Volume 6, No. 2, Art. 4 – May 2005

From Margins to Centers ... Hopefully

Lawrence J. Hammar

Review Essay: Judith Green & Nicki Thorogood (2004). Qualitative Methods for Health Research. London: Sage, 262 +xv pages,
ISBN: 0-7619-4771-X (pbk), $ US 39.95

Abstract: Qualitative Methods for Health Research is a well written introductory text for health professionals who are stretching toward more qualitative perspectives, methods and modes of analysis. The authors discuss key texts and apt case studies from medical sociology and medical anthropology, critical theory, ethnography, public health and research ethics to exemplify the merits of (and unflinchingly note the drawbacks of) qualitative strategies and perspectives. The text is reader-friendly in layout and pace and presents many interesting case studies drawn from the authors' research and that of others. It aims for rapprochement rather than scorched earth in its handling of the qualitative/quantitative divide. As such, it breaks little theoretical ground, but that is probably more a sign of the intended audience (the not-yet converted) than of the predilections and analytical skills of the authors. GREEN and THOROGOOD discuss the importance of considering epistemological and ontological questions in health research, but without getting bogged down in post- and post-postmodern anxieties. More of a friendly companion than a step-by-step recipe book, this text aims to show budding researchers not so much how, but rather, why to frame research questions better, how to conceptualize more appropriate choices of method, and ways that researchers can present data in more multiplex, multi-voiced fashion so as to be more persuasive. The writing is fresh, the perspective is honest and the outcome is a generally compelling, thrills-and-spills introduction to qualitative research on health issues and in health-care settings.

Key words: qualitative research methods, case study, health research, medical sociology, qualitative/quantitative divide

Table of Contents

1. Introduction and Summary

2. Substantive Contents

3. Discussion and Commentary

4. Concluding Remarks

References

Author

Citation

 

1. Introduction and Summary

Qualitative Methods for Health Research is one of the now 20-odd titles to have appeared in the Sage-published series, Introducing Qualitative Methods. These usually slim volumes amble their way through fields as disparate as cultural studies, social work, information technology, criminology, education, and monitoring and evaluation. They are marketed more to novices than to experts and are designed more to grease the skids of collaboration and encourage inquiry than to filter ever more finely for methodological purity. The introductory texts in this series unpack and explore methods and analytical styles in qualitative work such as archival research, narrative analysis, building case studies, and conducting focus group-type interviews. They are always scrupulously edited and thoughtfully put-together, although not always sold cheaply. Case in point: the text under review here is being sold in hard-cover for nearly U.S. $100. [1]

Qualitative Methods for Health Research makes a handy addition for health professionals who may be attending their first methods course and who as such have little or no grounding whatsoever in the methods by and ethics with which field researchers conduct their work. The intellectual light-bulbs of readers may glow more brightly as they contemplate the authors' solid introduction to research ethics in Chapter 3, partly by way of presenting in case study form the classic study of D.L. ROSENHAN, "On Being Sane in Insane Places" (ROSENHAN, 1973). In this infamous study, ROSENHAN and colleagues undertook research in a mental health facility that clearly involved deception and potentially serious risks—and that was just for the patients ... For most commentators (seemingly, present authors included), this made the study ethically dubious, but the research was undertaken so as to achieve a far greater good, namely, the revelation of iatrogenic disease, so as hopefully to undermine the mundane, routinized way in which "insanity" is produced and inscribed, not just recognized and treated. This reviewer knows of few better, more instructive cases of the wildly hegemonic hold that biomedicine has in western cultures. It is held together not just by means of political-economy, of course, but also by what the medical anthropologist Deborah GORDON (1988) has called its "tenacious assumptions." These are assumptions that I'm betting readers of the text under review hold fairly tenaciously, too. As just one of many examples of laudable intra-textual continuity that could be cited (backwards and forwards), the authors follow up this boxed case study with intriguing discussions later in Chapter 6 about "mystery shopping" and "pseudo-patient" studies. Throughout the text, the authors seem inordinately aware of the reader. [2]

Other likely readers may just be contemplating their own research but without yet really knowing where to start. Perhaps having already had a course in medical sociology or medical anthropology, they might find themselves wanting to ask someone, "Yeah, Huli notions of illness are interesting, but what about my culture, what about the institutional settings within which I'm going to work? I can see why health belief models are important to medical sociologists, but we don't have them—I mean, we don't, do we? Anyway, how will this help me interview the surgeons and administrators in my hospital? And what else is there besides interviewing, anyway?" Judith GREEN, for example, studied single-handed general practitioners, and Nicki THOROGOOD, the management of daily life and health of Afro-Caribbean women who migrated to the U.K. Perhaps not all qualitative methods texts would be appropriate, in the former case perhaps because they tend to skimp on the issue of the difficulties presented when researchers try to "study up," that is, in settings peopled by the more, not less powerful. Joan CASSELL (1991), for example, discusses the problem of researcher access in often painful detail in her brilliant study of surgeons, Expected Miracles: surgeons at work. [3]

