective as possible to not miss information because participants assume that the researcher knows the answers to asked questions and the researcher may be biased in favor of researcher's culture [37] [41]. The advantages around being an outsider (etic) are that it allows a researcher to ask any kind of questions, however, it takes a while to gain the trust of participants.
Mutual respect between researcher and participants, patience, avoiding judgment and continuous self-evaluation are the key elements that help the researcher understand the phenomenon [37]. Vandenberg and Hall (2011) advise that there is a need for a researcher to balance the distance from and involvement with participants [42]. They recommend the researcher team to work closely to address issues arising in the field, share emotions arising during data collection and analysis, and manage critical aspect arising in the critical ethnography methodology.

Axiological Assumptions of Critical Ethnography
Axiology is defined as a study of intrinsic value and what is worthy [43]. It is referred to as the moral positioning or values that form the basis for research activities [44]. In the broadest sense, axiology can mean ethics, economic, religion, aesthetics, politics, and/or science [45]. In critical ethnography, researchers acknowledge the ethical responsibility that addresses unfairness and injustice [17].
The outcomes of conducting critical ethnography to explore the experiences of mothers using the PMTCT program to prevent HIV transmission were to raise awareness that will lead to consciousness-raising about PMTCT of HIV, promoting maternal and child health, and community health care.

Ideological Assumptions of Critical Ethnography
Ideology is a system of beliefs detained by individual, group, or society. Rejai (1991) refers to ideology as an emotion-laden, myth-saturated, action-related system of values and beliefs about people and society, legitimacy, and authority that is acquired to large extent as a matter of faith and habit. Rejai (1991) considers that the values and myths of ideology are communicated through symbols in a simplified, economical, and efficient manner [46]. Ideologies have a potential for mass mobilization, manipulation, and control; in that sense, they are mobilized belief systems [46]. Critical ethnographers examine the dominant societal ideologies on a phenomenon and assert that ideological domination is the strongest when oppressed groups see their situation as inevitable, natural, or ne-cessary [47]. Scotland (2012) highlights that the pre-existing meaning making system which people are born into distorts their understanding of phenomena and they are unaware of this [26]. Therefore, participants might not be aware of an invisible ideology, which guides their actions. As participants might not fully understand the forces, which are acting on their agency, their explanations of phenomena are incomplete. Consequently, the researcher must have both etic and emic positions to uncover reality [26].

