Murray, C.D. and Sixsmith, J. (2002) Qualitative health research via the internet: practical and methodological issues.
Health Informatics, 8(2), 11-28.
QUALITATIVE HEALTH RESEARCH VIA THE INTERNET:
PRACTICAL AND METHODOLOGICAL ISSUES
Craig D. Murray* and Judith Sixsmith
* Address for all correspondence:
Psychology
Liverpool Hope
Hope Park, Liverpool, L16 9JD, UK
Tel: +44 +151 291 3883
E-mail: murrayc@hope.ac.uk
1
QUALITATIVE HEALTH RESEARCH VIA THE INTERNET: PRACTICAL AND
METHODOLOGICAL ISSUES
ABSTRACT
Electronic mail (e-mail) has become a ubiquitous form of global communication. Much of this
discourse concerns the experience of health and illness. As it is stored and accessible via the
Internet, it is then available for qualitative analysis by health researchers. In particular, researchers
can employ document analysis methods using Internet communication such as e-mail posts and
archives. This paper outlines ways in which such research could proceed, as well as the advantages
and disadvantages of using documentary analysis of Internet communication in qualitative health
research.
Key Words: (1) e-mail, (2) documents, (3) health, (4) qualitative research.
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INTRODUCTION
Qualitative research strategies are becoming increasingly prevalent in the study of health [1,2]. With
the continued growth in computer use at home, in the workplace, and in higher educational
institutions, health researchers can conduct qualitative studies using electronic mail (e-mail) as a
methodological tool. There have been a number of health-related studies that have explored the use
of e-mail in focus groups [3] and as a structured and semi-structured interviewing medium [4,5].
These have shown how flexible and versatile e-mail can be within the interview process.
As well as the utility of e-mail for interviewing, there are other qualitative methods to which e-mail
is particularly amenable. E-mail forums, such as Internet discussion groups, can provide valuable
information through documentary analysis of naturally occurring discourse in posts and archives.
This paper explores the application of documentary analysis techniques to e-mail exchange as it
occurs asynchronously from person-to-groups.
Person-to-group e-mail communication involves individuals sending and receiving messages to and
from a variety of mailing lists, bulletin boards (BBs), and on-line newsgroups. People use such
forums as these to discuss common topics of interest, exchange information, and to form new social
relationships [6]. Health-related discussion groups form a large portion of the total number of these
Internet forums. By joining a mailing list, all posts can be automatically sent to the researcher’s email address, almost as instantaneously as the posts are made, and archived stores of past posts can
also be accessed.
Alternatively, many discussion groups can be accessed via the World Wide Web (WWW).
‘Google’ (http://www.google.com) is one free service that archives the communication of many
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Internet discussion groups going back as far as 1995, including the discussions of a variety of health
related groups. Posts and archives can then be used as 'documents' or 'texts' in a similar manner to
the way in which letters, diaries, or other textual materials might be used in research. This means
that researchers can analyse the naturally occurring unsolicited everyday talk (albeit conducted online) that Potter and Wetherell [7] suggest can help social scientists to understand social
phenomena.
With the ease of availability of such archives, an increasing number of health-related qualitative
analyses of Computer-Mediated Communication (CMC) postings are taking place. Two studies of
note are those of Nochi [8] and Winzelberg [9]. Nochi [8] used e-mail archives to explicate the
social experience of traumatic brain injury, while Winzelberg [9] conducted a discourse analysis of
posts made to an eating disorder electronic support group for possible recommendations to
clinicians. The 'non-reactive' nature of this documentary research source has been useful when
researching sensitive issues, such as studies on recovering addicts [10] and survivors of sexual
abuse [11]. These studies have derived their data from mailing lists without engaging participants in
the research process but have not clearly defined the methodological advantages and disadvantages
of using e-mail posts and archives.
The aim of this paper is to explore the use of documentary research on CMC for health related
research. In doing this, we will explicate the nature of e-mail posts and archives as documents and
address the advantages and disadvantages of this form of data. In addition, practical guidelines on
how to access e-mail documents will be detailed. By way of illustration, issues discussed will be
related to our own research on the experiences of prostheses users using e-mail forums.