The authors, Judith GREEN and Nicki THOROGOOD, are both Senior Lecturers in Sociology at the London School of Hygiene and Tropical Medicine. Qualitative Methods for Health Research is an engagingly written and helpfully presented introduction to the ways in which qualitative research perspectives and methods might be applied by health professionals either or both to the work they do and as they contemplate new research initiatives. In addition to their obvious expertise in medical sociology, the authors also seem well grounded in conversational analysis, critical theory, ethnography, ethics and gender studies, among other qualitative disciplines and practices. (This reviewer's heart swelled to see that Monique WITTIG's The Straight Mind and Other Essays, published in 1992, had been used and cited.) The text is reader-friendly in layout, aesthetics and pace. It presents case studies drawn from their own research and that of others that are not only interesting, but that also in fact exemplify arguments made in the preceding text. Perhaps reflecting their longstanding responsibilities to profess to and instruct the not-yet-converted (to qualitative perspectives and methods), GREEN and THOROGOOD traverse within and between issues in biomedicine and public health with ease and confidence. It's a neat trick if you can do it, too—they do so without a trace of condemnation or rancor, without the kind of matronization that can and does often occur when margin meets center. [4]

2. Substantive Contents

Qualitative Methods for Health Research is divided into three roughly equal parts. It consists overall of a short preface, eleven chapters, a references section and a brief, but accurate, index. Although there are no brilliant photographs, colorful tables, arresting figures or humorous epigraphs to be found here, the layout of the text makes for easy reading and reference. Each chapter is summarized in outline and then narrative form at the outset and then summarized a third time at the chapter's close in the form of bulleted Key Points. The book thus follows a classic classroom pedagogical strategy: tell 'em what you're gonna do, do it, and then tell 'em what you did. Each chapter, too, is accompanied by suggested exercises and a few briefly annotated bibliographies of particularly apt readings. As such, the text is serious without being tedious, and brisk but without missing the mark over or under the reader's head. [5]

The three chapters that comprise Part 1, "Principles and Approaches in Qualitative Health Research," deal primarily with research design and implementation. The authors in a general way discuss ethical concerns and the better and worse conceptualization of research questions. They also provide a sort of running dialogue regarding the qualitative/quantitative divide generally and specifically as it is played out in health research. The first chapter, "Qualitative Methodology and Health Research," provides a good overview of the leading theoretical and methodological stances in qualitative research as they might be applied by health professionals and/or to research in a health setting. In this sense, the first part bears a striking resemblance to a recent new text now about to enter a revised, 2nd edition, Qualitative Methods: a field guide for applied research in sexual and reproductive health (ULIN, ROBINSON, TOLLY & MCNEILL, 2002). That text, too, includes the example provided by the work of STONE and CAMPBELL (1984) on Nepalese negotiation of external researchers who brought to the field a conceptually fuzzy research instrument designed to capture politically dodgy information about fertility concerns. ULIN et al.'s text also and similarly discusses macro- and middle-range theories, theories of knowledge, and some of the same theoretical approaches common to social science research. Here, GREEN and THOROGOOD discuss interpretivism, constructivism, and feminist and participatory approaches. [6]

Chapter 2 summarizes major issues in research design and conceptualization. Of particular use here is the authors' attending to the problem of how best to operationalize concepts. They discuss in clear detail how to design and build-in indicators with which researchers can not only assess how well they're doing, but also communicate their progress and success more effectively to funders and policy-makers. [7]

Chapter 3, "Responsibilities, Ethics and Values," reviews ethical guidelines and the not-always straightforward way in which researchers adhere to them. It demonstrates the sometimes evolving responsibilities that researchers can have to research subjects and participants. Of particular usefulness here is the authors' fine discussion of the responsibilities that researchers have to themselves and to their co-workers. ROSENHAN's case is again appropriate to mention in this regard, for he and his compatriots were permanently altered by the experience (as were the research subjects/objects in the "prison" experiments of Stanley MILGRAM), if not also rendered temporarily "insane." Field research can be hard, hard work, it can be dangerous and it can leave scars on both sides of the ledger. [8]

