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Enfermería: Cuidados Humanizados

versão impressa ISSN 1688-8375versão On-line ISSN 2393-6606

Enfermería (Montevideo) vol.6 no.spe Montevideo out. 2017

http://dx.doi.org/10.22235/ech.v6iespecial.1445 

Articles

Qualitative research in Health Sciences:contributions from Ethnography

Natalie Figueredo Borda1 

1Universidad Católica del Uruguay, Montevideo, Uruguay. nafiguer@ucu.edu.uy

Qualitative research in the field of health

Qualitative research in the health sciences, and especially in nursing, is developing with increasing dynamism due to the humanistic nature of the discipline. Qualitative research is people-oriented; what they feel, how they perceive and, above all, the search for meaning. Identifying and understanding the meanings that people and communities confer on health and illness processes is vital as it could contribute to improvements in the quality of care as well as the relationship between health professionals and those who require care. Moreover, qualitative studies help to promote adherence to treatment and health measures, both individually and collectively 1.

It is crucial to conceive the person as a complete being from various perspectives to acquire a deeper understanding of the emotions, habits and behaviour of those seeking care and of the health professionals. Qualitative research in health, according to Morse, is a line of investigation that aims to explore health and illness as they are perceived by the people themselves rather than from the perspective of the researcher 2. Similarly, qualitative research is defined by its focus and methods. The focus is oriented towards the health/illness process and the methods are primarily inductive as they were initially conceived to gather information on the behaviour or perspectives of individuals or groups of people 2.

The ethnographic strategy

In accordance with Denzin, in the qualitative research process the investigator moves into the field in search of information, shifting from the field to the text and from the text to the reader through a complex process of reflection. This process guides the researcher and specifies the way of looking at and understanding reality in what is known as epistemological persuasion or strategy, in which ethnography can be found 3.

Ethnography was originally developed in the fields of anthropology and sociology as the direct study of individuals or groups of people during a certain period when participant observation or interviews are used to learn about social behaviour. Prestigious ethnographers such as Malinowski, Mead and Radcliffe-Brown belong to the field of anthropology 4. In their time, ethnographic research was widely focused on understanding societies considered to be primitive, savage or unknown 5. Ethnographic research studies involved a long-term commitment to recognition of the subjects and numerous ethnographers travelled long distances to become part of the target community for long periods. The goals were to be accepted among them, to learn the language of the participants, and to understand different ways of living 6. The methods used by ethnographers to collect information were interviews, participant observation and fieldwork. Through these methods, a deep understanding of the participants' daily environment was obtained, along with the social meanings associated with a particular culture 4.

Ethnographic studies are used to investigate population groups and allow observation of a specific social reality in a given context. The information-gathering strategy consists of participant and non-participant observation as well as in-depth interviews to achieve a description and holistic interpretation of the phenomenon under study 7. Phenomena associated with people's health/illness processes have been linked to social and cultural aspects, integrating methods into health sciences that belong almost exclusively to the areas of anthropologists and sociologists. As Amezcúa reports (2000), ethnographic research has been concerned with understanding behaviour and social relationships in health institutions, based on the work of researchers including Caudill, Taylor, Goffman and Comelles between the 1960's and 1980's 7. Similarly, the study of aspects related to the health of groups belonging to ethnic or racial minorities, socially disadvantaged populations and vulnerable groups has also been of interest to researchers in the health sciences 7.

Ethnography has penetrated phenomena associated with health care. Through transcultural nursing developed by Madeleine Leninger, nurses have the opportunity to provide culturally appropriate care to immigrants, refugees and people of different cultures. Transcultural nursing represents one of the most important shifts in care provision, consisting of a comprehensive approach to people which has allowed research in the health care environment of each individual in recovery, wellbeing or the end of life care 8.

Greater understanding of the relationships between health professionals and their patients is important for the health system. Knowledge of relationship dynamics allows policy-makers to offer adequate information that effectively approaches the needs of people requiring health care 9. Thus, the aim of this article is to establish ethnography as a valuable strategy for research in the health sciences and describe the main information-gathering methods.

Once this strategy was adopted by researchers from distinct disciplines in the field of health, it underwent considerable expansion and diversification as a methodology. In this growth period, according to O'Byrne, ethnography as a methodology produced knowledge that would prove critical in generating health-related interventions that were of great value to researchers from various fields. As a result, professionals became increasingly aware that the area of ethnographic research contains great variability with respect to important factors such as the duration and depth of fieldwork, the epistemological/ontological framework, and data collection 10. Consequently, a wide range of ethnographic methods came to be used in health sciences research 11. The fluid nature and steady growth of ethnography means that many other forms of ethnography are now being developed that can be used in distinct disciplines with variable nomenclatures, such as visual ethnography, which refers to information-gathering by the researcher, based on the arts and other fields 11.

