Qualitative health research 101

Part 2 - Criticality

Last week I offered an all too brief potted history of qualitative health research (QHR), in the hope that what follows makes more sense.
There are a lot of misconceptions about QHR. Hopefully these blogposts will help clarify some core principles, and inspire people to see how incredibly powerful and useful good quality QHR can be.

Now you could say the first principle I want to tackle today’s is so important that it almost defines the difference between what is true qualitative health research and what is a pale imitation. And that is criticality.

More than any other principle, good QHR has always been critical. It has challenged convention; held a mirror held up to society and disrupted our normal way of thinking and doing things. It has been a source of counter-narratives, radical new ideas and, sometimes, perplexing revelations.

Take the work of Dave Holmes, a nursing professor in America, for example. Dave’s research has asked how nurses can work on death row, and why gay men continue to have unprotected sex. He was pilloried by his nursing colleagues for deigning to ask the first question, and the answers to the second confounded most of the received wisdom about public health (you can find a link to more of Dave’s research here).

So QHR is a place for critical disruption. And because Western healthcare is so dominated by biomedicine, there is ample scope for disruptive critique.

Two of the main ways this has developed in QHR are through the humanistic ‘turn’ and the rise of critical/social theory.

The 1970s and 80s saw what was called a ‘humanistic turn’, or the ‘turn to the voice’, as researchers started asking people how they experienced health and illness, what it meant to have Parkinson’s disease or cancer. And from this a whole industry in interview and focus-group based QHR emerged.

Running on a parallel track were the critical and social theorist, who turned their attention to the structural conditions in society, things like gender, race and social class. These researchers tried to understand why it was that poor people suffered the worst health, and what discrimination did to women’s pain management. From this came a big focus on social theories, systems and structures.

Over the last 50 years, both of these have been big drivers of QHR. What they both share in common is an interest in power and truth. For the humanists, their interest is in each person’s unique experience of the world and the particular way we each make sense of health and illness. For the critical/social theorists, it’s about the invisible hand that shapes the course of our lives, individually and collectively: how certain truths are claimed, who gets to decide, and who benefits.

These approaches have had a big influence on the way QHR has been conducted over the last 50 years. Because identifying how people feel about being a physiotherapist isn’t something you can measure on a scale, (since any scale you design will always be about your beliefs), research methods have been about empowering research participants (not ‘subjects’ note), ‘owning’ your bias (not pretending to eliminate it), and giving voice to ‘the other’.

The critical/social theorists have looked for concealed drives, social forces, and discourses, in texts and in people’s everyday practices; searching for those things that we know are there (homophobia and racism, for instance), but are often invisible to the naked eye.

And always, QHR takes a ‘minoritarian’ position. In other words, it critiques whatever is being promoted as the conventional or dominant way of thinking. It is always looking for the voice not heard, the opinion not expressed, and the path not chosen, because if qualitative health researchers don’t investigate this stuff, who will?

So if you do come across some qualitative research in the future, and want to know whether it’s any good or not, don’t ask whether it meets a set of standard criteria for validity and reliability - that’s for quantitative researchers to worry about - ask whether it’s really being critical and shakes the foundations of what you thought you knew. Then it might pass the first test of being a good qualitative health research study.

Next week, the emic perspective.