Part 2, "Generating and Analyzing Data," contains five more chapters designed to convey a sense of the range of methods and perspectives available for health researchers as they contemplate a more qualitative approach to their research questions. Documentary forms of research such as public records, photographs, archives and forms of mass media are covered in Chapter 7. The authors have sound recommendations to make here regarding how (and how not) to use documentary evidence and what are some of the methodological issues and drawbacks in terms of validity and representativeness. "Observational Methods" (Chapter 6), "Group Interviews" (Chapter 5), and "In-depth Interviews" (Chapter 4) are covered in sufficient detail. Particularly refreshing here is how many recent discussions and case studies the authors present, probably about half being drawn from research conducted since 1990. Chapter 8, "Analysing Qualitative Data," leans heavily on three tried and true strategies in qualitative research: thematic content analysis, grounded theory and framework analysis. They argue here that the somewhat Janus-faced task of the qualitative researcher when writing up the fruits of research is to convey simultaneously a sense of the complexity—even chaos—of the data alongside their underlying structure. [9]

The strength of Chapter 4 is its unwavering focus on language and the hidden assumptions thereof, even when the researcher is (or seems to be) studying her/his own culture. The authors make a signal point: "Translation is not merely a technical service, but a vital part of the data analysis" (p.85). So true, and yet countless articles begin the "Methods" section with claims such as that "audiotaped interview material was transcribed verbatim." Impossible. This reviewer might go further in suggesting that translations aren't just part of the data analysis, but more than that, are data themselves. [10]

Chapter 5 courses through the different kinds of group-style interviews available to the field researcher. They discuss in clear English how, why, when and where to construct "consensus panels" and focus groups, and how both of those may differ from more "natural" groups which are organized and assessed more on the run. Working here in Papua New Guinea as I do, I was particularly enlivened to read that "research in ... developing countries ... may involve a shifting group, as people (and even animals!) drift in and out of the room ..." (p.108). Yep—once again, so true! [11]

Chapter 6, "Observational Methods," is located firmly in Participant-Observationsville. They note correctly that in the qualitative sciences, participant-observation, while not quite a "method" in the strictest sense, is nevertheless the gold-standard criterion by which to evaluate field data. They show that participant-observation is an activity and philosophical stance that is certainly necessary if not by itself sufficient to guarantee the collection of "good" data. Rapid ethnographic assessment (something of a misnomer), for example, is examined in terms of its philosophical underpinnings, its methodological principles, and some of its drawbacks and strengths, one of the former being a too-quick conclusion being drawn about publicly accepted "truths" that don't bear out in more "private" thoughts and behaviors. Particularly good and recent examples are offered here of the difference between what quantitative researchers might (mis-)take as "fact" and what qualitative researchers will recognize instantly as "artifact," for example, how "birth" is not so much recorded or described as inscribed and invented owing to the nature of the interaction between researcher and researched, not the empirical realities of birth-dates themselves (pp.132-33). [12]

The three chapters that make up Part 3, "Doing Qualitative Work for Health," are among the most practical in the text, and have at the same time a mildly subversive streak to them (which is a compliment). Chapter 9 shows how and why researchers of all stripes should be collaborating more, and how one's choice of research methodology and strategies is ultimately a political choice, not just one of maximizing data collection or pleasing funders. Chapter 10, "Writing up Qualitative Work," contains sound advice and many good examples of writing style and publishing strategies. This chapter in particular will appeal to at least two kinds of readers: 1) those stretching out and beyond artificially-maintained disciplinary (if not also emotional) boundaries for the first time, and 2) new students in the health disciplines wondering whether there are publishing opportunities for them if neither the Lancet or American Journal of Public Health bite. The final chapter, "Reading and Appraising Qualitative Work," properly brings round the reader to what the authors might have wished were a starting point: ethnographic modes of practice and analysis and presentation. Taking a tip perhaps from Mortimer ADLER's How to Read a Book (1972 [orig. 1940]), they show readers and budding researchers how, literally, to read qualitative, social scientific research. But for the predictable resistance many quantitative thinkers have for such modes of analysis and presentation (not to say also for methods and philosophical stances), this final chapter could have just as easily come first. [13]

