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 Collections under
which this article appears: Qualitative
Research: descriptions |
Helen Lambert
a Department of Social Medicine, Bristol University, Bristol BS8 2PY, b Department of Public Health Sciences, King's College London, London SE1 3QD
Correspondence to: H Lambert H.Lambert@bristol.ac.uk
As a response to concerns about the standard of qualitative research, attention has focused on the methods used. However, this may constrain the direction and content of qualitative studies and legitimise substandard research. Helen Lambert and Christopher McKevitt explain why anthropology may be able to contribute useful insights to health research
Qualitative methods are now common in research into the social and cultural
dimensions of ill health and health care. These methods derive from
several social sciences, but the concepts and knowledge from some
disciplinary traditions are underused. Here we describe the potential
contribution of anthropology, which is based on the empirical
comparison of particular societies. Anthropology has biological,
social, and cultural branches, but when applied to health issues it
most commonly relates to the social and cultural dimensions of
health, ill health, and medicine.1
| Summary points
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What is wrong with qualitative research? |
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Explaining qualitative research to health professionals has been an essential step in gaining acceptance of these techniques.2 However, findings from such research have been deemed "thin," "trite," and "banal."3 Concerns about standards and the need for particular types of evidence have led to quality control measures being recommended for qualitative health research (procedures such as multiple coding, purposive sampling, and software packages for text analysis). Imposing these measures, however, may constrain the direction and content of qualitative studies4 and legitimise substandard research, as the procedures recommended can be incorporated without enhancing the quality of the empirical work or the analysis.5
The main problem with the quality of qualitative research in health lies not in the methods but in the misguided separation of method from theory, of technique from the conceptual underpinnings.6 Qualitative research is in danger of being reduced to a limited set of methods that requires little theoretical expertise, no discipline based qualifications, and little training. Such an exclusive focus on method should be resisted, an argument that parallels an ongoing debate in epidemiology. 7 8 Multidisciplinary research is necessary for investigating, understanding, and improving health, but simply using qualitative methods does not constitute multidisciplinarity. What is needed is not narrower specification of technical operations or better quality control procedures. Instead, we need research methods that are less generic, less atheoretical, and less narrowly focused, together with a more widespread application of concepts and knowledge originating in source disciplines.
Specifically, we advocate more anthropology. In the United Kingdom, the
growing appreciation of anthropology as a contributory discipline to
health research and health care has not been matched by efforts to
incorporate its theoretical basis (sociology has a better established
history of application to health issues). Anthropology has a
distinctive approach to gathering and interpreting data that can
yield productive insights. These insights derive from underlying
assumptions about the nature of social reality and human action, as
well as using participant observation (anthropology's most
characteristic research strategy, which involves direct observation
while participating in the study community and includes other
methods, such as interviewing). 9
10 The following sections outline some basic
characteristics of an anthropological approach with particular value
for health research.
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"Our" knowledge and "their" beliefs |
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A core conceptual feature of anthropology is that what is "rational" is seen
to be socially and culturally specific and valid in its local
context. The salience of this view for understanding participants
(other than patients) and issues in health care is not generally
appreciated. Using a biomedical approach to problems in qualitative
health research results in a narrow investigation of "lay" beliefs
(and occasionally, practices), often with the intention of
translating these to professionals, to inform ways of improving
adherence to their interventions. An anthropological approach does
not assume that biomedical concepts and practices are both normative
and universal. Rather, it regards the knowledge and practice of
"experts" as locally variable
as
are the knowledge and practice of lay peopleand
it includes both within the boundaries of empirical inquiry. Some of
the most relevant anthropological research for evidence based health
care has considered differences between epidemiological, clinical,
and popular concepts of health and disease in particular contexts and
has thereby shed light on the implications of such distinctions for
appropriate practice in these settings. 11
12
A more general point is that qualitative research need not and should not be restricted to discerning and describing the ideas or practices of lay participants but should encompass those of professionals too. The study of health professionals' discourses and ideologies draws on a rich tradition in the social sciences of the social and cultural construction of biomedical knowledge. However, such study also links with a trend in medical anthropology that argues for the need to focus beyond clinical encounters between individuals to the power relations that produce and shape sickness (box 1). 13 14
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Actions speak as loud as words |
