Abstract
Medical anthropology has existed since the early 1960s, and the encounters of ethnography in health research are recent. We will trace key historical markers and highlight several ethnographic studies in health research in this article. In particular, we are interested how aspects of classic ethnographic work have been taken up, and how the use has changed over time, as ethnographies, such as focused ethnographies and other forms of ethnography, have developed in health research. Understandings of culture have shifted and led to redefinitions of culture, and some key elements of ethnographic research have been lost. Ethnographies conducted in health research often do not focus on culture from a broader perspective; instead, the focus is on single health-related issues. Health researchers appear to spend less time in the field, time spent in the field is regarded as less important, and the importance of the context of field notes is underestimated.
Introduction
In this article, we provide an overview of how ethnography as a methodology evolved over time and how it is taken up in health research. The interest in taking up this challenge emerged from the desire to understand the progression of ethnography as a methodology in health research. We present ethnographic studies to examine how and to what extent ethnographies have been incorporated in health research. We provide a brief history of ethnography and its origin, with a focus on ethnographies that emerged in the field of anthropology in Europe and those that emerged in the era of ethnography in North America specifically, the Chicago School of Ethnography. Looking at this work provides insights on how contemporary forms of ethnographies differ. We then provide an introduction to five major contemporary forms of ethnography, which are extensively used by researches in the area of health research. Reviewing the range of contemporary forms ethnography indicates the shift that has occurred in ethnography over time. Further, it shows how difficult it has become to draw specific boundaries in regard to its use. Ethnography is changing and getting popularized in many health scholarships. We also explore future consideration and challenges pertaining to the use of ethnography in health research.
Ethnography in Health Research
The origin of ethnography in health research dates back to the development of a branch of anthropology known as medical anthropology. “Medical anthropology concerns its self with a wide variety of health-related issues, including the etiology of disease, the preventive measures that human members of sociocultural systems have constructed or devised to prevent the onset of disease, and the curative measures that they have created in their efforts to eradicate diseases or at least mitigate its consequences” (Baer, Singe, & Susser, 1997, p. vii). Ethnographic research conducted by anthropologists for many years has included descriptions about health beliefs and practices of different cultural groups (Hill, 1985). For example, Balikci (1963) provided an elaborate account of shamanic practices among the Netsilik. Moreover, Turner (1967) studied rituals for healing among the Ndembu tribe of Africa. Medical anthropologists have also suggested that researchers should incorporate both universal and culturally specific elements of clinical activities in their research (Kleinman, 1981). Brink (2015) who is trained as an anthropologist was one of the first nursing ethnographers engaged in classic ethnographic work.
Medical anthropology emerged in the 1950’s and it was only after World War II that most anthropologists focused directly on health research and issues related to patient and doctor relations (Baer et al., 1997). A better understanding of patient and heath professional relationships are significant for the healthcare system, since understanding the dynamics of those relations will allow policy makers to provide appropriate information that effectively addresses patients’ needs (Goodson & Vassar, 2011). Research conducted by medical anthropologist mainly focused on mental health, public health, biomedical ethics, health improvement, and nursing and global health (Baer et al., 1997). In addition, medical anthropologist recommended that thorough knowledge acquired by doctors about patients’ perception of an illness will enable them to deliver better quality care (Kleinman, 1981).
A huge change in the etiology of diseases and its treatments was also observed at the same time. Hence, traditional medical practices were considered no longer useful in treating modern diseases such as heart-related problems, cancer, and other injuries (Hill, 1985). New approaches to research and treatments were needed to cure and prevent such diseases. Kleinman was a well-known medical anthropologist in the 1970s. He promoted the need for developing interdisciplinary research teams which collaborate to improve health care (Kleinman, 1981).
In recent years, the focus of many ethnographic researchers and anthropologists has shifted from exploring traditional cultural medical practices to technologically advanced medicine in clinical setting (Geest & Finkler, 2004). In the past three decades, ethnographic studies published in health research have increased, and ethnographic work has become popular among health researchers (O’Byrne, 2012). Cook (2005) has attributed the increased demand of ethnography in health research to the congruency that exists between the two. In health research, the key focus is to understand meanings and patients’ experiences of their illness (Morse, 2010). Therefore, researchers suggest that some features (experiences of patients and meanings associated with patients’ medical conditions) of the clinical setting are best suited to be examined through methods of data collection such as participant observation common in ethnographic research (Rice & Ezzy, 1999). Ethnography allows researchers to gain deeper cultural knowledge about health and illness (Hodgson, 2000).
