dohan

Advances in Qualitative Methods in Health Research:Making the Case for Ethnography: 

Advances in Qualitative Methods in Health Research: Making the Case for Ethnography Daniel Dohan, Ph.D. Institute for Health Policy Studies & Dept. of Anthropology, History, & Social Medicine University of California, San Francisco

Overview: 

Overview What is ethnography? and how does it compare with other HSR and policy research methods? What are recent advances in ethnography? and in its potential role in policy and services research?

What is ethnography?A tool for social analysis: 

What is ethnography? A tool for social analysis Qualitative data Often from participant-observation (p-o) Findings, themes, ideas, and interpretations emerge holistically through iterative analysis Analysis guided by theoretical reflexivity Engagement with theory & focus on understanding separates ethnography from non-fiction writing. Commitment to self-reflexivity distinguishes ethnography from other qualitative research.

How does ethnography compare to other HSR and policy research methods?: 

How does ethnography compare to other HSR and policy research methods?

Ease of Research Design: 

Ease of Research Design Bench Sciences Physics Humanities Philosophy HARD EASY RCT Psychometrics Econometrics Epidemiology SEM Ethnography

Interpretability of Results: 

Interpretability of Results Bench Sciences Physics Humanities Philosophy HARD EASY RCT Psychometrics Econometrics Epidemiology SEM Ethnography

Ease of Research Design: 

Ease of Research Design Interpretability of Results Semi-strc iv’s Ethno- graphy Harder to Interpret Easier to Design Easier to Interpret Harder to Design Focus grps Grounded theory Ethno- graphy Content analysis DATA COLLECTION DATA ANALYSIS

Producing qualitative research: Intrusiveness, control & scalability: 

Producing qualitative research: Intrusiveness, control & scalability Semi-strc iv’s Ethno- graphy LOW HIGH Focus grps Grounded theory Ethno- graphy Content analysis DATA COLLECTION DATA ANALYSIS

What are recent advances in ethnography?: 

What are recent advances in ethnography? None, really; ethnography is an old craft Yet constantly contested and in turmoil Last big ‘innovation’ was post-modernism (1970s) —neither very recent nor much of an ‘advance.’ A more relevant question: what are recent developments in the potential role for ethnography in health policy and services research?

Advancing policy & practice via ethnographic understanding*: 

Advancing policy & practice via ethnographic understanding* Goal: “advancing” policy & practice Hazards of advancement: unintended consequences, ironies of good intentions, self-interest lurking behind altruism and the “public good” By surfacing, documenting and illuminating these hazards, ethnography may allow policy to focus less myopically on improvement, perfection, efficiency, justice, happiness, health, etc. * Bosk AcademyHealth ARM 2005

The need to deploy ethnography selectively: 

The need to deploy ethnography selectively As a research method, ethnography is time-consuming and inefficient Its findings are complex and highly contextualized, i.e. hard to digest And once digested, these findings may not be seen as good or uplifting news So, pick ethnographic cases (and battles) carefully

Case studies: 

Case studies Explore the sensitive: errors in surgery or stigma in the ED (how disagreement about appropriate care shapes decision-making) Document the significant: how doctors are trained or what is good care (when cancer MD’s introduce issue of end of life care) Elaborate the obvious: how we die or how clinical trials recruit (why E.H.R. reminder systems stop working)

Explore the sensitive:Stigma in the ED: 

Explore the sensitive: Stigma in the ED Case study of how social stigma arises in the emergency department Observation is only method available Stigma arises as a seemingly inevitable product of well-designed care processes and despite the individual good intentions of providers

Document the significant:What is good care: 

Document the significant: What is good care Comparative ethnography of what people consider “high quality care” in multiple cancer practices Document that no “right” definition exists and how definitions vary by role, place, & organization Potentially significant implications for quality reporting & pay for performance

Elaborate the “obvious”:How clinical trials recruit: 

Elaborate the “obvious”: How clinical trials recruit Clinical trials have elaborate protocols defining eligibility and institutionalized ethical standards to guide recruitment Requirements of minority inclusion is an opportunity to “lift the hood” via ethnography It turns out providers often can’t or don’t follow the protocols or standards The informal & interactional often structure recruitment processes

Conclusions: 

Conclusions Ethnography is a good tool to investigate a limited class of questions and problems This class includes several potential “growth areas” in health policy and services research, e.g. the meaning & measurement of quality, mechanisms underlying health disparities Including projects that embrace a critical and self-reflexive mode of social analysis may potentially advance the field generally