USING E-MAIL POSTS AND ARCHIVES AS DOCUMENTS
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Much research has been conducted using documents as the prime source of qualitative information
[12,13]. Studies that have carried out different types of documentary data include analyses of
suicide notes [14], diaries of the daily lives of the unemployed [15] and looking for relationships via
personal columns in newspapers [16]. As these examples testify, the term 'documents' has referred
to a number of different textual sources [17].
E-mail posts and archives can similarly be considered as documents. As such, they can provide a
potential wealth of data on individuals, institutions and social groups. One exciting property of email documents is the fact that they are the record of (transpired) conversations between numerous
individuals, that is, the product of emergent conversation unsolicited by the researcher. In contrast,
traditional written documentary sources are often constructed specifically as written documents by
one or more people via many edits and from a particular viewpoint. As such, they tend to be much
more finished and polished than the evolving nature of computer discourse.
The interpretation of information contained in e-mails can begin with an analysis of the contents of
the header and signature files before going on to the substantive content of the message. As Baym
[18] notes, the header of a message often informs a recipient of the sender’s name and institution of
affiliation, which are useful indicators of gender, ethnicity, and, possibly, age. Similarly, 'Signature'
files (set segments of text which users can add to their message) can convey a person's social
position. For example, a person may include the letters 'PhD' to denote their academic status.
From a practical point of view, e-mail documents are readily available for textual analysis. The
holistic pre-transcribed nature of e-mail exchange [19] allows a variety of qualitative data analyses
to take place, including discourse analysis [20] grounded theory [21], or interpretative
phenomenological analysis [22]. Where thematic analysis is preferred, the nature of the e-mail
document affords easy import into many qualitative computer software packages (data e.g.
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NUDIST, and ETHNOGRAPH) and allows the researcher to code the data.
ADVANTAGES OF E-MAIL DOCUMENTARY ANALYSIS
There are a number of advantages of using e-mail posts and archives as research data in qualitative
health research. Here, the special circumstances that surround documentary analysis of e-mail
sources are highlighted, including issues of: accessibility; invisibility of researcher at the research
site; access to sensitive information; the non-contrived nature of e-mail discourse; and the holistic
universe of communications that e-mail archives provide.
Accessibility: Access to a diverse sample of material is a distinct advantage of documentary
analysis. This is particularly so with e-mail posts and archives. The fact that it is possible to
understand the experiences of people who would otherwise be unavailable (because of time and
space constraints, or health specific issues – see Fleitas [23]) expands the potential social and
cultural diversity of the data sample [24]. In our own research into the experiences of prostheses
wearers, the study of e-mail exchange gave us access to the experiences of prosthesis wearers across
the world, including participants from the USA, GB, Canada, Australia and the Netherlands.
Invisibility of the researcher: A common feature of documentary material is that it is
‘uncontaminated’ by the preconceptions, personal values and opinions of the researcher at the point
of their production, since it is produced for purposes other than research. This is also the case in the
study of e-mail forums, such as mailing lists and newsgroups, where it is also possible to analyse
ongoing and emergent communication between a number of individuals without the knowledge of
those being studied. The invisibility of the researcher at the site reduces the dangers of distorting
data [25] and this is especially important when considering ongoing social communication.
6
We do not intend to suggest that qualitative analysis is (or should be) a process of detached
observation, but that e-mail communication can often make the viewpoints and concerns of
communicators more salient than does participation in a formal research study. In support of this,
we would refer the reader to the work of Cornwell [26] who makes a distinction between ‘public’
and ‘private’ accounts of health and illness. ‘Public’ accounts are described as those given by
individuals when concerned that what they say is acceptable to other people. In contrast, ‘private’
accounts are those given as if to people like themselves, which involve using terms and making
assumptions normally shared by a particular social group. Therefore, the use of e-mail exchange in
computer forums can be considered valuable in obtaining talk that is not a response to interview
questions, but, rather, has been conducted prior to the research being formulated.
Sensitive topics: Sometimes research involves an understanding of highly sensitive personal
experiences, thoughts and feelings. For example, the qualitative exploration of elder sexual abuse
(the abuse of older people by, usually, family or carers) could face participants with a potentially
harrowing interview or questionnaire session. The value of conducting documentary research means
that people do not have to reveal their personal experiences to an embodied person (the researcher).