Rationale for Use of Critical Ethnography to Study the PMTCT Program
Critical ethnography was the most appropriate research methodology for this study as it allowed for an in-depth exploration of HIV positive women's experiences toward using the PMTCT program to prevent HIV transmission in Rwanda. The emphasis of critical ethnography research is on holistic human experience and its relationship to power and truth and offers the opportunity to closely examine health challenges from the perspective of those who live them daily [5]. It allows the researcher to not only study and understand society but also critique and potentially bring about change in society through her work.
Additionally, it is an appropriate methodology for health research considering the contemporary perspective of health as a sociopolitical phenomenon that is influenced by power issues and dominance [48]. It has been effectively applied in communities, healthcare settings, and common working areas of nurses.
Critical ethnography is based on different ideologies, including emancipation, liberation, and social change [2] [26]. Furthermore, it is based on relativist ontology and believing in multiple truths [2] [26]. Relativism in critical ethnography believes that if there is an absolute truth, it is difficult to know. Epistemologically, the truth is both socially constructed and influenced by the power of relationship and reciprocity from within society [2] [27] [49]. Critical ethnographers think that truth and reality are socially constructed and influenced by interpersonal relationship in society [26]. The point is that truth is co-constructed by research participants and researcher. Thus, in my research, the knowledge was constructed in collaboration with HIV positive women using the PMTCT program, researcher, healthcare workers, experts in HIV/PMTCT, and policy and decision makers. The knowledge generated through this type of research is defined as an active and context-based process influenced by the history, values, and practices of both research participants and researcher [49].
In exploring the experiences of the mother using PMTCT program to prevent HIV transmission, by identifying the complex factors in which the HIV positive mothers were exposed, the emic position was required to explore how families, health institutions, community, and society integrate the HIV positive mothers.
A need for managing subjectivities results from qualitative research studies calls for the implication of political agenda for emancipation [50]. In line with this, the research team believed that exposing the existing system and liberation ide-ologies might lead to emancipation. Critical ethnography critiqued and exposed existing systems in a bid to serve the interests of disempowered or marginalized people. There was an assumption that the dominant or existing system is unjust or repressive and needed to be exposed to trigger the possibility for change [50]. As the PMTCT program at BUTH is the collaborator and primary knowledge user of our study, we presented the preliminary findings of this study to the key stakeholders. Immediately at the end of the meeting, the hospital leader appointed a staff to support the PMTCT at the Obstetrics/Gynecology department which experienced a remarkable shortage of staff. They also decided to put in place an interdisciplinary committee that should meet regularly (once a month) under the multidisciplinary meeting coordination who was elected after the preliminary presentation. The elected coordinator is the PMTCT leader in pediatric. In addition, all stakeholders decided to start the development of local policies and guidelines that implement national PMTCT guideline and the training staff on the PMTCT policies.
We are also planning to do the final presentation and submit a written report sharing participants' voices about recommendations to support the effective implementation of the PMTCT program at BUTH. Moreover, we will present the results to HIV+ women at PMTCT program/BUTH to increase their awareness.
We will also give briefing notes of the findings of my study to the BUTH's leaders.
This research methodology attempted to expose the political nature of knowledge and unmask the dominant forces that shape our worldview or research participants views. By critical examination of worldviews, power, and ideology, a critical ethnographer attempted to contextualize the current situation in a larger socio-historical framework that offers and encouraged others to engage in critical reflection [50]. Its primary goal was to understand and interpret situations from both inside and outside dominant thereafter naming and distancing him/herself from cultural assumptions in a bid to allow alternative assumptions or conceptions, consequently by doing this, the investigator may present different alternative and potentially liberating realities.

Benefits of Using Critical Ethnography
During the research process, the critical realist ontology provided the grounds to uncover challenging factors that directly and indirectly influence the HIV+ women to uptake of the PMTCT program at BUTH in Rwanda. A close exploration of the experiences of HIV+ mothers using the PMTCT program to prevent MTCT of HIV suggests that limited information was previously available about factors that expose HIV+ mothers for low uptake of the PMTCT program. Use of the ontological assumption of critical ethnography provided an opportunity to gain insight into a reality that is multifaceted, complex, and interrelated. The findings suggested a wide range of challenging factors that are shaped by social, political, cultural, economic, ethnic, and gender values, and that directly and in-directly affect the uptake of the PMTCT program. While using the critical realist ontology [28], we discovered multiple truths about the challenging factors for HIV+ mothers to uptake the PMTCT program by gaining access to their experiences and triangulating those experiences with the facts gathered from HCPs, PMTCT leaders and policy-makers interviews, field observation, and document analysis. None of the previous studies in this area used a critical lens to explore the reality behind a wide range of experiences of mothers using the PMTCT program to prevent HIV transmission in Rwanda. The critical nature of this inquiry contributed to the depth and breadth of knowledge related to the delivery of the PMTCT program to prevent MTCT of HIV.

Conclusion
Within this paper, we discussed ethnography, critical ethnography, and their related philosophical assumptions as well as illustrating the rational for the use of critical ethnography to study the PMTCT program. The research aimed to explore the experiences of HIV positive women using PMTCT program to prevent HIV transmission. Despite the effort put in the PMTCT program, there are still a number of children who are becoming newly infected through mother to child transmission of HIV especially in Rwanda. Critical ethnography was a suitable method as it aligned well with the study questions and objectives and ultimately would contribute to raising awareness on how we can prevent the new infection among children born from HIV positive mothers who are in PMTCT program. This study has already brought some changes as mentioned above.