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As box 1 shows, what people (including health professionals) say can be different from what they think and do. This goes unrecognised in most health research that is designated "qualitative" but which in fact relies mainly or solely on interview based methods.16 The ambiguous relation between language and action fundamentally informs anthropological research using participant observation. Ideas about treating illness and lay explanatory models, for example, are shaped by contingent circumstances and forms of practical "reasoning in action" that are not always expressed orally, especially in one-off interviews, which tend to produce orthodox responses. Qualitative health research often fails to distinguish between normative statements (what people say should be the case), narrative reconstructions (biographically specific reinterpretation of what has happened in the past), and actual practices (what really happens). Anthropological practice ensures awareness of these distinctions even when interpreting interview data, by "situating" an interviewee's statements and the circumstances of the interview as far as possible in the broader context of that person's life. Participant observation may not always be feasible or appropriate given constraints on time, funding, and expertise, but the methodological lessons from anthropology are transferable. These lessons are that words cannot be taken at face value and that naturally arising informal situations involving talk and action are more useful than formal interviews in highlighting this.17
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Context specificity and comparative evidence |
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A key anthropological contribution to health research lies in its empirically based grasp of the context specific nature of social processes. This focus on the particular, which anthropology insists on through documenting the complex details of everyday life, provides an important corrective to misleading generalisations and abstractions that can, according to Singer, "grotesquely flatten" the diversity of different settings.18 However, analysis of specific situations or cases can also provide more general insights into the type of phenomenon under study, through anthropology's comparative approach. Comparing primary data with secondary evidence about similar issues (such as a particular health problem) in different settings can produce stronger analytical insights with greater potential generalisability. This is achieved through logical (rather than statistical) inferences that make use of relevant empirical knowledge and theoretical principles.19
Just as most health professionals specialise in particular diseases or body systems, so most medical anthropologists specialise in particular regions of the world or topics. This specialist knowledge is a major source of comparative evidence and, like clinically specific knowledge, it is informed by core disciplinary concepts (such as classification, ritual, and symbolism) and theoretical approaches (such as those of political economy or cultural interpretation) (box 2).
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Questioning categories |
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Qualitative methods of data collection have become popular in health research
mainly because they are seen to "reach the part other methods cannot"that
is, the views of ordinary people in the real world.23
Implicitly, the methods are a valuable but purely functional means of
gathering data to answer an initial research question. Hence the bulk
of qualitative work in, say, health services research, seeks to
discover (through semistructured interviews and/or focus group
discussions) people's views of a biomedically defined phenomenonfor
example, a disease or a health service. Although such research can
undoubtedly be useful in operational terms, genuinely new insights
are rarely obtained because this approach fails to incorporate a
central feature of social science researchthat
of reconfiguring the boundaries of the problem.
A particular way that anthropology achieves this is by its focus on
classification and meaning. This interest probably derives from
anthropology's development as a discipline associated with the
ethnographic study of "other" cultures, in which the nature and
boundaries of apparently basic categoriessuch
as family, religion, and medicinecould
not be presumed but required empirical investigation. Thus an
anthropological approach, rather than taking phenomenon x or y as a
given and investigating views of or beliefs about it, also
investigates the form and contents of the thing (x or y) itself.
Insights derive both from examining the nature and meanings of
apparently familiar categoriesfor
example, clinical terminologies, or health service constructs, such
as "patient satisfaction"and
from investigating how and why such categories are constructed and
maintained (box 3).
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Conclusion |
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Anthropology has its roots in a Western fascination with the "exotic" and the
associated attempts to make the strange comprehensible.
Anthropologists working in health settings today question the
apparently familiar so that health issues may be better understood
and health outcomes improved. This is a key promise of qualitative
research generally for health professionals. Anthropology can offer
relevant conceptual frameworks, substantive knowledge, and
methodological insights. These are essential for truly multidisciplinary
research, which extends beyond selective incorporation of specific
methods to encompass research conceptualisation and theoretical
synthesis. Funding sources, institutional support, and publication
requirements should reflect this.
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Footnotes |
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Funding: None.
Competing interests: HL is the chair and CMcK is a member of the Royal Anthropological Institute's medical committee, which advises the institute on medical anthropological matters and presents and promotes anthropological perspectives and understanding among non-anthropologists working in health related fields.
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References |
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(Accepted 14 February 2002)
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Collections under
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Research: descriptions |
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