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

1. 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

2. 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?

3. 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.

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

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

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

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

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

9. 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?

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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