The field of medical anthropology has always been rich in ethnographic studies (Bloor, 2002). For instance, there are a vast number of landmark medical ethnographies, including Boys in White conducted by Becker, Geer, Hughes, and Strauss (1961). This study particularly focused on understanding the culture of medical students and their day-to-day lives. Another study conducted by Goffman (1961) known as Asylums captured the lives and experiences of people in a mental institution. A study conducted by Buckingham, Lack, Mount, MacLean, and Collins (1976) focused on the care provided to dying patients in the general surgical ward/palliative care unit. Buckingham and colleagues explored the topic of family needs using participant observation. These highlighted studies show that ethnography has been a significant methodology in deepening our understanding of health-related issues.
Historical Development
The term ethnography emerged from an ancient Greek word for “folks” (ethnos) and “written representation” (graphe; Almagor & Skinner, 2013; Jones, 2010). Ethnography as a field developed at the end of the 19th century and the beginning of the 20th century (Brewer, 2000); it arose primarily in the era of western colonization. In general, ethnography refers to a “formal description of foreign people, their habits, and customs” (Almagor & Skinner, 2013, p.2).
Major ethnographic development was witnessed in Europe, particularly Britain, which included the development of classic ethnographies within the discipline of anthropology (Macdonald, 2002). Renowned ethnographers such as Malinowski, Mead, and Radcliffe-Brown belonged to the field of anthropology (Brewer, 2000). In this era, ethnographic research focused extensively on understanding “other,” “primitive,” “lower culture,” and “savage” societies (Taylor, 2002; Wolcott, 1999), or an unfamiliar culture. The scope of the research was generally vast and required a long-term commitment to gain an insider’s perspective (Richards & Morse, 2007). Many ethnographers travelled long distances where they spent a great deal of time learning about participants’ language, understanding unfamiliar ways of life, and most important to be accepted by participants’ communities. The primary methods used by ethnographers were interviews, participant observation, and fieldwork to gain an in-depth understanding of their participant’s everyday environment and the social meanings attached with being part of a particular culture (Brewer, 2000).
Ethnographers in North America, specifically the work of researchers at the Chicago School of Ethnography (Brewer, 2000; Picken, 2013), contributed and advanced the field of ethnography. It is significant to note that similar to classic ethnographers, the Chicago school researchers were also interested in understanding the other. However, the focus of researchers from the Chicago school was to examine “the urban ‘other’ where as anthropologist focused on colonial non-European ‘other’” (Jones, 2010, p.21). Culture is a vital concept to the development of ethnographic anthropology. It is vital to note that there was distinction in how culture was viewed in different disciplines. For instance, sociological and anthropological ethnography have common characteristics but mainly come from distinct traditions. The main subject of investigation in the sociological and anthropological ethnography were groups of people in contrast to psychological and medical research that took the individual as the unit of analysis. Interestingly health researchers using ethnography often have had a community orientation.
In the beginning, ethnographers were involved in studying underprivileged sections (homeless population, drug dealers, and immigrants) of industrialized cities (Brewer, 2000). A wide range of ethnographic methods were used (Deegan, 2002). For instance, Shaw’s multiples studies on Juvenile delinquency in the 1930s exemplified the diversified nature of methods that were used, which included life history or biographical methods. Furthermore, Blumenthal’s (1932) study of small town staff used participant observation methods (Deegan, 2002). Overall, it is evident that the majority of researchers from the Chicago School valued triangulated data, indicating the fact that ethnographies were methodologically more rigorous. In 1990, Brink, one of the first ethnographers in nursing, raised issues of reliability and validity in ethnographic health research studies.
A large number of ethnographies that emerged in the initial stage of ethnographic development in Europe and North America were male oriented (Ardener, 1972; Macdonald, 2002: Jones, 2010). Ethnographers predominately focused on observing male subjects and studied cultures from a single standpoint (Ardener, 1972; Macdonald, 2002). It was only in the 1970’s that critics of traditional ethnographic work in anthropology emerged (Macdonald, 2002). The two important areas that were under criticism “included anthropology of women and ethnographic reflectivity” (Macdonald, 2002, p.68). The male centric nature of traditional ethnographic research led most critics to question the universality of their ethnographic work (Macdonald, 2002). In an influential study entitled Women of Value, Men of Renown Weiner (1976) examined the position of women in the economic system of Trobriand Island. Weiner’s findings suggested that women played a significant role in their communities’ economics activities. This study extended the work by Malinowski (1922), whose account of the economic system of Trobriand Island was an incomplete representation.