Ethnographic typology

The methods par excellence of "classical" ethnography consist of participant observation and qualitative interviews. However, within the variety of techniques used to obtain data in ethnographic research, investigators can choose from a number of methods; participant observation, interviews, life stories, photographic records and video-recordings, among others. Through these methods, the researcher can offer a reliable representation of what the participants say in their own words and the ways in which they behave 12.

Reviews of relevant sources of information can identify the most common ethnographic methods widely used by investigators involved in health research. Among them, the following stand out: focused ethnography, critical ethnography, autoethnography, institutional ethnography and visual ethnography.

Focused ethnography

Focused ethnography is an applied research methodology used in investigation of culturally specific fields characterised by differentiation and fragmentation, as well as in small groups within a society 13. In accordance with Erickson, it constitutes an adaptation of traditional ethnography that approaches a phenomenon as experienced by a particular group in a certain context 14.

Use of this strategy allows information to be obtained on a special issue or shared experience and is particularly valuable when researching situations that represent a problem in specific contexts, such as between a small group of people and a majority in a large society 6)(15. This modality in ethnography permits understanding of diverse situations related to questions from the perspective of participants or from the emic point of view. This strategy has been used by nurses conducting research into abuse of elderly institutionalised individuals in long-term care facilities 16. It has also been employed in the study of various vulnerable ethnic groups in Latin America, where being female, indigenous and a sex-worker involves belonging to a high-risk group. In this framework, the perceptions of sex-workers and health professionals regarding HIV-AIDS prevention programmes are explored with the aim of identifying cultural aspects that could contribute to success or failure. In this regard, the study found that nurses can develop culturally appropriate interventions and HIV-AIDS prevention programmes, as well as promoting health in these social groups 17. Important features of focused ethnography are the extensive collection of data and their detailed analysis, shorter time in the field, with occasional participant observation and the use of advanced technologies 18. It is considered suitable for examining experiences within a culture or subculture in particular settings, such as outpatients or emergency rooms 19. Focused ethnography can be used by researchers to understand specific social aspects that affect distinct practice dimensions, allowing understanding of the interrelationship between people and their environments in the society in which they live 19.

Critical ethnography

Critical ethnography is a strategy that is not in opposition to conventional ethnography but does propose a more direct style of thinking about the relationships between knowledge, society and political action. As the most important purpose of critical ethnography is understanding a culture with the aim of triggering changes in society, the researcher takes the role of defender of the group under study 20. Researchers who support this strategy speak on behalf of the participants so that their feelings can be communicated. A clear instance of this would be the voice of a penitentiary culture. Critical ethnographers advocate reflexive inquiry as an important practice that allows researchers to explicitly detail their own subjective opinions that could influence their interpretation of data 20. Collection of information in this type of ethnography is the same as in the classical form. Through this typology, applied in a urban, pediatric rehabilitation centre in Canada, researchers McCabe and Holmes found that, even in an outpatient setting, time constraints, resource limitations and privacy concerns contribute to nurses' perceptions that the provision of sexual health care for young people with disabilities can be stressful and difficult as more acute medical issues usually take precedence 21. In addition, nurses in this context must respond to patients' needs with information on sexual health, balancing this with the family's beliefs, values and necessities 21.

Autoethnography

In autoethnographic research the investigators are committed to recognising their own experiences in wider social and cultural contexts. There must be a personal experience in order to understand oneself in the context of a culture seeking similarities or confronting personal experiences with others in the same environment. Autoethnography is centred on the actors' narratives, which are analysed in the context of a specific culture. Thus, the focus increases knowledge based on such experience 22. Both conventional and autoethnography compile data using the same collection methods, and data interpretation and verification are performed through the triangulation method 23. The work of Hassan and Jamaluddin describes, through autoethnography involving information accumulated over a decade, the experience of caring for a child with a cerebral injury by elderly caregivers and their sense of satisfaction with the rehabilitation process 24. Interpretation and evaluation of the positive and negative responses of other people contribute a crucial matrix to autoethnography, which proposes triangulation with various caregivers and other actors in the process 24.

