Qualitative Methods and Health Policy Research
Murphy, Elizabeth and Dingwall, Robert
Aldine de Gruyter, New York
This text is aimed primarily at those who commission and use research for planning health services or informing policy, rather than research practitioners or those more interested in analysing health policy as a topic. However, it also serves well as a general overview of the uses, and perhaps more importantly, limitations of the main methodologies used in and issues raised by doing policy-orientated qualitative health research. Murphy and Dingwall take a resolutely ‘subtle realist’ approach, a sensible pragmatism that assumes reality is filtered through various lenses, but that it is none the less not infinitely malleable, and that it is, to an albeit limited extent, knowable. The key aim of research should be, they argue, not theory building, but producing credible, testable knowledge about that reality. Used rigorously, qualitative methods shed light on exactly how different social actors frame their understanding of health, health services, and health care organisations. Here, in their argument, lies the value of qualitative methods for health care planners, in that they can uncover the taken-for-granted practices that shape policy implementation, and identify the interactional structures that sustain behaviour in organisations. Thus qualitative methods offer an essential tool for developing relevant, feasible and appropriate interventions for health or health care organisations. This is a robust defence of qualitative research as science, in that it can and should proceed by contributing to building a cumulative evidence base, through even-handed (rather than overtly partisan) approaches, and with a commitment to rigorously testing emergent explanations.
In defending the subtle realist approach against other perspectives, particularly from those they term ‘the romantics’ and the strong social constructionists, Murphy and Dingwall are occasionally guilty of rather caricaturing the opposition, especially as the aims of many of the social scientists they critique under these headings are not those of contributing in any direct way to health policy, but of developing social theory or our understanding of how knowledge is produced and disseminated. It is also perhaps doubtful that many research commissioners or health managers are disenchanted with qualitative research because they have been exposed to the more radical epistemological readings from sociology journals. Apart from these rather unnecessary attacks on alternative qualitative perspectives that dominate the early chapters and pepper the rest, this book presents a sophisticated introduction to what methodological strategies such as interviews and observation can offer, and how good quality qualitative work can generate useful knowledge for health policy. They are pragmatic on the need, for instance, to treat interview data with caution: that care must be taken to account for the social and interactional context of its production, and that superficial readings of the ‘views’ of interviewees are impossible. The chapter on analysis is a very useful general overview of the issues qualitative researchers (should) consider in deriving categories from their data and determining the representativeness of data. There is an excellent chapter on sampling and selection, a topic often under-developed in methods texts, which discusses the need for theoretical justification whilst developing pragmatic sampling strategies. The examples, largely from the USA and the UK, including from the authors’ own extensive experience of qualitative research, are well chosen and explained in enough detail to make clear the links between methodological strategies employed in the research and the quality of findings. The chapter on ethics discusses the regulatory system of the USA in particular, but follows with a more general discussion of the problems of ethical review of qualitative research protocols, which are often not well suited to either the risk-benefit calculations or the checklists of more medical research orientated boards. The final chapter is on how to judge the quality of research, which returns to a refutation of the partisan and extreme relativist positions (that, for instance, research should be judged on its contribution to emancipation, or that it cannot be judged at all as there is no objective standpoint from which to judge it) to advance the subtle realist answer: that we can never be sure we have ‘the truth’ but, as in any other scientific discipline, we can be increasingly more confident that we have searched thoroughly for contradictory evidence, been open and transparent about our methods of data collection and analysis, and ensured we have dealt as objectively as possible with competing claims.
London School of Hygiene and Tropical Medicine