3. Discussion and Commentary

A persistent theme throughout the text is what to make of the qualitative/quantitative divide. The book is aimed more at the not-yet converted (to the qualitative side of the ledger) than to already practicing qualitative researchers. This particular discussion is informed by relatively little theory or deep archeology of the origins of biomedicine (and quantitative, objectifying research stances), but neither should much of such be expected from an introductory text. Probably more than a few new readers will be amazed to learn that their assumptions, too, have ontological debt and epistemological weight to them. "Few researchers," they note correctly, "state the assumptions they have about the social order and why these have shaped their particular research question as a legitimate one or as a puzzle that needs explaining" (p.8). To their credit, the authors' remonstrations as to the limits of quantitative methods and perspectives are surprisingly gentle (if persistent), as if to say "we know that the world isn't even this simple ... but there are other books out there, so we're going to assume that it is." Qualitative Methods for Health Research will thus likely strike a chord with those newly pursuing health systems research and with nurses and other kinds of health professionals thinking afresh about medicine's taken-for-granted practices. This reviewer's experience has been that such people "can only take so much" when it comes to wrestling with such weighty philosophical issues as are briefly touched on here. Perhaps only the chapter on ethics (Chapter 3) could be used in stand-alone fashion, but the text would prove a welcome component of many a course on research methodologies. [14]

There is not a lot to complain about here or with which to quibble. Some readers may find themselves mildly annoyed at needing to go back and forth between regular and boxed text. It might be suggested to have boxed text be no longer than ¾ page or thereabouts and providing case studies that can be rendered on facing pages. [15]

While perhaps not agreeing with it themselves, the authors nevertheless substantially reproduce here the "soft/hard" dichotomy by which the qualitative/quantitative divide has come to be known. Sprinkled throughout Chapter 2 and elsewhere is the same tell-tale language as anywhere else. Research methods are rendered throughout the text as being more or less "flexible" and "loose," as hewing "tighter" to the "bedrock." Of course, more "rigorous" research methods are more attractive to ethics committee members and external funders. What irks this reviewer, however, is that quantitative research, which can be just as sloppy and loose and wrong-headed as any other style (if not markedly more so!), is assumed to remain "hard" simply because it purports to relate to some empirical designation of numerateness. Even when all the boxes are ticked, it doesn't mean that any of the answers have fit truthfully within the categories. Quantitative research styles can be extractive, poorly conceptualized, methodologically dodgy and superficially carried out, too, but still they're seldom if ever dubbed "soft." Perhaps this reflects the unwillingness of the authors to step on the toes of their likely audience (biomedicine- and public health-trained students and professionals), but this reviewer would like to see this dichotomy tossed out altogether (if not turned around the other way) or revealed for what it is. [16]

It is a measure of how good this book is that the only major quibble that can be registered is in regards to an extremely minor point. Although this may very well again be due to the nature of the intended audience (and as such does not reflect the authors' real opinions), the authors say that social constructivists might inquire as to "what are the processes by which diseases become classified in particular ways ..." (p.13). To play Social Constructivist's Advocate is to say:

"Not so fast. This isn't radical enough. A good social constructivist would never say it that way. It lets off the hook what is 'disease' and who gets to say so. Plus, it goes against the grain of your keen insights on language and the danger of 'commonsense' assumptions that can be, well, nonsensical. This phrasing implies that there are such 'things' as 'diseases' out there in external-reality land, waiting only for this or that system of classification system (ethnomedicine, biomedicine, Ayurvedic principles, etc.) to recognize them. Diseases as such, according to an extreme Foucaultian position, do not exist, but discourses about them surely do." [17]

In Case Study 6.2, for example (beginning on p.151), the authors unreflectively use constructions such as "a man with epilepsy" and "a woman with diabetes" and/or follow the original authors in doing so. Ann FADIMAN's superb quasi-ethnography of _______________ (you fill in the blank), The Spirit Catches You and You Fall Down (FADIMAN, 1997) is just one of many that could be cited of the dangers of assuming anything. Notice that the author didn't title her book Epilepsy, and Why Some Crazy Hmong Don't Recognize it When They See It. Even apart from the intricacies of the case of Lia Lee (including an absolutely stupefying amount of over-medification that undoubtedly did permanent bodily damage), "epilepsy" is a particularly good example in the biomedical pantheon, for as FADIMAN shows, a goodly chunk of what are designated its "cases" are in fact idiopathic. Even the ones for which is claimed sound etiology are yet somewhat idiosyncratically understood, and again, iatrogenic causes for such are easy to find in the clinical literature. Uncritically following biomedical practitioners' thought-styles (e.g., "a man with epilepsy"), but then attempting to decipher what patients think about their "disease," to what degree they recognize it as such, and so on (in "good" story-telling), leads merely to enriched monologue, for physicians still hold the reins of power (and can pat themselves on the back for having elicited "good stories" from their patients). That is, while some see the illness/disease dichotomy as being a step forward in medical sociology, others see it as further reproducing the inherent power imbalances in biomedicine (and some would say, in quantitative, objectifying research traditions). To say that the "disease" is what the patient has, whereas "illness" is what the patient thinks she has is simply further to entrench biomedicine's hegemony. This reviewer has taught FADIMAN's book a number of times over the years and has given it to many a professional in the health field. Nary a once has a reader steeped in the biomedical tradition questioned what the little girl protagonist "has"—she has "epilepsy," to a one. Amazement is continually expressed only as to the apparent misunderstanding by Hmong of true disease etiology while at the same time appreciating the subtlety of their illness narratives. Were this book not purporting to instruct health professionals in the true goodness of qualitative approaches, this criticism would not need to be made, but this is one of many examples in the book of where the authors could have and perhaps should have stepped on a few toes. [18]