Thus, access to sensitive topics may be increased when conducting research with e-mail texts. In
addition, there is some evidence to suggest that revelations of a personal nature are encouraged on
the Internet [27], making this a potentially rich source of information on highly sensitive topics.
Non-contrived nature of e-mail discourse: It has been noted earlier that Potter and Wetherell [7]
suggest access to unsolicited, everyday talk can enrich our understandings of social phenomena. The
talk that is contained within e-mail archives has this characteristic. It is the product of naturally
occurring discussions that evolve over time and include many participants. This means that
researchers do not take an active part in forming the data, yet have available for their work the
7
concerns and experiences of ordinary people in their social context. Moreover, they have access to
the evolution of conversation and the development of attitudes, opinions, and values as e-mail
conversants share and argue about their social worlds.
A universe of communications: Analysing e-mail postings presents the researcher with a more
holistic picture of the universe of communications surrounding the research topic. With e-mail
archives the total sum of the social interaction that occurs within the group domain is available to
the researcher. In our research, as subscribed members of relevant lists, we were able to observe
evolving disputes, debates, and other social interaction on a daily basis.
DISADVANTAGES OF E-MAIL DOCUMENTARY ANALYSIS
All forms of documentary analysis are limited by a range of problems associated with the creation
and use of documents as data sources in research [13]. In this section, the disadvantages of using
documentary research are discussed in relation to the analysis of e-mail posts and archives. The key
problems here include: the selective deposit and survival of source material; the distance of
documents from the realities they represent; researcher selectivity; establishing the authenticity of
documents; and attention to group language and culture.
Selective deposit: Documents are constructed for particular purposes using selected information
(from their author’s perspective) and without the researcher’s aims and objectives in mind. This
means that they are a selective deposit of information that can be biased in certain ways [28]. In the
context of e-mail posts and archives, our concerns are the following: Firstly, the representative
nature of any information derived through computer-based discussion groups can be compromised
by the demographic structure of Internet users who are biased towards young, male, middle class
8
professionals [29]. This was apparent in our own research where, in contrast to the general
characteristics of prosthesis users as older persons who have lost a limb due to illness, our data
sample were predominantly young persons who had lost a limb due to trauma. Therefore, any
information drawn from such databases will at present tend to be biased towards the experiences of
these social groups, although the scale of this problem may decline as computer access is socially
widened.
Secondly, the social production of computer archives needs to be taken into account. E-mail
discussion groups are often maintained and guided by a moderator who has the power to include or
exclude any messages sent to the group. This means that the moderator’s vested interests can shape
the form and content of the discussion.
Thirdly, some e-mail users continually send messages to discussion forums, thereby heavily
influencing the nature of the debate conducted therein. Baym [18] notes one e-mail participant of a
group with an estimated size of 52,000 as being responsible for 1.5% of the total discussion.
Conversely, a sizable number of subscribers who have an interest in a forum do not reveal their own
experiences (otherwise known as ‘lurkers’). ‘Lurking’ may be the 'principal mode of participation'
in certain CMC systems [30], an issue that again implicates the representative nature of e-mail
documentary material sources.
This problem became evident during our own research. Some amputee members of a discussion
group refrained from making posts as a protest to the moderator’s decision to exclude ‘devotees’
(people who are sexually attracted to amputees). They became 'lurkers' on the group list as a means
of demonstrating their discontent. The fact that these group members were alienated diminished the
range of experiences, attitudes and opinions expressed within the group.
Clearly, the selective deposit of e-mail archive material needs to be considered carefully before
9
generalisations can be made from documentary analysis using these sources. This problem may be
minimised if documentary analysis is supplemented with interview methods on representative
populations. A multi-methods approach was a useful strategy in our own research where analysis of
group posting went hand in hand with face to face and e-mail interviews.
Distance and reality: Shipman [31] points out that, ‘All documents are distant from the reality that
they reflect’. As such they may have undergone a number of translations and interpretations before
being presented in documentary form. Throughout this process, mistakes and misinterpretations are
a hazard, yet are extremely difficult to detect within the document.