Often ethnographer reports were based on representing only small segment of the community (e.g., males). However, the reports that were generated by anthropologist were generalized and were shown to be representative of all the members of a community. Such representational practices resulted in creating silences of some voices, more specifically for woman participants. Following the moment of criticism in the field of ethnography, women, whose voices were silenced in the works of anthropologist, were given more importance. It is vital to note that it was not only women participants whose voices were silent but also those of female ethnographers. Women’s work and their contribution in the field was disregarded and devalued. It was evident that Park an eminent ethnographer of this era, who trained many ethnographers, considered the work of a woman ethnographer Donovan (The saleslady) as not sufficiently academic (Deegan, 2002). Further, Margaret Mead’s work entitled as the “Coming of Age in Samoa” was evidence which indicated that regardless of androcentric nature of the ethnographic work, women continued to contribute to greater extent to the field of ethnography (1928).
In the following section, we will discuss contemporary forms of ethnography that emerged in health research. We want to identify how ethnography has evolved and what might be some of the most important transitions that ethnographers have made in the health sciences. It is important to bear in mind that the contemporary forms of ethnography that we have listed in Table 1 and the studies (examples) in Table 2 are based on an overview of health research and not a systematic review of literature. Our goal was not to conduct a review rather critically examine the exiting literature to make claims about the progression ethnographic research has made in the health sciences. The typology in the Table 1 was created based on two main criteria: (1) we incorporated ethnography designs used in health research studies that were true to contemporary ethnographic forms and (2) our focus was on health research alone hence, we did not incorporate exiting contemporary from of ethnography that may be used by researchers in different disciplines. Further, we do not claim that the typology of different forms of ethnography (Table 1) is definitive, as fluid and ever growing nature of ethnography continuous. There are many other forms of ethnography that may be used by the researchers in different disciplines with alternative names (e.g., visual ethnography may be referred to as arts-based ethnography by researcher in other discipline).
Contemporary Forms of Ethnography.
Exemplary in Ethnographies in Health Research.
Note. ICU = intensive care unit; PICU = pediatric intensive care unit.
Contemporary Forms of Ethnography
As noted by Boyle (1994), the “doing ethnography” has gone through an extensive evolution and has changed significantly. The fact that ethnography has been used by researchers in different disciplines such as medicine, business, public health, and nursing (Hughes, 1992) and has been growing in popularity is a noteworthy factor for the diversification of ethnography as a methodology (Boyle, 1994). In addition, O’Byrne (2012) highlighted that ethnography as methodology produced knowledge that was critical for generating health-related interventions, which were of significant value to researchers from different disciplines; he concluded that “ethnography becomes a disciplinary and bio-political tool” (p.866) in public health. Furthermore, the field of ethnographic research is diverse and much divided about important factors such as the length and depth of fieldwork, the epistemological/ontological frame work, and data collection (see Table 1 for a comparison of different forms of ethnography). Hence, it is not surprising that a wide range of ethnographic forms are used in health research. In this section, we show the five most common forms of ethnography that have been widely used by researchers involved in health research. We want to emphasize here that we only looked at the most commonly used forms.
Focused Ethnography
Numerous forms of ethnographic practices have been developed including focused ethnography. Focused ethnography is a response to individual’s lives that are “socially and culturally highly fragmented and differentiated” (Knoblauch, 2005, p.1); thus, it is the study of shared experiences of a more confined, predetermined phenomenon. Important features of focused ethnographies include intense data collection and data analysis, less time spent in the field, occasional participant observation, and technologically advanced (Higginbottom, Pillay, & Boadu, 2013; Muecke, 1994; Knoblauch, 2005). According to Cruz and Higginbottom (2013), focused ethnography is best suited to examine experiences within a culture or a subculture in particular settings, such as emergency departments, outpatient clinics, or trauma units, as opposed to investigating an entire hospital culture or a community. Furthermore, focused ethnography is pragmatic in nature and offers a proficient means of collecting specific data that is well suited for health care professionals and care providers (Higginbottom et al., 2013; Muecke, 1994). In addition, focused ethnography emphasizes the understanding of participants’ perspective (emic or insider perspective). However, emic perspectives are understood from a specific point of view in regard to a culture (Knoblauch, 2005). In comparison, conventional ethnographies emphasize long-term fieldwork, prolonged participant observation, and the involvement of larger unknown communities (Atkinson & Hammersley, 1998; Hammersley & Atkinson, 1995; Picken, 2013).