4. Concluding Remarks

The preceding quibble aside, Qualitative Methods for Health Research is a first-rate and much-needed text in the health sciences. It has been thoughtfully composed and scrupulously edited. The first incentive of the authors was "to provide an introduction to qualitative methods that used examples of health research from a number of different settings, so that we can demonstrate how key methodological issues may have different implications in different contexts" (p.xiii). In that, they succeed easily. The authors claim that a second incentive was to "bridge a gap that is sometimes apparent between policy-orientated field guides that aim to provide 'toolboxes' for novice researchers and theoretical introductions to social research that may appear to have little relevance to researchers working in applied areas" (p.xiv). In this, too, they have succeeded admirably. Even the most directly applied health research still has to be properly conceptualized and theorized, even when constraints of time, money, labor-power and other resources are tight. Insofar as this text aims at this kind of researcher, a perhaps less academically-inclined one at that, it succeeds on many fronts. The authors explicitly show researchers how to frame research methodologies more thoughtfully, collect data more contextually, and analyze data more convincingly. [19]

References

Adler, Mortimer (with Charles Van Doren) (1972). How to read a book: the classic guide to intelligent reading. New York: Simon and Schuster. [Orig: 1940 How to read a book: the art of getting a liberal education].

Cassell, Joan (1991). Expected miracles: Surgeons at work. Philadelphia: Temple University Press.

Fadiman, Ann (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Strauss, and Giroux.

Gordon, Deborah (1988). Tenacious assumptions in Western medicine. In Margaret Lock & Deborah Gordon (Eds.), Biomedicine examined (pp.19-56). Dordrecht: Kluwer Academic Publishers.

Rosenhan, David L. (1973). On being sane in insane places. Science, 179, 250-258.

Stone, Linda & Campbell, J. Gabriel (1984). The use and misuse of surveys in international development: An experiment from Nepal. Human Organization, 43, 27-37.

Ulin, Priscilla; Robinson, Elizabeth; Tolly, Elizabeth & McNeill, Erin (Eds.) (2002). Qualitative methods: A field guide for applied research in sexual and reproductive health. Research Triangle Park, North Carolina: Family Health International.

Wittig, Monique (1992). The straight mind and other essays. Boston: Beacon Press.

Author

Lawrence J. HAMMAR is a Senior Research Fellow at the Papua New Guinea Institute of Medical Research in Goroka, Eastern Highlands Province, Papua New Guinea. As a cultural-medical anthropologist who has longstanding interests in gender and sexuality, Melanesia, and qualitative research, his publications range to and between medical humanities, ethnography, gender studies, public health, Pacific studies and medical experimentation. He currently helps to lead a nationwide study in Papua New Guinea of HIV and AIDS and sexual health. In a previous issue of FQS Lawrence J. HAMMAR has written a review on Shattering Frames: Transgressions and Transformations in Anthropological Discourse and Practice (by Klaus-Peter KÖPPING).

Contact:

Lawrence J. Hammar, Ph.D.

Senior Research Fellow
Papua New Guinea Institute of Medical Research
P.O. Box #60
Goroka, Eastern Highlands Province
441 Papua New Guinea

E-mail: lawrence.hammar@pngimr.org.pg
or gorokadubu@daltron.com.pg

Citation

Hammar, Lawrence J. (2005). From Margins to Centers ... Hopefully. Review Essay: Judith Green & Nicki Thorogood (2004). Qualitative Methods for Health Research [19 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 6(2), Art. 4, http://nbn-resolving.de/urn:nbn:de:0114-fqs050242.

Revised 3/2007



Copyright (c) 2005 Lawrence J. Hammar

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