Institutional ethnography

In this typology, interest centres on understanding the link between the institutions and people's experiences. Study focuses more on the institutions and their experiences than on those of people 25. The theoretical foundations of institutional ethnography are found in the works of Marx. This strategy begins with people, their work and the conditions in which they carry it out 26. Institutional ethnography understands that reproducible texts and visual materials have an important role in the coordination of social relationships. The texts, according to their location, allow procedures in one place to influence actions performed elsewhere. This allows researchers to track the translocal coordination of activities 27. These researchers engage in a data dialogue, which is developed during the initial research stage between the interviewer and the participant being observed by the researcher (25). Subsequently, the dialogue is between the researcher and the text, the transcription and the field notes to search for patterns and themes in the textual data. This strategy has been used in research to examine health-related aspects, such as understanding stress in nurses or diverse interventions in health care 28. Data collection and analytical methods correspond to those in conventional ethnography. Institutional ethnography has been used in mother-infant scenarios in Uganda, examining the social organisation of maternity care in a rural region in the north of the country, and confronting differences in the role of texts in the southern region 27. Based on this methodology, it was determined that in low-literacy contexts, the texts worked differently than in high-income countries 27. Identifying the texts and considering their role in the sequence of actions is essential for institutional ethnographers working to understand social organisation.

Visual ethnography

Ethnographers consider the use of photographic records as an important strategy in information-gathering. Guidelines designed to determine the richness of photographic data are lacking, although the content analysis of this information is subject to certain aspects such as context, time, who carries out the analysis and when the analysis takes place 29. The method of obtaining information has an advantage as it provides a solution to the ethical dilemma associated with intrusions into the participant's personal space; individuals have the autonomy to take their own photographs rather than rely on the researcher. Additionally, participant and researcher contribute to the analysis of the record, placing more emphasis on the voice of the participants in the analysis so that the information can be understood from the participants' perspective 26. The use of videos constitutes another important strategy in information collection and enables the researcher to understand particularities and behaviour in the participants' social and cultural activities 30. Moreover, the use of these information-gathering instruments ensures the capture of non-verbal data, and gestural and corporal information, which is important in the interpretation of participants' responses. The information informs the researcher when carrying out analysis of interviews and field notes. The strategy of using the dynamics of video recordings has been used in primary health care and in the operating theatre, allowing the development of a series of assessments and procedures that researchers can use to analyse the interaction between health professionals and patients. A video with methodological orientation is of unprecedented utility to research in the clinical area. It permits detailed observation of real situations in practice and provides an analytical resource to both the academic and professional spheres 30.

The use of this strategy was recognised as highly appropriate in a study whose aim was to explore the potential of visual ethnography as a methodology to improve the care of people with life-limiting illnesses in the hospital setting. It was concluded that the application of visual ethnography facilitates reflection on the care of people in an advanced stage of illness as it allows the care team to see itself and others who provide care in a different way. In addition, institutions can see their employees, patients and family members from another point of view, and consider video-reflective ethnography to be a potential methodology for the development of clinical practice 31.

Final reflections

Qualitative research now occupies a privileged position in the health sciences. The understanding of problems associated with the care of people can be approached using a wide methodology that covers all their dimensions, and which are complemented by traditional methods.

In ethnography studies, data collection is direct, mitigating the difficulty encountered when researchers and participants may not remember, or report on their actions in a biased manner. Furthermore, social groups are directly observed in their usual, everyday surroundings. This method is useful for understanding how people behave in real life, whether in settings where they receive health interventions, in the family or in social situations where health behaviour occurs.

These studies are very useful when new behavioural skills are implanted. This can be of great value when studying groups that are difficult to access such as drug addicts, prostitutes or sexual minorities since some health behaviours are only conducted in specific places 32)(33. Additionally, ethnography facilitates observation of the links among the various data on practice, facts and environments, rather than being collected in a fragmented manner as separate and unrelated elements 34.

The transformation of research in ethnography has led to the emergence of research strategies in the health domain, where the time element has been reduced. However, one of the inherent aspects of the methodology continues to be observation, a fundamental technique in the exploration of care practice, illness experiences, life experiences and many other phenomena. All these aspects are exposed to the rigour of scientific analysis.

The ethnographic focus entails interaction with the subject of study and knowledge from observation of the reality in its context. Consequently, in health settings, with health professionals and the relationships established there, understanding of the meaning and subjectivity that professionals give to their actions is reached. Thus, the approach constitutes a valuable research strategy for nursing and other health sciences.

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Received: June 10, 2017; Accepted: September 15, 2017

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