Critical Ethnography
Critical ethnography “is a way of applying a subversive worldview to the conventional logic of cultural inquiry. It does not stand in opposition to conventional ethnography. Instead, it offers a more direct style of thinking about the relationships among knowledge, society and political action” (Thomas, 1993, p. vii). There are numerous similarities between critical ethnography and conventional ethnographies in terms of how data are collected, methods used to collect data, and the interpretation of data (Thomas, 1993). It is equally important to underline the distinct features of critical ethnography and conventional ethnography. The central question examined by critical ethnographers is “what could be,” whereas conventional ethnographers mainly examine “what is” (Carspecken, 1996; Thomas, 1993). The type of questions examined by critical ethnographers is engraved with political purpose, understanding the depth of social problems and the goal to eradicate power imbalances in a particular culture (Madison, 2012). The main goal of critical ethnography is to understand a culture with the intent to bring about change in the society. Whereas, in conventional ethnography, the main goal is to merely acquire understanding of a particular culture (Thomas, 1993). In critical ethnography, the researcher plays a role of advocate for the population under study. As Thomas (1993) noted, critical ethnographers often speak on behalf of participants to ensure that participant voices were heard. Critical ethnographers advocate for reflexivity as an important practice that allows researchers to explicitly layout their subjective opinions that might influence their data interpretation (Lincoln & Guba, 1985; Thomas, 1993). For critical ethnographers, the “dynamic and mutual influence of ethnographer and research field on each other is referred to by the term reflexivity” (Muecke, 1994, p. 194).
Autoethnography
Historically, autoethnography emerged from the field of anthropology. “Autoethnography shares the storytelling feature with other genres of self-narrative but transcends mere narration of self to engage in the cultural analysis and interpretation” (Chang, 2008, p. 43). A vivid distinction between conventional ethnographers and autoethnographers are presented in the excerpt given subsequently: We [autoethnographers] think of ethnography as a journey; they [analytical ethnographers] think of it as a destination. Caring and empathizing is for us [autoethnographers] what abstracting and controlling is for them [analytical ethnographers]. We [autoethnographers] want to dwell in the flux of lived experience; they [analytical ethnographers] want to appropriate lived experience for the purpose of abstracting something they call knowledge or theory (Ellis & Bochner, 2006, p. 431).
The existence of personal stories or experiences is essential in understanding oneself in the context of a culture by comparing personal experiences with others in the same domain, which increases learning from such experience (Ellis, 2004). Autoethnographers write about the most distinct incidences they encounter; experiences that were profound and had life changing meaning (Ellis, Adams, & Bochner, 2011). Autoethnographers, on the contrary, mainly evaluate their significant experiences that are related and linked to a culture. While doing so, autoethnographers must connect these to experiences by others in a similar cultural context (Ellis et al., 2011). There are several intersections between conventional ethnography and autoethnography. For example, both examine how data are collected, the methods of data collection, data interpretation as well as verification of data through the method of “triangulation” (Chang, 2008). In sum, the focus in the autoethnography is on the personal narratives of people, which are examined in a particular cultural context.
Institutional Ethnography
In institutional ethnography, the focus is on understanding the link between institutions and peoples’ experiences. “Institutional ethnography is a method of inquiry that investigates how everyday experiences are coordinated by work done with texts in organizations” (Walby, 2013, p. 141). Therefore it is not the people themselves who are the object of inquiry; rather the institution and their experiences are the target of the investigation (Smith, 2005). Guiding questions that are of interest to an institutional ethnographer are “how does this happen as it does? How are these relations organized?” (Campbell & Gregor, 2002, p. 7). The major theoretical underpinnings emerge from Marx’s work and feminist discourses; institutional ethnography also begins with people, their work, and the conditions in which they work (Given, 2008). The rationale behind examining texts is to get an in-depth understanding of how these texts impact the working process of individuals and how it coordinates action among institutions (Mills, Durepos, & Wiebe, 2010). Institutional ethnographers engage in a phenomenon known as “data dialogue.” Data dialogues occur at two levels (Smith, 2005): The initial stage occurs between interviewer and the participant who is being observed by the researcher, at the second level, the dialogue is between the researcher and the text (the transcript/ field notes).
The concept of data dialogue is parallel to the methods of data collection and data analysis used by conventional ethnographers. Once the data are collected, the researcher then immerses themselves in the text (transcripts /field notes) to look for patterns and themes in their textual data. In explaining the ontological underpinnings of institutional ethnography, Smith (2005) proposed that no individual can be objective since we live in a world of experiences. Smith does not view subjective experiences as undesirable biases, instead, she sees them as vital in shaping our understanding of experiences (Slade, 2010). Institutional ethnography has been used in health research to explore a wide range of health-related issues ranging from understanding nurses’ stress (McGibbon, Peter, & Gallop, 2010) to understanding the production of health care disparities (Sinding, 2010).
Visual Ethnography
During the 1960s to the1980s, there was some skepticism expressed by researchers in terms of “whether visual images and recordings could usefully support the observational project of social science” (Pink, 2013, p.19). The criticism of visual data was based on its lack of meeting standard requirements of social sciences. This was primarily because it was open-ended, unstructured, unsystematic, and not objective in nature (Brewer, 2000; Pink, 2013); some have refuted critics by stating that only subjective methods are capable of capturing meanings that shape the everyday lives of people (Hammersley & Atkinson, 1995).