In relation to e-mail documentary material, the continuity of ongoing discussions are usually
preserved, so errors and misinterpretations can be more easily detected. One reported exception to
this is provided by Rheingold [27], who reports on a list where the archives were severely corrupted
when a participant removed their own communications over the previous two-year period. This left
the fabric of the archive in a precarious state, with huge gaps and discontinuities disrupting the
thread of discussions. Such practices frustrate researchers’ attempts to obtain a complete record of
contributions to a list, leaving the research with a very partial picture of events.
Researcher selectivity: The process of selecting and analysing documentary evidence can be
compromised when researchers pinpoint only those data that support their own ideas, models and
theories while discarding data to the contrary [31]. Archived e-mail documents are equally open to
this form of bias. Thus, it is necessary to report meticulously on the social production and
authenticity of the documents used, the reliability of the interpretations and the context and culture
within which they were produced. To this end, it is useful to reflect on the ways in which e-mail
archives are constructed. In this light, in the following issues of authenticity, language and culture
within e-mail documentary analysis are explicated.
10
Authenticity: Establishing the authenticity of documents (including who produced the document,
when and for what purpose) is a common problem in documentary research [27]. Establishing the
authenticity of e-mail postings and archives can sometimes be difficult. It is possible that an e-mail
account is being used by more than one person. For instance, an e-mail account in a female's name
may be used by her male partner, or children. In addition, CMC creates the potential for
communicators to present themselves in any way they wish, that is, inventing identities, because
they are not visible within the communication [32]. Clearly, this presents problems for the health
researcher in interpreting experiences, activities and events in terms of person characteristics such
as gender, age, marital status and sexuality [33].
Platt [34] proposed a number of techniques for evaluating document authenticity which are pertinent
to e-mail postings. The notion of inconsistency is of importance here. Differences in writing style
and lack of consistency in the author’s overall account can alert researchers to the
possibility
that different people have been involved in creating a document. One way of checking consistency
[cf. 27] is to examine different documents posted by the same author that might exist within
different electronic forums. A note of caution should be struck here, as it needs to be borne in mind
that people are not always consistent in their reported opinions or feelings [7]. Therefore, this
particular check on authenticity should be used carefully and critically.
Different versions of the ‘same’ document are also indicative of inauthenticity. In the construction
of e-mail posts, it is easy and popular practice to edit and incorporate others’ e-mail
communications within a ‘new’ message. Conventions exist for differentiating others’ messages
from new content, but if these conventions are not used, the real identity of the author(s) may be
hidden. The extended nature of e-mail contact, as well as the historical archives, means that
messages can be evaluated in terms of writing style, consistency of internal content and across posts
11
and forums to ensure that, as far as possible, document authenticity and author identity is
established.
Language and culture: Social groups often develop their own terms and forms of language and
expression that can act as a cohesive force within the group. A similar situation seems to develop
within e-mail discussion groups (e.g. our own researched communities referred to people without
leg amputations as ‘the bipeds’). As such, terms used in e-mail forums may have particular
meanings for the members of that community. Cultural norms, jokes, intentional mistakes and the
use of irony can take place within a common frame of reference between communicators [17].
Unless the researcher is privy to such common linguistic and cultural understandings,
misinterpretations may result.
One way of tackling this problem is to become familiar with a research community before formally
beginning any research [35]. This involves observing posts to a forum, witnessing exchanges, and
becoming ‘au fait’ with the group 'culture' before formally beginning the study. Reading through email archives is a useful way of achieving this. Monitoring language use and cultural context as they
develop organically within the discussion group can continue throughout the whole research
process.
The disadvantages of e-mail documentary analysis are similar in nature to any form of documentary
analysis. While it is possible for rigorous research to tackle some of these problems, it must be
acknowledged that qualitative documentary research conducted with e-mail health-related forums
may be compromised by social, cultural and practical constraints.
