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
• 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
• 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?
Ease of Research Design
HARD
• Bench
EASY
• Humanities
• Philosophy
Sciences
• Physics
RCT
Psychometrics
Econometrics
Epidemiology Ethnography
SEM
Interpretability of Results
• Humanities
• Philosophy
HARD
Ethnography Epidemiology
SEM
EASY
• Bench
Sciences
• Physics
Psychometrics
Econometrics
RCT
Ease of Research Design
Harder to
Design
Easier to
Design
DATA COLLECTION
Focus
grps
Semi-strc
iv’s
Ethnography
Content
analysis
Grounded
theory
Ethnography
DATA ANALYSIS
Easier to
Interpret
Harder to
Interpret
Interpretability of Results
Producing qualitative research:
Intrusiveness, control & scalability
DATA COLLECTION
Focus
grps
Semi-strc
iv’s
Ethnography
HIGH
LOW
Content
analysis
Grounded
theory
DATA ANALYSIS
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*
• 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
• 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
1. Explore the sensitive: errors in surgery or
stigma in the ED (how disagreement about
appropriate care shapes decision-making)
2. Document the significant: how doctors are
trained or what is good care (when cancer
MD’s introduce issue of end of life care)
3. 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
•
•
•
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
•
•
•
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
•
•
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
• 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