Photographs have been utilized by ethnographers as a major method for data collection, with cameras being the most important element of the “tool kit” of ethnographers in the 1920s (Pink, 2007). There is no set criterion to determine whether a photograph is ethnographically rich or poor. The analysis of photographic content depends on a number of factors including context, time, who is analyzing them, and when they are being analyzed (Pink, 2013). These aspects are subjective and ambiguous; ambiguity shall not be viewed as a lax quality “rather, [it is viewed as] multiple meanings negotiated by viewers [which] can be mined for the rich data they yield” (Schwartz, 1989, p.122). Recently, Photovoice has gained popularity among ethnographers. It allows participants the flexibility and privacy to photograph certain experiences of their life. This technique could serve two important purposes: first, it assists in resolving the ethical dilemma associated with disrupting a participant’s private space, since the participants are free to photograph themselves rather than a researcher. Second, participants and researchers are actively involved in analyzing the photos but with more importance given to the participants’ analysis, which will help understand the photographs from the participant’s perceptive (Given, 2008).
The use of videos as a vital source of data collection was popularized in the 1980s (Given, 2008) after the technological revolution that gave rise to complex and intricate visual methods (Lomax & Casey, 1998). As Pink (2007) proposed, it is now commonly recognized that videos are not only used to record data but “as a medium through which ethnographic knowledge is created” (p.96). Videos are significant in analyzing the data by enabling an ethnographer to understand fine details about social and cultural aspects of participants’ activities (Heath, Luff, & Sanchex, 2007). Furthermore, the use of videotaping helps ethnographers in capturing the broader array of behavioral data, which is difficult to collect via traditional methods. Nonverbal data such as facial expressions are crucial for interpretation of informants’ responses and they can also crystallize the analysis of interviews and field notes. Contextual knowledge is essential in enhancing our understanding (Knoblauch & Schnettler, 2012). Yet, disadvantages of audiovisual methods of data collection remain. Technologically advanced methods of data collection such as cameras are costly and easily noticed (Nastasi, 1999).
Looking Across Ethnographic Approaches and Research Studies
We have developed two tables for this article. In Table 1, we highlight some of the main components of the five main forms of ethnography that have been of most interest to researchers in health research. From Table 1, it is evident that the main epistemological and ontological underpinnings of each from of ethnography are distinct; hence, making them diverse in nature. With such diversification, it is not surprising that there is greater variability in how different methods of data collection are tailored to the basic purpose of theses ethnographic forms. It is remarkable to note that the modern forms of ethnographies incorporate the basic methods of data collection (interviews, participant observation, and field notes). In terms of functionality, these methods differ, because the methods are to a great extent based on the form and main purposes of the type of ethnography a researcher wishes to use. For example, in focused ethnography, the use of participant observation is of short duration and time intensive and in autoethnography participant observation might be entirely over looked. Further, additional approaches such as visual ethnography and institutional ethnography have resulted in enriching the methods of data collection in ethnographic works in health research. For example, in institutional ethnography, there is textual analysis, and in visual ethnography, there are photovoice or images of everyday life that are the main sources of data collection. In Table 2, we provide examples of ethnographies in health research. We have selected these studies to show examples of each form of ethnography used in health research. Studies presented in this table were selected based on the methods of data collection described to provide a comprehensive picture of how different forms of ethnography are incorporated in current health research. The examples of this table also highlight that there is tremendous variability and flexibility in how the methods of data collection can be used. This flexibility might be viewed as a positive feature, because it allows the researcher to use the best method of data collection for their studies. Alternatively, it could also be argued that there is lack of standardized methods of data collection due to the versatile nature of this methodology. From the studies in Table 2, it is apparent that diverse approaches to data collection are used in health research. Each of these approaches involves different techniques. With technological development, studies in health research are depending on modern techniques as means of data collection. Recent studies in health research have used a wide range of advance techniques to collect data such as DVD, video recordings (Liu, Manias, & Gerdtz, 2012; McCabe & Holmes, 2013), and picture/snapshots (Gates, Lackey, & Brown, 2001). Further, journal entries (White & Seibold, 2008), written reflections of the participants’ experiences (Bright, Boland, Rutherford, Kayes, & McPherson, 2012), and reflexive focus groups (Liu et al., 2012) are being used as a major sources of data collection in ethnographic health research studies. The use of multiple methods enhances the trustworthiness (i.e., accuracy) of the data collected and guides the ethnographer in making decisions as the study progresses. It is critical to note that the use of the above-mentioned methods for ethnographic data collection was not only present in the works of classic ethnographers such as Malinowski but also continues to be utilized in health research.