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ETHICAL CONSIDERATIONS
Conducting qualitative research on Internet communication implicates a number of ethical issues,
yet there is very little published material specifically on the ethical dilemmas that surround the use
of computer-mediated research [36,37]. This is particularly the case when considering ethical issues
that surround the use of publicly available email posts and archives. We have discussed these issue
in more depth elsewhere [38], but summarise here what we feel are the key areas of importance. We
do this in order to illustrate some of the ethical dilemmas that may face researchers interested in
conducting this form of health research, but it is not our aim (nor do we feel it possible) to provide
definitive and invariable solutions to these problems. Under consideration here are issues of
accessing voices, consent, privacy, anonymity, interpretation, and ownership of email research
material.
Firstly, we argue that health researchers have an ethical obligation to develop inclusive research
methods and techniques. For instance, one of the authors has recently been involved in interviewing
adults with acne via e-mail, as not all adults with facial imperfections are willing to participate in
face-to-face research. In this manner, the documentary analysis of Internet material can be seen as
an effective way of fulfilling our ethical obligations to help vulnerable people be heard.
A cornerstone of research ethics relates to consent. As applied to the study of Internet
communication, the issue is whether it is ethical to use such communication without their authors’
consent, or if consent should always be sought and obtained prior to use. Groups often operate
under their own rules regarding the public availability of postings, and for this reason we would
argue that consent to use such communication should be sought wherever possible. In our own
research, negotiated consent was achieved but was somewhat problematic. Permission to carry out
13
the research was sought for and granted by the moderator of the discussion groups. In addition,
when a valid e-mail address was available, individuals were contacted and asked for permission to
use their posts.
A respect for the privacy of persons also underpins ethical research. When email posts are made to
mailing lists, tens, hundreds or thousands of people are able to read those messages. In this sense,
they constitute material that is firmly in the public domain: however we argue that e-mail
communicators’ expectations of privacy differ according to the form of Internet discussion group,
and that these expectations should be considered seriously by health researchers. A member’s
expectations of privacy, for example, may differ markedly depending whether they are posting to an
academic forum, or an electronic support group.
A number of precautions can be taken in order to safeguard an individual’s anonymity when
conducting this form of health research. Any potentially identifying information contained within an
email message should be removed, which would ensure that personal anonymity is maintained. This
includes real names and any pseudonyms used by participants in their emails, as well as the names
and locations of lists and newsgroups from which the posts are taken.
Exactly who ‘owns’ any particular electronic post or archive is of ethical interest also. This issue is
complicated when researchers appropriate such material for their own use. For instance, the
communication that takes place between people who self-harm might be used to help devise
intervention strategies. Such an approach by health professionals could be perceived as oppressive
by the authors of those posts. The question then is whether researchers can disregard such a view.
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SUMMARY
The application of documentary analysis to e-mail posts and archives for health research purposes
has been explored. Practical concerns, such as locating research ‘sites’, data collection techniques,
and analysing and interpreting data have also been addressed. Moreover, while all documentary
analyses have advantages and disadvantages, we have examined them here with particular reference
to the special circumstances surrounding e-mail posts and archives. As such the advantages of using
e-mail documentary techniques are outlined below:
Ease of access to information widely available on the World Wide Web;
Downloading electronic documents constitutes an unobtrusive data collection technique;
Sensitive topics can be effectively and appropriately researched;
The nature of e-mailer’s unsolicited talk is non-contrived;
A more holistic picture of the communication around a research topic is provided.
Similarly, disadvantages of using e-mail posts and archives as documents have been identified:
The selective deposit and survival of information can provide only partial pictures;
E-mail documents are distanced from the reality they represent;
The researcher may select particular issues/concepts to support their interpretational framework;
Establishing the authenticity of electronic documents is sometimes problematic;
Understanding the language and culture of the e-mail group becomes necessary.
Finally we have summarized some of the ethical issues which researcher must address while
engaging in this research, namely accessing voices, consent, privacy, anonymity, interpretation, and
ownership of e-mail research material. Rather than providing definitive guidelines, our intention is
to alert researchers to potential problems, and to stimulate an active engagement with these issues.
15
Despite problems associated with documentary analysis of e-mail posts and archives, the benefits
for health research are clearly evident. As researchers we need to be mindful of how we use this
documentary data source, particularly concerning access to and interpretations of e-mail
information. This paper argues that there is a need to report on the social production and
authenticity of the e-mails used, as well as the validity of the researcher’s interpretations with
relation to the context and the culture within which such material is produced.
16
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