Qualitative Health Research: A guide for the perplexed - Power

Part 4

So far in this weekly series on qualitative health research, I’ve talked about where QHR came from, and the important parts played by criticality and the ‘insider’ or emic perspective.

This week I want to look at power.

Perhaps one of the most important methodological decisions a qualitative health researcher will make in undertaking a piece of research is exactly how much theydesign, and how much is done with the people they are researching.

Perhaps not surprisingly then, attacking the traditional power of the quantitative researcher and the institutions they represent has led to some of the most radical technical developments in QHR and healthcare generally.

Traditionally, we gained knowledge of our patients, by subjecting them to a battery of tests and assessments that yielded objective resultsthat could be externally verified. (My italics here are to show how even the language we used privileged a quantitative, positivistic understanding of health.) This was harddata.

Softdata on the other hand (note how terms like ‘hard’ and ‘soft’ are gendered), was gathered through the patient interview. Here an expert, researcher, or clinician, would pose questions based on a study or clinical hypothesis, and test the patient’s variability of expression and meaning against standardised expectations.

So if the patient said “my knee hurts here when I bend it right back”, we would evaluate that as normal given their known pathology. And even if they said “my knee hurts when it rains”, we had the training to know that this was just folk wisdom and was clinically irrelevant.

We thought that that we were being objective because our tests were standardised and supposedly free form bias. But of course we were forgetting that it was only people on one side of the table that were defining what hypotheses needed to be tested, what questions should be asked, and what test measures were going to be used.

In the 1960s, social science researchers started challenging the latent power and privilege that came with being able to design every item on the research agenda, and led the way to what we now know as co-design.

Nowadays in QHR it is normal for research participants (not ‘subjects’, note) to help shape the study. They may be involved from the very beginning and help work out what questions need to be posed, or throughout, helping to design the study methods, and analyse the findings.

One of my Māori colleagues wanted to do a PhD looking at the neural mechanics of low back pain and took his idea to his tribe. They told him they weren’t interested in a study like that, and that there were far bigger problems facing their community. So he changed his project to examine pathways to wellness for Māori.

Another primary healthcare researcher I know studied local influenza pandemic preparedness among remote and isolated Canadian First Nations communities, using a community-based participatory research approach. I once asked her to talk about her research on a podcast and she refused, saying it wasn’t her data to share and she would need to gain permission first before publishing it.

Such attitudes directed at subverting the traditional power of the researcher are increasingly common now in QHR, and researchers are acutely aware that when they decide what questions to put on the questionnaire, or what kinds of answers a person can give, they are claiming all the power and imposing theirvalues on the research.

This kind of privilege is endemic in quantitative health research but it is never acknowledged, of course, because qualitative research is always ultimately about control - controlling ‘variables’, experimental conditions, and, in clinical work, controlling people.

Good qualitative researchers takes a completely different path, and researchers are always asking how they are positioned in the study, what power they are taking for themselves, and in what ways that runs counter to the spirit of giving voice to the other.