Future Considerations/Challenges
Blurring of the Field
Fieldwork is an important element of ethnographic research. It is apparent that ethnography as a methodology has progressed and continues to grow. However, with the evolution of ethnography, the dynamic of fieldwork has changed extensively. Researchers in health disciplines do not divulge much about their fieldwork. Vital questions that are often undermined in ethnographic health research about the fieldwork are: how was the fieldwork conducted? What part of the data comes from their field notes? Why and what elements of their research was captured in their fieldwork, which was not achieved through their interviews? As pointed out by Brink in 1990, these questions are related to issues of reliability and validity.
The majority of the studies noted in Table 2 do not reveal much about the field aspects that were undertaken. This might be indicative of the fact that the value of fieldwork is not acknowledged in existing health studies (Bright et al., 2012; Braaf, Manias, & Riley, 2014; Carroll, Iedema, & Kerridge, 2008; Gustafsson, Kristensson, Holst, Willman, & Bohman, 2013). From the studies in Table 2, it becomes apparent that health researchers use the most convenient form of ethnography to explore a particular phenomenon. For instance, focused ethnography used in heath research studies (Gagnon, Carnevale, Mehta, Rousseau, & Stewart, 2013) is quick and convenient in design, and autoethnographic design (White & Siebold, 2008) does often not integrate long and complicated fieldwork at all. This may be viewed as a positive aspect of modern ethnography, as ethnography is becoming more manageable as a methodology, which may reflect modern research standards and demands. It is evident that new forms of ethnographies used in health research studies (such as Bright et al., 2012) do not incorporate a wide range of conventional ethnographic features and often result in less time spent in the field. Furthermore, ethnographers are no longer in surroundings that are neither geographically distant nor unknown. They often engage in narrow research topics conducted in familiar surroundings and issues. Time spent in the field is of great importance in ethnographic research and the length of time spent in the field will help the researcher understand their participant’s life from a wider range of angles (Boyle, 1994). Nevertheless, this aspect of fieldwork is often disregarded in the current literature. Perhaps a reminder of the era of “armchair anthropologists” who worked simply by re-evaluating text books and other archives to understand distinct and unknown cultures in a more convenient manner.
Context
Another issue that is critical in ethnographic work is the context and contextual analysis. Context provides a comprehensive picture of particular issues that are being investigated. It is vital information to correctly analyze the data collected through interviews and observations. To illustrate this point in our own study [unpublished, study ongoing] of parents who have a child with traumatic brain injury, we realize that our potential data and the recommendations we intend to produce will only make sense if presented in the light of extensive contextual background information. “In fact, without contextualization, interpretation of the specialized finding can be dangerously narrow and unethical (the high tolerance of certain cultural group to pain stimuli comes to mind as an example)” (Thorne, 1991, p.182). Solid contextualization will avoid misrepresentation of the participant’s meanings and purposes. We believe that ethnographic work conducted in health research must focus more on contextual components of the data. Researchers who conduct ethnographies in health research might not explicitly state the context in which their data were analyzed (Braaf et al., 2014; Bright et al., 2012; Carroll et al., 2008; Kidd & Finlayson, 2010). Researchers also avoid elaborating on the important contextual question such as what was the context in which the participant made a statement about the phenomenon under study? Why did they make the statement? and What is the main contextual base for driving the study’s themes and sub themes? While researchers provide quotes taken directly from the original data and provide a direct analysis of their quotes, they often avoid contextual background information. Health researchers who conduct ethnographies need to focus on contextual data as much as they focus on what was said.
Missing Depth of Ontological/Epistemological Underpinnings
We have examined a large body of literature in health research which indicates that qualitative studies conducted in health research have overlooked the importance of the ontological and epistemological underpinnings (Braaf et al., 2014; Bright et al., 2012; Carroll et al., 2008; Kidd & Finlayson, 2010; McCabe & Holmes, 2013; Pino, Soriano, & Higginbottom, 2013). Epistemology is the theory of understanding. It is focused on the “relation between the knower and what can be known” (Guba & Lincoln, 1994, p.108). Ontology focuses on the nature of reality by exploring questions such as what is a reality and how does it function? (Guba & Lincoln, 1994). Therefore, we recommend that researchers pay more attention to elaborating on ontological and epistemological foundation of their research methods. We note that there is a lack of balance between background and methodology in published ethnographic studies. Researchers should be explicit about their ontological and epistemological stance to better understand the perspective from which they explore and find answers for their research question. Many authors claim that their study is a “focused ethnography,” even though methodological background information commonly focuses on “qualitative methods” or “ethnography,” in a general manner (Gustafsson et al., 2013; Magilvy, McMahon, Bachman, Roark, & Evenson, 1987; Pino et al., 2013). In conclusion, we recommend that health researchers conducting ethnography be more explicit in detailing their “tradition and paradigm of inquiry” (O’Byrne, 2007, p. 1389).
Redefining Culture
Since the evolution of ethnography, the meaning of culture has changed. Traditionally, ethnographers explored culture in a broader context. They learned about ethnicity, religious activities, and languages of entirely different communities. Intercultural differences (differences within cultures; Fetterman, 2010) were crucial factors for ethnographers. More recently, ethnographers have attended more closely to exploring specific cultures within a border range of cultures or intracultural diversity (examination subcultures with culture; Fetterman, 2010). Similarly, existing ethnographic health research listed in Table 2 (Braaf et al., 2014; Bright et al., 2012; Carroll et al., 2008; Gustafsson et al., 2013) does not focus on culture from a border perspective. For example, in health research, the focus is often on single issue such as understanding experiences of patients with chronic pain (White & Seibold, 2008) or exploration of a deaf identity (McIlroy & Storbeck, 2011) and exploring issues of case managers for older persons with multimorbidity (Gustafsson et al., 2013). This trend was not apparent in classic ethnographies, where the focus was on exploring a whole culture rather than a specific issue. Culture is a core concept in ethnographic research.
Culture has been defined in many different ways by anthropologists. In fact, more than 60 years ago two anthropologists, A. Kroeber and C. Kluckhohn (1952), reviewed all the definitions to date and they numbered in the hundreds. There has been a lot of criticisms of the use of the term “culture,” but most anthropologists continue to use it in a very general way to refer to ideas, attitudes, values, and so on learned by humans in the course of growing up in a particular community and affecting the way people behave. Human behavior is of course shaped by human biology and is therefore shared by many if not all societies, hence culture tends to be applied to things that vary between societies and which therefore cannot be entirely determined biologically, for example, what people consider proper food, what times of the day they eat, or with whom they eat. The understanding of culture has become more intricate with the development of different forms of ethnography and theories that emerged in recent years. According to Nuckolls (1998), culture is a problem that can never be resolved, mainly because of its paradoxical nature (individualist/collectivist). This paradoxical element of culture ultimately forces people to compromise with opposing ideas and results in development of new and different forms of defining what culture is. Hence, it is not surprising that there is still an ongoing debate about the concept of culture and how problematic it is among contemporary ethnographers. According to some contemporary ethnographers, culture is viewed as an overly simplistic concept, suggesting an essentialized point of view. A view that recognizes that culture is unique to specific social groups while undermining divisions within groups. Culture was and continues to be a contentious concept in ethnography.
Ethics
Ethnographers emphasize that ethical procedures are integral to all aspects of an ethnographic study (Lincoln & Guba, 1985). A substantive amount of attention is given to ethical considerations regarding participants of research studies. However, the issue of ethics extends beyond a consent form, assuring participants that their privacy and confidentiality of information are fully maintained. Studies in health research (Carroll et al., 2008; Gagnon et al., 2013; Kidd & Finlayson, 2010) do pay close attention to the requirements involved for appropriate informed consent demanded by institutional review boards. However, approval granted by the institutional review boards does not always mean that ethical issues, which health researchers might encounter, are fully addressed.
Health researchers who conduct ethnography often enter an “unknown zone” where they are not aware of what they are looking for or what to expect (Fine, 1993). Hence, spending time in the field, interacting with members of the group is the best way to gain insight to the phenomenon under consideration (Warr, 2004). This provides context-dependent understanding and allows a better sense of the data collected. The point we want to make here is that it is not surprising that health researchers are often face with ethical dilemmas. Ethnographers become often much immersed in their data and come to know participants well. Due to their close connections, ethical questions are often encountered. Some of these questions are: How much information can be included in final research texts that are publically accessible? To what extent will the exposure put their participant’s identity in jeopardy particularly, when conducting ethnography on a sensitive topic? Many ethnographers also raise concern about how to give voice to participants in their data? Other questions might include whose property is the data an ethnographer collect?
However, we found health researchers conducting ethnographic research rarely discuss ethical concerns that they might have encountered during the conduct of their research (Braaf et al., 2014; Bright et al., 2012; Carroll et al., 2008; Gates et al., 2001; Kidd & Finlayson, 2010; Liu et al., 2012; Pino et al., 2013). In ethnographic research, extensive efforts need to be made to attend more closely to ethical dilemma researchers face while conducting their research. We note that this factor is greatly undermined in the current health literature.
Rigor
Tremendous efforts have been made by classic ethnographers to produce rigorous ethnographic work and this trend continuous in ethnographies produced in health science research. Ethnographic work published in health research, show researchers have extensively attended to the issue of rigor in regard to their data. To ensure rigor in their studies, we found that researchers in health research focus on using following wide range of criteria: (1) triangulation, (2) prolonged engagement, (3) peer debriefing, (4) member checking, (5) thick description, and (6) reflexivity.
Researchers often engage in activities such as prolonged engagement, triangulation, and peer debriefing. Triangulation means using different styles of data collection such as observation, photographs, and field notes. Triangulation (Gustafsson et al., 2013; Liu et al., 2012; McElroy et al., 2011; Pesut & Reimer-Kirkham, 2010; Townsend, 1996) and prolonged engagement (Braaf et al., 2014; Liu et al., 2012) was used by health researchers to account for the reliability of their study. Using prolonged engagement and triangulation as approaches for data collection will also serve the purpose of establishing credibility. Further, prolonged engagement will help participants become comfortable with the researchers’ presence in their natural settings (McCabe & Holmes, 2013; McElroy et al., 2011).
Peer debriefing is a common technique adopted by health researchers to establish credibility (Braaf et al., 2014; Gates et al., 2001; McGibbon et al., 2010). It is significant to note that member checking was widely used in the health research literature to account for rigor (Braaf et al., 2014; Liu et al., 2012; Magilvy et al., 1987; O’Mahony & Donnelly, 2012; Pino et al., 2013).
Thick description was integrated in the majority of the health research studies we reviewed to demonstrate rigor (Mahon, 2014; McCabe & Holmes, 2013; Liu et al., 2012; Siddique, 2012). According to health researchers, thick description of a study and its use in the process of coding is essential as it facilitates contextual evaluation of the data (Mahon, 2014; McCabe & Holmes, 2013). However, several researchers question the transferability/generalizability of ethnographic findings. For example, Willis (2010) raised issues about the reliability and validity of ethnographic data. Willis (2010) argued that “ethnographers become frozen in time as is his or her account of event in the field” (p.556). Furthermore, Willis (2010) believed that when we return back to the participants for verification, our minds are still frozen in our data, whereas our participants have moved on in their lives. We encountered this issue in our own study examining parental experience of those who have a child with traumatic brain injury [unpublished, study ongoing]. A participant declined to revisit and talk about the initial stage of their child’s injury because they have “put it behind them.”
Qualitative research has been criticized by the lack of “objectivity” and the potential influence of the researcher on the data (Ahern, 1999). To help minimize the effects of researcher bias throughout the study, an informal journal of researchers’ experiences, views and judgements must be kept (O’Mahony & Donnelly, 2012). The journal is a way to practice reflexive processes. Reflexivity is the ability to note one’s personal feelings, preconceptions, and be able to think critically about them in relation to the research being conducted (Ahern, 1999). Several health science ethnographic studies (Bright et al., 2012; Carroll et al., 2008; Kidd & Finlayson, 2010; Mahon, 2014; McCabe & Holmes, 2013; Siddique, 2012) have acknowledged the critical role of reflexivity.
Although rigor has been addressed in health research however, the focus on the quality of data and understanding rigor as a process has been undermined. One of the first steps to ensure rigor is by determining methodological congruence (Richards & Morse, 2007). This means evaluating the fit between the various components of the study design. For example ,questions can be asked: Does the methodology and subsequent methods fit with the research question? Does the type of strategy for data generation fit with the chosen methodology and is the analysis congruent with the strategy? (Richards & Morse, 2007). However, current health research studies (Braaf et al., 2014; Bright et al., 2012; Carroll et al., 2008; Gustafsson et al., 2013) to greater extent undermine such vital questions in their research design section.
Conclusion
We show that classic ethnographic work has been increasingly taken up in different ways in health research and ethnography as methodology has changed over time. While new forms of ethnographies have developed as a response to shifting understandings and to re-definitions of culture, some key elements of ethnographic research have been lost. A close examination of multiple ethnographic studies suggests that ethnography continues to be important in the field of health research. There are different contemporary forms of ethnography that have emerged in health research (see Table 1). Ethnography as an approach to research has been in a constant state of development since the 19th century and much of this article points to the many changes over time and that ethnography as a methodology is inconstant flux. Health researchers have made ethnography into a more standardized methodology. However, on the other hand ethnographic practices that were used traditionally are disappearing. It can be concluded that ethnography is an intricate methodology and with the passage of time it has become multifaceted in nature. However, with all this evolution of ethnography, we fear that it is losing some it is core elements, including the loss of the appreciation of extensive and long term fieldwork.
Footnotes
Authors’ Note
We would like to acknowledge Alberta Centre for Child, Family & Community Research (ACCFCR) for their support. We would also like to thank the reviewers of our paper for their valuable comments.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.